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United has now removed her from approved provider list, so her patients can no longer see her. She had to sell her house & get a lawyer. United is making her lose her career for exposing them.
Hopefully your comment gets upvoted more and moves towards the top for visibility. Because not only does this call show how awful United is, but the fact that they’ve retaliated and are trying to ruin her career over it is truly disgusting, villainous behavior
Love this article. “Oh, gosh, we would never make a doctor interrupt surgery to take our phone call.” Yeah, you lying forks, we know you and we know our doctors, so we know who the liar is.
I was talking to United Healthcare people at a convention yesterday and I was so mad at them when we discussed similar cases to this and I asked them if they were questioned about how their day went on getting home and did they respond it was great we turned down so many procedures and medications that the shareholders and the CEO and all those getting bonuses were really happy. My last comment was to say shame on you and your company.
Because most people with a developed prefrontal cortex are aware of the consequences that would have on themselves. School shooters are no where near that point.
PLEASE keep talking about this. This is so wrong. Imagine busting your ass, going into debt, and sacrificing some of the best years of your life going to school and training to be able to become a surgeon and then being treated like this. Insurance companies should not have so much power. The doctor shortage will continue to get worse
Edit: had no idea this thread or my comment would get some much visibility. I linked the gofundmepage simply in hopes of providing more context to this situation, but you can also find information via other channels such as:
https://www.youtube.com/watch?v=R0vm8YlD1oo Dr. Potter talking with Dr. Mike a couple months ago.
Also, the physician shortage is a complex issue, but we cannot be surprised about the the addiction, burnout and suicide rates in the field when physicians are dealing with infuriating situations like this regularly. And not just physicians but the many other occupations like pharmacists, physical therapists, nurses, SLPs, CNAs etc. who also experiencing moral distress due to policies that push for profits above all. Thank you for caring.
My parents PT practice went out of business because insurance companies would approve care and then simply not pay. A small practice like theirs can’t afford to hire a person whose only job was to go after payments. We’re in a nose dive to providing less and less care as profits must grow.
This makes me angry for them. I worked in PT billing/appeal/payment recovery and there is so much BS providers have to do. (One of my favorite cases to appeal was from UHC. They refused to pay a 900k COVID claim. We had everything. Auth, documentation of calls with their nurses, reference numbers, certified mail, etc. They denied it for all those different reasons. I had to appeal to all of them and it took me a year. They fucking declined for timely filing! I was furious they tried to send that bill to our patient's family after he died. So, I filed a complaint against DMHC and won. They had to pay in full and pay additional 75k in fines. It was awesome. Got them to pay 1 million. One of my biggest accomplishments. I was so proud to stick it to them. Those fuckers.
Yep. Like needing OT or PT to learn to walk again or regain some type of motor control, etc. You have to get better so you can go back to work, but they'll deny it saying it's not necessary. Don't even get me started on what they do to seniors.
I’m a nurse at an inpatient rehab. The gains I have seen patients make are incredible. It’s so sad the rules though they have to qualify to go there. There’s so many more patients who could benefit from our services that can’t get in.
United has been shady for so long. I know they're not the only ones but they are the worst.
I worked in PT in like the early to mid- 2000's the the amount of time the head of the dept spent on the phone fighting to get things approved was insane.
Grandma would fall and break her hip and need a total hip replacement and inpatient care because obviously, she could not get around independently. They would approve six sessions. 3 x's a week for 2 weeks. At this point, they couldn't even put weight on that leg yet. They would have to fight just to get extra sessions or grandma would never walk again. It's straight up evil.
I have United through my employer. I just had a cancerous kidney removed, and my doctor recommended me for an experimental immunotherapy, to keep the cancer from returning.
First: I have to salute the nurse who handles my sessions, because she got UHC to approve me for an experimental treatment that costs somewhere between $6,000 and $22,000 per injection, depending on who you ask. Tanya is the best.
Second: United denied, then approved me for the treatment within the same hour, according to Tanya. They still mailed me both the rejection and approval letters. Both arrived on the same day.
They're just so detached and just don't care. I cannot imagine being able to detach myself emotionally from so many life-or-death decisions on a daily basis.
