Health Insurance Practice of Profit by Delay and Denial of Care is Unethical, Constitutes Practicing Medicine Without A License, And Must Stop. Physicians Must Stand Up For Patients.

April 21, 2016

Dear Aetna Pharmacy Management Medical Director, Dr. Muna Enshiwat-Salman,

My dear patient of 15 years just presented me with a 12 page Notice of coverage decision dated 3/18/2016 which she received from you stating “Aetna Pharmacy Management received your request for authorization of coverage for Lumigan Solution 0.01% (Bimataprost). Your request was denied for the following reason(s): …

FYI,that was not a request. That was a valid prescription I wrote for my patient for a proven, indicated glaucoma drug that she has been using since I first prescribed it on March 22, 2011 in the course of her treatment for glaucoma, a potentially blinding but treatable condition. She was diagnosed with glaucoma in 2002 and has been in my care on a series of drops from Timoptic to Travatan over the past 14 years to keep her from losing her sight. My patient and I have been pleased that the Lumigan has controlled her eye disease perfectly since 2002. We are stunned, if not incensed, that you and Aetna have the audacity to deny her treatment, putting her at great risk.

My patient is mandated by the federal government under threat of penalty to purchase insurance coverage, and your company is willingly accepting over $600.00 a month in premiums to provide such coverage. According to her insurance card, her RX benefits are listed as: “$10/$30/$55/50%/40% variable copays may apply.”  She last paid $55.00 on 1/30/16 using her coverage to purchase the Lumigan. When she ran out of the drops, she went without them because of your denial, until she became so fearful of going blind that she found an online discount coupon from the pharmaceutical company and was able to purchase the Lumigan for $164.99- instead of the $55 copay you advertised.

So, how much did Aetna make by denying her care? Over $100 this month alone on this one individual? If you multiply this practice of denial, or shall I say malpractice of denial, by hundreds or  thousands of patients, it appears that Aetna may be profiting millions of dollars by simply denying and delaying patients’ care and disrupting the patient-physician relationship. Aetna is certainly making enough to justify your position and the “Aetna Pharmacy Management” division.  Are Aetna, your division, and you liable for visual loss this patient sustains as a result of your denying her care? In Texas, the Medical Practice Act and Pharmacy Act require that a valid patient-relationship exist before prescribing or treating a patient. You have no such relationship with this patient. Your actions are unethical and constitute failure to practice according to the ethics espoused in the Texas Medical Practice Act, in particular failing to safeguard against potential complications and making therapeutic decisions in the absence of a valid patient-physician relationship. Again, my prescription was not a request, it was an order for a pharmacy to lawfully dispense needed medication to my patient with whom I have had a valid patient-physician relationship for the past 15 years.

I suggest you and Aetna expend the time, money, and effort (including that spent on your 12 page Dear John denial letter) relegated to denial and delay of care to actually providing the care patients are paying you to provide. This pattern of unethical behavior by insurance companies is exactly why I have severed all agreements with 3rd party insurers like you and work only and directly for my patients.  You must honor your agreement with your customer and provide the promised coverage for this medication AND reimburse her for the $164.99 she had to spend last month as a result of your denial. This is wrong and unacceptable on many levels. I fear that this unethical way of doing business will continue until a myriad of patients are permanently blinded, harmed, or even die. I will no longer enable this inhumanity. Will you?


Kristin S. Held, M.D.


4 thoughts on “Health Insurance Practice of Profit by Delay and Denial of Care is Unethical, Constitutes Practicing Medicine Without A License, And Must Stop. Physicians Must Stand Up For Patients.

  1. You’re absolutely on target. I applaud you for standing up for your patients.

    Suggest you and your patient write the commissioner of insurance and lodge a formal complaint there. While an individual complaint may not motivate change, the ins. commissioner’s recognition of a pattern will generate attention and cause them to be investigated. Likewise your specialty society and ask that they get involved as a policy issue. Consider also your legislature’s committees on health oversight. Get them involved.

    The only way we’re going to change this system is through combined assertive action like yours. Since a significant element of care is now entailed by having to get everyone’s buy-in – esp. the ultimate self-designated decider, the payor – we also ought to demand that a CPT code be developed to apply to 15 minute increments of time devoted to “optimal care management.” Why not? After all, discussion with them ultimately determines the optimal health of the patient. It is, in fact, a form of consultation, involuntary though it may be. I suspect that when insurers saw what it was costing them to engage in these “coverage decisions,” they’d be a lot less willing to pursue this manipulative coverage defrauding strategy.

    For that matter, since every bureaucrat wants each patient encounter documented as though it was a legal transcript of a second-by-second encounter, we ought to add the cost of 10 minutes of documentation per patient visit. Again, why not? This is the cost of doing business, and docs are getting fried trying to accommodate to everyone’s demands.

  2. I would guess they are denying her coverage because you opted out of Medicare/Medicaid. We knew this would be a consequence of opting out, that pharmacies would not be obligated to fill prescriptions for patients if they physician/NP/PA/whatever had the termerity to opt out.

  3. Pingback: Health Insurance Practice of Profit by Delay and Denial of Care is Unethical, Constitutes Practicing Medicine Without A License, And Must Stop. Physicians Must Stand Up For Patients. | drginareghetti

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