Your patient's health insurance doesn't agree with your diagnosis and treatment—now what?

By Anastasia Climan, RDN, CD-N
Published May 15, 2023

Key Takeaways

  • Insurance issues can vary depending on the medical specialty; for example, insurers may be more likely to question a psychiatric diagnosis than a cancer diagnosis.

  • Patients usually understand that their insurance company, not the clinician, is responsible for delays or denials.

  • Documentation, advocacy, and even legal action may be necessary to get patients the care they need.

Sometimes clinicians and insurance carriers don’t see eye-to-eye on the best course of action for a patient. This can cause denials, delays, and excessive costs when it comes to diagnosing and treating your patients.

MDLinx spoke with our psychiatry advisor Dr. Amanda Zeglis and our oncology advisor Dr. Nitin Chandramouli to learn more.

What has been your experience dealing with insurance issues when treating your patients?

Amanda Zeglis, DO, MBA: There can be circumstances where insurance does not align with specific diagnoses; though in psychiatry, this more often occurs with coverage of certain treatment plans (be that medications or level of care in management).

Related: Doctors speak up: The most common patient health insurance challenges

Oftentimes, insurance companies have various policies regarding which medications are covered or not, alongside specific flow charts for which medications (or groups of medications) ought to be trialed before opting for a more expensive alternative or a newer agent.

"This can be tough to navigate, as patients all have varying insurance providers."

Amanda Zeglis, DO, MBA

Thus, it requires healthcare providers to be cognizant of the covered options for each of these individuals to ensure the medications are within budget in order to maintain utmost patient compliance.

Nitin Chandramouli, MD, FACP: There is no problem with disagreements on diagnosis; a cancer diagnosis is proven quite easily with biopsy, surgery, etc. I've never had an insurance company disagree with a diagnosis. The problem has been in obtaining pre-authorization for treatment regimens.

Related: Pre-authorizations: Bureaucratic nightmare, harmful to patient care

Do you feel insurance issues affect a patient’s trust in doctors and willingness to seek treatment? If so, how?

Dr. Zeglis: Insurance issues can cause some distress to patients, and I think that can always translate to a leeriness in seeking treatment.

Oftentimes insurance coverage issues can arise from treatment discrepancies. If documentation is not present to effectively and appropriately support your treatment decisions—be it a specific level of care that a patient needs for continued management or a particular medication that would be of benefit—there is a likelihood that insurance coverage will be challenging.

This can end up translating to patients incurring costs at their own expense due to insurance companies finding that documentation does not align with standards of care policies that indicate an alternative treatment option may suffice.

Dr. Chandramouli: I do not think any of these insurance issues affected patients' trust in their doctor or willingness to seek treatment. It was easy to explain how their insurance company and their contracted third-party pre-authorization company were getting in the way of the patient receiving timely treatment. 

"In fact, many times in my experience, the patient became more of an advocate for themselves by contacting the insurance company directly to complain."

Nitin Chandramouli, MD, FACP

Can you give examples of when insurance discrepancies are most likely to occur?

Dr. Zeglis: Insurance coverage discrepancies for psychiatry tend to be related more toward treatment provisions. Certain medications may not be covered if formulary alternatives have not been trialed first, or certain levels of care may not be covered if a patient has not been documented to have an appropriate severity of their presenting concern.

Dr. Chandramouli: Many insurance companies use third-party vendors (AIM, Evicore, etc.) for pre-authorizations, and they all use an online entry system that is supposed to automate the process of pre-authorization. Multiple times, our practice has had to raise concerns and complaints that their system doesn't work.

Initially, they would presume that it was simply a ‘user error’ on our part despite explaining multiple times their online entry system was not working. It finally took a demonstration to show them what was wrong with their system. (These problems can still crop up now and then). This, of course, delayed obtaining pre-authorization in a timely manner and forced the rescheduling of patients' treatment start dates.

"When these third-party companies started doing the pre-authorizations, patient care suffered."

Nitin Chandramouli, MD, FACP

This included delays in treatment as well as inadequate supportive care meds being authorized (leading to more side effects that could have been better prevented and, thus, patient harm). I have personally experienced two instances where patients almost died because of delays in obtaining pre-authorization from these third-party companies. 

Because of those two events, I have been hugely critical of these companies and the insurance companies who contracted with them. I have directly told these companies how they adversely affect patient care and cause patient harm. In a couple of instances, I have even told them I would recommend the patient seek legal counsel.

Do you have any tips or strategies to help prevent insurance problems?

Dr. Zeglis: Documentation is critical when ensuring that insurance coverage will align with your treatment plans. If you feel strongly that a patient needs a certain level of care or a particular medication, be sure to identify the reasonings for that plan throughout your assessments, including why a lower level of care would not be sufficient to manage the patient's concerns or why an alternative medication would not be beneficial.

If a treatment isn't covered, it is less likely the patient will follow through on it or be consistent, as the financial strain can create difficulties in their compliance. 

"Being an advocate for your patient and working to help identify an effective treatment plan that also aligns with their insurance coverage is the sweet spot where patients will thrive."

Amanda Zeglis, DO, MBA

Dr. Chandramouli: I strongly pursued our local insurance reps and complained hard and fast about how their contracted third-party pre-authorization companies were adversely affecting patient care. I would advocate all physicians take this approach, as the insurance company will listen (eventually).

Reaching out to insurance companies every time issues arise is important. If egregious problems occur, it's important to file a complaint with the respective state insurance regulatory department.

It is very important for physicians to speak up frequently and loudly about these problems.

What this means for you

It is imperative that clinicians speak up and make a clear case to insurance companies when a pre-approval or claim gets denied, as these issues significantly affect patient care. Keeping patients informed of these insurance barriers can prompt them to join you in advocating for the best care.

Read Next: Insurers dictate how we practice: Is this relationship toxic?
Share with emailShare to FacebookShare to LinkedInShare to Twitter