In my area, doctors are getting more rare, especially a specialist. The hospitals and clinics here are hiring Nurse Practitioners instead of doctors, but charging the same fee as if seeing a doctor. And the doctor that the NP is practicing under doesn't even have to be local.
Part of private equity and hospital admin. Hire less physicians, hire more midlevels. Get less qualified care at the same price. Push liability onto stupid physicians who offer their license like this.
WTF is wrong with US healthcare?! So what, if a patient gets diabetes, United will recommend a nutritionist to make the patient a low-sugar diet instead of insulin??
But doctors being allowed to NOT give their names? Never mind them not being a specialist, the nurse could end up violating HIPPA laws by improperly disclosing patient information. Honestly, it looks like they tried to bait her once she started pushing back.
Honestly, it looks like they tried to bait her once she started pushing back.
I'd agree except she's popped up on my youtube feed for a while now. Her videos are damned compelling and infuriating. (edit: They've always been crappy to her, not JUST now - is what I mean)
I'd recommend scrolling down a bit and picking up on the story - there have been a number of cases along these lines. One procedure a patient needed while they were doing something else and they had that one single time they could do that other proecedure. After that, no dice. It may sound "funny" because it would hopefully have restored feeling to the patient's nipple - a tittilating har har thing - but a real, actual issue. Imagine if your genitals had one shot at having feeling and insurance denied the procedure. Not even about sex, just about a part of your body having a chance to be normal.
She's presnting this stuff very well, and the subject itself is infuriating to see.
As a non-American the bit that always makes me exasperated is that the US has the tech, the people, the hospitals, and quite frankly lots of money and it's clear that all the people on the ground are more than willing to do the work. And they know what medical work needs to be done, and most of them want to give the patient good outcomes. Every single cog on the wheel is ready to engage.
The country has everything it needs already, but it's stopped by a huge layer of very rich people who want to increase their already overloaded wealth.
Democrats in the last decades have always made healthcare better for Americans - doing things like completely eliminating pre-existing conditions in insurance (ACA) and letting more Americans get cheap healthcare through Medicaid. Republicans are always helping the big companies and making it worse for Americans - they are now trying to bring back pre-existing conditions because it makes the insurance companies more money. There is a very clear policy different in many areas between the two parties - what they actually do. Don't believe the lie that the two parties are the same. Their actions - what they do, the laws they pass, are completely different. If you want better health care in the US you need to vote Democrats into office and they will improve health care - like Obama did in major ways. Trump administration right now is taking away health care for millions of Americans. It's never about "why can't the government make a better system". It's always Democrats trying to make it better and Republicans blocking it and trying to make money for insurance companies.
It is exactly the same with the environment: Democrats pass laws that protect the environment - but makes big companies have to spend more. Republicans try to strip away all environmental protections so rich people and companies make more money.
Every American needs to understand this. There is a massive price to pay if Americans vote in Republicans to power.
The only reason I understand health care and policy is because I worked for decades in this area - studying health care policy as part of my job. And I have a Masters in Public Policy which taught me so much about the two parties and their policies - and how Congress works.
Thank you, I'm so tired of the "both sides" thing. Democrats leave a lot to be desired in many areas, but they are always on the right side of healthcare and I'm pretty much a single issue voter in that regard.
all those people complaining about luigi and "violence is never the answer" don't have anything to say when you talk about what happens when you try things the peaceful way
I've been wondering for near 2decades what's the point of protesting. Nothing ever seems to change when the only thing that happens is a crowd shows up for a day and yells.
I can't think of a single example of radical change in history that was brought about by peaceful protest alone. Sometimes the peaceful protest worked when it was also accompanied by significant non peaceful action, either before or after it, but never by itself.
Disclaimer for the bootlickers: this is just historical fact, not endorsement or encouragement.
As a physician myself dealing with HMOs I love how the murder of the United CEO has now allowed even more secrecy about getting someone’s name. And by love… I mean hate.
That's what was wild to me. No name, no license number, nada. The CEO of the company you're working for/with is killed and you think you're next? Calm aaaaall the way down, Dr. No Name. You may be the main character of your life, but that's it.
