Insurance Companies Use Stalling Tactics to Save Themselves Money – The American

Insurance companies are causing burnout in healthcare providers and posting record profits in the process. These profit margins are not an achievement of market forces. They are the fruits of crony capitalism. The insurance companies have rigged the game.

Before we can perform a surgery that is agreed upon by patient and surgeon, we have to get approval from the third-party insurance company. This shows a blithe disregard for the very ethos of the patient-physician relationship. Moreover, the process causes confusion and delay.

Below is a snippet from an otherwise ordinary day. 

I saw a patient with a disc herniation, or a protrusion of the spine’s shock absorber, that was pushing on her nerve that goes to her leg and foot. She had seen several surgeons. We saw each other at least four times over a one-year period. She had weakness in her foot. This is known as a partial foot drop or an inability to raise the foot properly. It happens when the nerve that goes to the foot gets pushed or trapped by the disc herniation.

We aggressively tried to avoid surgery. This included all different aspects of care, from a fitness regiment of core strengthening to an epidural steroid injection that places medication directly around the nerve. The patient underwent multiple rounds of physical therapy.

After several discussions, we decided together that surgery was the only and the best option. We talked patient and physician and then patient, physician, and family. We had a distinct plan that follows the guidelines on how to treat a very common pathology, a lumbar herniated disc. All the necessary documentation is present and confirmed.

Then, the insurance company representative denied the surgery.

Since the indications are clear, the insurance company will eventually approve surgery, as is the typical process. Their goal is to obfuscate. It’s effective. Our study group’s peer-reviewed publication in a major neurosurgery journal proved that insurance companies delayed a decision regarding surgery for more expensive procedures. It wasn’t that they said yes or no, it was that they just delayed giving an answer. 

The burnout waste this creates within the healthcare sector is severe.

Our nurse team has to then commit to a phone call for an entry-level evaluation with the insurance company. This takes time and effort that could be spent quite literally with this patient discussing the softer parts of surgery. They could discuss things like tricks to making being NPO (or not eating) prior to surgery more tolerable and how to prepare for a short or same-day hospital stay.

Instead, our nurses have to spend time regurgitating what is already in the chart to an insurance representative. Most of the time, it’s an administrative clarification issue, but calling into the insurance abyss is like dialing into a time warp.

If a higher-level evaluation is needed, either myself or my physician assistant or nurse practitioner will have to get on the line and debate the merits of a neurosurgery with some other type of health representative who is acting on behalf of the insurance company. It’s not unusual to be discussing the nuances of a minimally invasive spine surgery with a pediatrician or emergency room doctor who is working on behalf of the insurance company. 

This isn’t a “peer-to-peer” evaluation to uphold medical standards. It’s an intentional deterrent.

Delaying has value. Some physicians just don’t have the bandwidth to combat this matrix. Certain patients will give up. Patients change insurance or switch to government insurance. This theoretically also gives more time for the insurance company to invest the insurance premiums. In short, the insurance company is indirectly asking how it can cover patients without covering care.

Again, this destroys an already strained healthcare workforce. A survey from the American Medical Association noted that, on average, offices spend 13 hours per week in prior authorizations. This is thankless work that leads to burnout.

And it’s impressive.

Burnout numbers for physicians are at an all-time high of 63 percent. The burnout rate for nurses is also capping out at 62 percent. The only thing more impressive is UnitedHealth posting $5.2 billion in profit in the third quarter. 

Congress needs to adopt the Improving Seniors Timely Access to Care Act. This legislation seeks to streamline prior authorization in specific Medicare Advantage Insurance patients. It requires transparency and oversight in the insurance companies. It passed the House in a unanimous voice vote. It has 50 bipartisan sponsors in the Senate. Most importantly, it links prior authorization to actual evidence-based guidelines. It would be a reform that at least moves in the right direction.

Richard Menger MD MPA is the Chief of Complex Spine Surgery and the Director of the University of South Alabama Spine Institute. He is the lead editor of the textbook The Business, Policy, and Economics of Neurosurgery 

Jessica Murfee, RN, BSN and Erin Roberts, RN, BSN are clinical spine nurses at the USA Health Spine Institute in Mobile, AL.