I took a picture of this advertisement taped to the wall of the OR when I started practice.
During college, medical school and residency/fellowship, prospective doctors spent countless hours committed to helping heal and promote health for future patients.
After completion of a lifetime of study, they begin clinical practice only to also begin a new curriculum — learning how to heal and promote health in a world with overhead, office staff, insurance companies, hospital systems, medical device and pharmaceutical companies, government regulation, etc.
I want to share some experiences and lessons I have had so far.
So here goes:
Charles is a 71 year old with sacroiliitis, a common cause of lower back pain. Patients with persistent sacroiliac pain, despite 6 months or more of non-surgical treatment, have proven benefit from sacroiliac joint fusion.
Charles met all the criteria. He tried physical therapy, injections, and medication. His pain persisted. His quality of life was significantly affected. I recommended surgery and we submitted his claim to his insurance for pre-authorization.
2 weeks later, a member of the office staff approached me saying Charles’ surgery had been denied by his healthcare insurance. Why? I asked.
Charles was 71. Sacroiliac joint fusions had been proven to be affective in clinic studies that excluded patients younger than 18 or over the age of 70. Six months ago he would have been eligible, but not anymore.
Despite letters and discussions with the insurance company, they refused to cover Charles’ surgery. Even my clinical experience with several other patients in their 70s didn’t matter. He was out of luck.
The lesson here is insurance companies ultimately don’t want to pay. If they can find an excuse not to, they will.
Disclaimer: Although this is a real patient, I have used a different name for privacy protection and added a few details for educational purposes