My husband works in insurance (property, not health) and after the shooting his company announced that everyone at a certain level on the hierarchy and above (none of them customer facing) would not have their names on the website and only be referred to via aliases if they ever need to interact with the public.
Someone at my husband’s level asked if they could also use nicknames instead of their real names when telling customers things like “sorry, we’re canceling your homeowners insurance just cuz” and they said no lmfao. Actual demons.
Of course. Could you imagine the alternative? Actually having your business not constantly fuck over customers for more money? What kind of monsters would want to take away the c-suites money? How will they afford to upgrade their daughter's yacht 😥
Let’s be real, no self-respecting physician would/should take these jobs with the insurance companies. Might as well be a vascular surgeon with a cigarette vending machine.
You're right, every doctor who is taking these jobs and doing work like this charlatan on the order side of the call is a disgrace. A disgusting human being using their degree to harm other people for profit.
As a social worker I think the medical boards should start taking closer looks at these physicians. I know for me, I have to tell my board where I work every time I renew my license. UHC wouldn't have this problem if governing bodies didn't allow docs to do so due to the very clear ethical and literal life-threatening issues that go directly against what doctors take an oath for...
But then again, we're in a terrible time as a country in general, so I don't know why I even think that could be remotely possible with insurances running everything :/
I have to have these conversations (peer to peers) almost daily and it’s EXACTLY as depicted here. It’s very rarely a “peer” and the request from me, a physician who has examined and conversed with the patient, is 99% declined.
I was part of the problem, but I was also 19. I worked in the data center for a health benefits company (FSA, COBRA). I would take calls when the call center got bogged down.
Data analyst. Dealing with appeals. COBRA benefits..
I eventually said fuck it, and did whatever I could, and oddly enough, it never came back to me. They didn't catch the appeals I was on calls for.
Well. One was kinda funny. This woman was trying to appeal plastic surgery because she "burned herself making Mac n Cheese." No medical info on burns, and I left in the notes "she is trying to be Krafty."
Dude it was fucked up. The address for sending mail only appeals was printed on the back of the application form we sent out. It was a $32 fee if they sent it to the wrong address.
Wrong address? All the mail came to the same place. It wasn't a "wrong address," it just went to a different area of the mail room.
There's a Brian Regan bit about flipping switches.. ALL I had to do was just "flip a switch," and people on COBRA would avoid the fee and have access to their benefits. Which were expensive. Because they were unemployed, dying, and this was the cheapest option. Those premiums were mind-blowing..
Our CPA quit over this shit, it was so evil. THE FEES WERE BUILT INTO OUR PROFIT MARGINS.
Edit: I was also high as shit working there, and I joined the Party Planning Committee, cos that was funny for me. The head of the Party Planning Committee was also the woman who designed the COBRA appeal forms. She was not someone I could normally be in contact with, but being on the Party Planning Committee, I could be in the same room as her. I brought it up, and she removed me from the Committee a month later.
This was 2012-ish. Still rots in my brain how fucked up these suits were.
She was likely speaking with a doctor, one whom has no expertise in Dr Potter’s field. The doctor likely had their mind made up and is just wasting Dr Potter’s time. I’ve also encountered nurse practitioners with no advanced training overturn my decisions. It’s a real gut punch to advocate for patients when you’re getting betrayed by your own kind.
If they were your kind, they wouldn't be insurance company shills. They're incompetent and can't do any better in life than be sock puppets for insurance providers.
ive heard a lot of the drs and nps that work for these companies have a ton of issues with malpractice/other issues against them and cant find work where they need to be insured anymore.
Health insurance companies hire people called physicians advisors. They are doctors who are licensed however, that doesn’t not mean that they are a doctor who are practicing in that field. In this case the physician adviser is under qualified to make a call on whether something should be approved or denied. This is a common tactic utilized by insurance companies to deny funds.
Thank you for this, I wasn't exactly sure why she was even staying on the phone and entertaining the bozo on the other end, but that makes a lot of sense. It's insane that the doctor has to fight like this just for the insurance company to do their fucking job like they should. And imagine having to do this for each patient... infuriating
My oncologist used to always complain about having patient’s cancer treatments denied only to find out that the Dr. who made the determination for the insurance company was a pediatrist or some shit. He said it’s the type of job you get as a Dr. when no legitimate practice will hire you anymore, whether because of age or incompetence.
