Tightening the leash: Managed care hassle factors getting bigger

Although the restrictive rules aren't as pervasive as they used to be, physicians are seeing new constraints in their plans' contracts.

By Robert Kazel, amednews staff. Oct. 18, 2004.

If doctors seeking coverage for patients think they're detecting a resurgence of the managed care "hassle factor," their instincts may be right.

Insurance executives argue that any bureaucratic bridles placed on physicians are tolerable -- and comfortably loose compared with those of a decade ago. They point to the trend toward elimination of such barriers as gatekeeping requirements for access to specialists. But don't ask Randy Wexler, MD, MPH, for confirmation.

For one thing, he doesn't have much time to chat: That's Dr. Wexler on the telephone, waiting to talk to a managed care doctor to dispute a denial of a patient's request for precertification. The Columbus, Ohio, family physician has been on hold for 10 minutes.

"It is probably one of the most frustrating things I deal with in my life," Dr. Wexler says. "I'm sitting here with my patient in my office, trying to determine with him what the best treatment is. Then I have to go outside the room, and leave the patient, and talk to a faceless entity somewhere else in the United States who is trying to review what is best for my patient. And what's frustrating is I don't necessarily believe, in a lot of instances, it really saves any money."

For Dr. Wexler, new opportunities to navigate the managed care maze present themselves daily. Requests to do MRIs of patients' joints get rejected as a matter of course, with the insurer telling the patient to consult an orthopedist instead. One insurer routinely declines to cover an antidepressant because it suspects the drug is being used to treat nicotine addiction and requires the doctor to fax over paperwork assuring that it isn't. A payer insists that patients with allergies buy over-the-counter medication unless the staff documents why a prescription is required. Another refuses to pay for osteoarthritis drugs unless the office fills out a 10-item questionnaire -- every time, even for refills.

[...]

Full text of American Medical News content is available to AMA members and paid subscribers.

Access details

Join the AMA