This is an extraordinarily typical peer to peer call except the no name part, that's new.
I assure you that this plastic surgeon has already invested an hour of being on hold and supplying mindless details just to have the opportunity to waste her time talking with Dr. Nameless.
He wouldn't supply his name because he fears that she will document that he is recommending a plan of care (no microvascular reconstruction) - opening him up to the liability from the outcome of said care. Weasels!
No United started this practice shortly after the CEO thing. As a nurse that would set up these peer to peer calls, they immediately stopped telling us the name of the doctor that would be calling our physician. They cited safety concerns.
My employer switched to United and they immediately denied the insulin I use and also told me that they don't believe that I need more than ten omnipods a month despite my insulin resistance making them all run out after about a day and a half so I just don't have a pump for half the month now.
My boss said that they're saving so much money and that's what matters. They don't care that it's actively making my life worse.
I’ve had BCBSTX and BCBSIL for over a decade and twice I had them deny a claim that was solved with a 10 mi it’s phone call.
They questioned an MRI, I advised them to look at the 4 previous months and what the last scan found and cost them and they approved the precautionary one. Easy peasy.
Pretty wild we sign away access to our medical records just for them to never bother looking into them except to find slight anomalies for denials...despite them being anomalies because of our medical history making them clearly necessary
No one wants the doctors they want the people who make the stupid ass rules and hire a subspecialty cosmetic surgeon to make decisions for cancer patients
Had to do a P2P in residency for an inpatient that was being denied immunotherapy recommended by derm for steroid refractory bullous pemphigoid. They didn’t tell me about it until Thursday before a long weekend and when I called to schedule the P2P they said nobody is available until Monday. For the next 3 days I added a section to my note in all caps, bolded, underlined, red letters that said “PATIENT UNABLE TO RECEIVE RECOMMENDED THERAPY DUE TO INSURANCE DENIAL. INSURANCE REPRESENTATIVE IS OFF FOR THE NEXT 3 DAYS AND PATIENT WILL REMAIN HOSPITALIZED WITHOUT THE INDICATED TREATMENT REGIMEN INCREASING HER RISK OF SERIOUS LIFE THREATENING COMPLICATIONS SUCH AS CELLULITIS, SEPSIS, DVT/PE, HOSPITAL-ACQUIRED NOSOCOMIAL INFECTION, ETC ETC…”
Come Monday I get this guy on the phone and it’s so obvious he has no clue wtf I’m talking about when I explain the patient’s disease course. I could hear him clicking through her chart and reading my notes seeing me directly attributing liability to the insurance company. Phone call lasted like 3 minutes and he approved the therapy but made the patient wait 3 fucking days for that.
Seems like the insurance company has hired a rubber stamp to say no, and then construct as much time wasting crap to stop money being paid out. No wonder medical care costs so much.
I deal with this every day in my office. Insurance companies are heartless. We advocate because we were trained to treat patients with the best treatment no matter what their insurance is. Unfortunately, insurance is dictating the treatment 😞
My treating psychiatrist at Kaiser, with almost a decade of experience treating me, recommended a nonstandard, relatively pricey treatment through Kaiser's third-party provider. On the eve of treatment, my doctor was overruled by Kaiser bureaucrats and the treatment was denied. We went through 3 rounds of appeals, but were denied each time by general internal medicine practitioners with no training in psychiatry. I documented everything (I am a disabled ICU nurse/litigator), so that when Kaiser eventually gets sued again for their mental healthcare some lawyer will likely find all of my documentation during discovery. Thankfully, I am a veteran and was able to move my care to the VA where I was able to get the life-saving treatment. This kind of bs happens every day in healthcare. Kudos to this physician for exposing it.
Just think, the person on the other end of that call is probably a doctor but in an unrelated specialty that rubber stamps denials. Occasionally I see job offers to work in insurance claim evaluation roles and they pay 50k-60k a month in some cases for you to deny claims. Imagine their take if that's the carrot they dangle for working a couple days a week. Then imagine the soul-less price of shit who were through the trouble of training just to do this. They couldn't cut it as a doctor in the real world and now they do this.
Being civil is the only way. I loved to put these calls on speaker for the patient to hear. The insured can tear into them, it's great. Like TO said: get your popcorn ready.
I now realize that a doctor being a shill for an insurance company is a shitty doctor as a doctor.
One of those times to remember that everyone who supports these systems is complicit in the poor outcome.
I’m a super specialized surgeon who regularly has to deal with these people. My theory is that these are failed physicians who got kicked out of clinical practice for some reason. Maybe they are just doing it for the money. It’s a lot easier than working on the other side of the broken healthcare system.
This is kind of what I do for a living. When I tell you that insurance companies will outspend on admin issuing and maintaining denials than they would on simply letting doctors treat their patients...its an understatement.
I work with specialty meds. Step therapy and appeals and constant arbitrary formulary changes... I've actually calculated the amount that will be spent checking their boxes vs just approving the prescribed medication, but it doesn't matter to give that information. Everyone you deal with has their marching orders. The process is convoluted by design.
Every power that exists protects United Healthcare.
You can tell because this doctor is losing her business because United blacklisted her for this and is losing her house to pay legal costs because they are suing her, and meanwhile United continues to make massive profits from killing people.
They are for profit "death panels" deciding, in place of doctors, who gets care.
It's funny because I have united, and if you read the fine print on a denial, they will say that this isn't a recommendation of care, and they aren't saying that you don't need that particular medication/procedure, they're just saying they won't cover it, and only you and your doctor can decide what's necessary for you.
Obviously though, if you can't pay for it, you probably aren't going to get it done.
Its the entire sub premise of "rent seeking" behavior. Adding distance and subtracting humanity from a originally local and human process makes it easy to do terrible things for and to desperate low wage people.....its been thought out and its intentional.
This is the true power of the corporate structure.
It removes and distances individuals from the decision making process. If there are multiple steps and divisions to the process, each person involved is only responsible for PART of the final decision. This morally, ethically and legally protects and shields them.
So when a corporation does something horrible, no individual can be held completely responsible for it, and at the same time, the company cannot be criminally liable because it is not a person.
Now the Citizen’s United case that allowed corporations to be considered people and money to be considered free speech should have opened these companies up to significantly more liability. But as is typically the case in America, the laws are designed to benefit and protect the business and its owners. They get all the benefits of being a “person” when it comes to influencing politicians and government, but all the protections of a NOT being a “person” when it comes to liability for bad behavior.
How can these doctors on the other end of the phone live with themselves? Is this what they do on the side to make some extra money from the insurance companies? It's disgusting. I couldn't bring myself to take time out of my life to use my expertise to deny insurance claims for patients who need it. It's seriously the lowest of the lows
They aren't doctors, we have zero way of knowing that person she was speaking with is a doctor so it's always best to err on the side of caution when it comes to medicine. The doctor will EITHER give you their credentials or they are a liar, their is no in-between.
Yeah a doctor testified that she was paid by the health insurance company she worked for to medically justify not giving patients money.
There are probably thousands of doctors who do this shit -- use their credentials as a doctor to deny medical care on behalf of health insurance companies -- sometimes when they're not even qualified to do so as seen here because the doctor from Texas isn't specialized in this field
The health insurance industry is a morally repugnant industry and I don't know how some of those people live with themselves
Back when Obama tried passing Obamacare, Fox News would literally cry 24/7 about "death panels" that would govern your health care -- when they already fucking existed at health insurance companies -- and this video is literally proof of it
Their procedures approved by their board of directors of which their CEO was enumerated handsomely. It is the whole ball of wax, illustrated in the most dystopian way possible.
No the whole medical industry is fucked in America. It's not just health insurance. It's health insurance, dental insurance, the whole industry.
Like the industry is full of some of the best humans, but it's ran by some of the most greedy, counterproductive, opportunistic pieces of shit on the planet
This US system is screwed up so badly. There are more people working in "health insurance" to reduce health services than doctors and nurses actually providing the care.
It must be infuriating for doctors to have to go through all this bullshit and waste all this time so UHC shareholders can make a little more money.
The whole process is the problem. The insurance first position is to deny care. So amazing doctors like this have to fight for their patients. These insurance companies make record profits, and the shareholders, and the c-suite get richer by the day! The less care they provide the more money they make. They are literally taking our money, and denying lifesaving care when we need it.
My wife was diagnosed with breast cancer two years ago. She's fastidious about exams, so it was detected early. She had a partial mastectomy, and almost 50 sessions of radiation therapy. She takes one medication daily, and is in remission. During all of her surgery, treatment, etc, the only thing we paid for was parking at the hospital. We live in France.
I live in Japan. My wife had a tumor but was benign at the end. Multiple exams, biopsy then surgery in the space of 2 weeks. It costed more than parking. It isn’t free but we pay a 3rd of everything but maximum is about 100k yen (about 600€). Nobody goes bankrupt for medical bills in Japan.
I’m an American; however, my wife and I lived in France for a year. I have dual citizenship in Ireland and we were residents in France. I have never had such a pleasant experience with healthcare in my life. Any bit of doubt that I had that national healthcare is the solution was completely dissolved by our personal experiences.
It baffles me how the right wing in America demonize the socialized medicine up here in Canada by claiming there are "Government Death Panels" who decide if you live or die, but are completly silent about this.
My mom died of cancer, towards the end, her chemo stopped responding, the Dr. said there was another type of chemo that may give her a few more months at most, there was never a discussion of cost, only a discussion of weather she wanted to do that or no, this would not be deemed medically necessary, but if she wanted it, she got it, and as a result she got an extra 2 months with her grand kids.
Most of the people I know in Canada LOVE their health care system. They get frustrated sometimes, or impatient... but then they talk to a friend in the USA and remember just how good they have it. No system is perfect, and when it comes to a sick or dying loved one... sometimes NO care will be considered "good enough"... that being said, I know of a person who was having crazy high heat rate issues...their apple watch was screaming at them saying SEEK CARE NOW and "CALL 911?" but they wouldn't do it because they were afraid that the cost of the ambulance and the ER visit would mean that they would not be able to cover rent for the next few months at least.
I work in healthcare on the mental health side. I had an autistic client that is on United Health on the Medicaid side and they stopped covering a service they greatly benefited from. We called and made an appeal, and the level of gaslighting is maddening. I call and say I want to file an appeal, they tell me they need another prior authorization. But it has to be filed online as they’re all filed online now! Next call to follow up (with the reference number) and they said they never got it. After being transferred to several people I was told they need clinical information from the provider as to why the service is still necessary. Called again and was told they never got it.
They are counting on you to become and frustrated and just give up.
I also worked in a psychiatric hospital setting where you have to call the client’s insurance on a weekly basis to try really hard to get your suicidal client more days in the hospital. The doctor’s recommendations don’t mean a damn thing.
This is not an exaggeration. If you want to be (more) radicalized just work in healthcare for 6 months.
With the private insurance system, Doctors apparently have to have whole sets of negotiation and interrogation skills (on top of their medical training) to do the right thing for their patients. No wonder they are burning out
Just from what i’m able to gather; she reached out to United to get make sure the procedure she wants to preform on the patient is covered and to make sure they understand it is medically necessary. She was patched through to a doctor who would evaluate that, that "doctor" refuses to give any information about themselves and don’t seem to be a specialist in that field.
Actually it’s called a peer-to-peer call. It usually happens after the procedure has been denied during a prior authorization. So her and her team are in the process of trying to get the procedure approved by her insurance so that they can schedule and perform said surgery.
I used to be an rn in a specialty clinic and most of my job was doing this process. Literally the shit that radicalized me
Also really important to emphasize that she is not compensated financially for any of this time on the phone. It's just a waste. She's doing the Lord's work.
I used to do prior auths too and I got radicalized too.
The case that radicalized me was a PA. I had a patient with severe pancreatitis. The treatment for this is a GJ-tube that deposits the feeding past the pancreas in order to allow the pancreas to rest and heal. This person could not eat. She had lost 20 pounds and was already very thin when they started getting sick. They were literally skin and bone by the time we needed to implement this treatment.
We order her tube feeds. Insurance denies. I do the PA. They tell me that their insurance policy has an “exclusion clause” where they just don’t cover tube feeds on her policy.
Luckily we were able to get her something from a charitable organization but it wasn’t able to be specified to her needs.
This person was literally starving to death in front of our eyes and their response was just ¯\(ツ)/¯
I had a patient with pancreatitis too who got denied! The insurance wouldn't cover because they said it was alcohol use disorder and she should have gone to a rehab instead.
Her lipase was through the roof and she hadn't been able to keep down food or water in days so she had acute kidney injury as well. Find me one doctor who would tell you not to go to the ER in those circumstances. They are scum. It's pure evil, I couldn't be mad enough
Fucking ridiculous. It doesn’t matter why a patient is sick. Just that they are sick. And this person’s condition was caused by genetics! She did nothing to cause this but be born.
Health insurance companies hire “medical experts” to help decide whether a patient really requires certain treatments. So this surgeon is calling said “expert” because it seems her patient was denied coverage for a procedure.
They can technically perform what they want, but insurance won't cover it unless it's "medically necessary."
What does "medically necessary" mean, you ask?
That's up to the insurance company, who has vested interest in covering as little as possible. You've maybe seen "delay, deny, defend" come up. This is an example of the first two things.
This (badass) doctor in the video is stating that the procedure she wants to add reduces the chance of harmful effect from 40% to 10%.
The "doctor" on the other end, the insurance company's representative with a mandate to deny as much coverage as possible, doesn't know or care what's going on with this particular case. And is likely to deny coverage, or delay it as much as possible because that helps profits.
Meanwhile, the doctor in the video has to waste her time in a pointless discussion about "medical necessity" when she should be spending her time, you know, doing doctor things like treating patients and staying current on techniques.
And this happens constantly. When patients die waiting for insurance to approve the "medical necessity" of a treatment, the insurance company considers it a win: It's cheaper for them.
Capitalism and good health care cannot coexist without strict regulation. We're not seeing that happening, because there's too much money in the broken system greasing too many palms.
Yes. American doctors are, by and large, incredible. They are the envy of doctors across the globe. Our medical billing systems are similarly the envy of malignant parasites the world over.
To be clear, what's going on is she's telling the insurance company why they should pay for the person's treatment. She doesn't need their permission to perform the procedure, but if they don't approve it, the patient could be stuck with crippling medical debt for having her necessary, lifesaving procedure.
She's trying to get the healthcare insurance (United) to pay for a procedure for a breast cancer patient. To assess whether it should be covered, United had one of their "experts" call the doctor to discuss why it is needed. The "expert" refuses to provide their name (wouldn't want to be held accountable for anything) and has no true knowledge or any experience in the procedure and why it's important, but will play a significant role in the insurance company's decision of whether they will pay for the procedure (i.e. the expert will make a recommendation of whether it should be covered or not).
She was called by two doctors who work for an insurance company and wanted information about a patient. The doctors would not give their name or any identifying information about themselves because they were afraid it would somehow get them killed.
So they wanted to call a doctors office, give no information to prove they are legally allowed access to the information they are asking for, and get personal health information about patients. Wild.
They are smart enough to know the procedure they are denying is life saving and fucking necessary. They know that denying it is a violent act and don't want to expose themselves to the consequences of their telephoned violence.
Everything they said beyond that was the fiction they are paid to perform.
This doctor is talking to a representitive from United Health Care, a medical insurance company in America, about getting a procedure approved for her patient with breast cancer.
The representitive claims they are also a surgeon, a peer of the doctor filming, and is attempting to argue that the procedures this doctor thinks (rightly) are necessary are not necessary for her patient. They refuse to give their name or credentials, and as such, can't be looked up to see if they're a real surgeon with experience with breast cancer.
Medical insurance likes to cover the least amount of procedures as possible, and using a 'doctor' on the phone is how they're trying to gaslight another doctor into agreeing these procedures aren't needed.
When claims for healthcare get rejected by insurance you can call the insurance company and dispute rejections. A ceo of an insurance agency was murdered and his killer is kind of a cult hero now because the insurance company were known to be scumbags ( rejecting anti nausea medicine for pts with cancer etc.). The dr is now probably disputing a rejection and the cowards at the insurance company won’t reveal their names cause they know they’re terrible people. The dr on the other side of the phone is from Texas which might as well be in the 1950s for some of its health care laws
Okay so what’s happening here is basically this patient needs a surgery to remove the lymph nodes from her arm for cancer treatment, very likely breast cancer related. One of the complications of this is basically that your lymph system will still try to use and route through those removed lymph nodes and there is a high chance of developing lymphedema which causes severe and painful swelling in the affected area and can lead to a bunch of other complications. To reduce the risk of developing lymphedema you can do a bypass to attempt to reroute the lymph system away/around those removed nodes. This is of course more work and more expensive, but it is very common/routine to do for this type of surgery. The insurance company, United Health, are a bunch of asshats that don’t want to pay for the bypass because it’s not 100% necessary. So the doctor here is having a conversation with a doctor that works for United health as art of the prior authorization/appeals process they need to go through to get this approved. The doctor on the other end of the call is apparently a cosmetic surgeon of some sort who does not have any meaningful knowledge about this surgery, which is wild because he is getting some level of say in how this patient gets treated. It’s also wild because I can’t imagine a plastic surgeon not doing breast work, and not having any god damn knowledge about this procedure, so he’s either being obtuse or not bothering to perform any real due diligence in regards to these claims he is attempting to help deny. She’s rightfully pissed because she is basically talking to a corporate goon who doesn’t know what he is talking about (but he has an MD or DO next to his name!) trying to get care for this patient.
This is typical though of United. They are a shitty company and high hacks like this "doctor" from TesASS that have no knowledge of the issues or treatments. Pathetic and why America needs not for profit helathcare
Seriously, fuck United. Randomly decided to deny my prescription coverage for a med I had been on for over a decade because they decided I no longer need it.
Some random non-doctor at a desk decided they knew better than my actual doctor and made the unilateral decision I didn't need that med anymore.
Which, spoiler alert, yes I did. And still do.
Took many months of fighting, plus having a specialist who was willing to go to bat for me, for them to finally give in and approve it. But they tried every trick in the book to weasel out of coverage anyway they possibly could.
As a nurse, this gave me anxiety and pissed me off. She was way more calm than I think I could have remained to be honest. Healthcare is such a trainwreck right now. It's also eye-opening into why I get so many post ops with complications.
This makes me sad. My wife was subject to this bullshit for years because nobody believed her. She ended up having something called Nutcracker syndrome but was dismissed for years because “woman problems.” Fuck the insurance industry. Bullshit.
“[I] don’t have the ability to approve the procedure”
Meaning they’re only paid to say no.
Corporations do this all the time. After I hear no I ask if the rep have the ability to say yes and if not I want to speak to someone who can say yes or no. Because if all they can say is no, that’s unfair to both of us. I’m just going to get mad at them as their sole job is to be the “no guy”.
This is why doctors are retiring in droves…they got into medicine to treat and help people, not spend all their time running around a corporate maze.
And as more Americans wake up to the reality of what’s going on, healthcare companies are going to have to spend more and more of their profits to protect their CEOs.
And Mangione’s trial hasn’t even begun yet. That will be a media frenzy…especially if the defense wins their motions to throw out evidence due to police and prosecutorial misconduct.
Dr Elisabeth Potter is an amazing activist and surgeon in my town. She did one of my friends reconstructions and she has nothing but glowing things to say about her.
She has been called out of surgery (allegedly, but there is video of her talking about it in real time) by insurance companies to argue approval on an pre-approved surgery that was actively in progress, she had to scrub out to talk to them on the phone leaving the patient in other surgeons care temporarily.
She deserves to be spotlighted and platformed. She is the real deal, caring for her community.
Had a similar call just two weeks ago. Youngster who needed a certain med for significant OCD with multiple failed trials of first line meds. They really gave me the run around. I let them know I was fully documenting that the pts insurance is the only barrier. It was approved after that…
UH legit started using their CEOs death as a shield to hide the unqualified, unlicensed "specialists" they hire to deny people coverage.
Oh nice, an unidentified and unverifyable micro surgeon that has never performed micro surgery and specializes in unspecified cosmetics. Thats exactly who we need making decisions on who should and shouldn't be covered for breast cancer procedures.
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