Why Are Insurance Companies Telling Doctors How to Practice Medicine?

Woman sits over insurance documents

Doctors draw on years of experience when making decisions for their patients. However, physicians often have to go through insurance companies before they can actually provide their patients with medicine and services.

If there are “cost-effective” alternatives, an insurer may require doctors to use that method — or withhold treatment altogether. All too often doctors and their staff have to fight with insurance companies in order to secure the care they believe their patients deserve.

Similarly, insurance companies often deny disability claims, dismissing the severity or legitimacy of the illness. This contributes to many patients and workers feeling overwhelmed by rising health care costs.

If you were denied disability benefits, Sokolove Law may be able to fight for the money you need. Get started with a free case review today.

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How Do Insurance Companies Control Doctors?

Known as “utilization management” or “utilization review,” insurance companies have set up systems that allow them to evaluate and overrule doctors.

According to the insurance industry, utilization-management tools manage healthcare costs by assessing the appropriateness of patient-care decisions against so-called “evidence-based guidelines.”

In theory, these reviews were meant to keep doctors from overprescribing expensive medications or treatments. However, in practice, these reviews only help insurance companies limit how much they’ll pay out for their patients.

Broadly speaking, the 4 most common utilization-management strategies are:

  • Prior Authorization (PA): Some medications and treatments require doctors to obtain authorization. Without PA, insurance plans will not pay, regardless of what the doctor says.
  • Step Therapy: Also known as “fail first,” step therapy involves trying the least expensive options before “stepping up” to costlier drugs or treatments, leaving the patient’s care to potentially worsen in the meantime.
  • Quantity Limits: These limits restrict the amount of a particular medication a patient may receive during a specific time frame.
  • Nonmedical Switching: If an insurance company stops covering certain medications, it will force patients to receive an alternative or pay for their original medication out of pocket.

As insurers broaden their use of these techniques, many patients have started to wonder if some companies have crossed over from promoting cost-effective healthcare decisions into bad faith insurance.

Did You Know?

The insurance company Cigna began using an algorithm to assess claims, which denied over 300,000 health insurance claims after only spending an average of 1 second investigating each claim.

Do you believe your insurance provider is denying your disability claims in bad faith? Call (800) 995-1212 now to see if you may have options to challenge their denial.

Putting Profits Ahead of Patient Safety

Prior authorization requirements for medications and treatments were once reserved for a small fraction of new and expensive procedures.

Increasingly, though, doctors and their staff are spending more time getting routine drugs, tests, and services approved by insurance companies.

One Michigan-based surgeon told ABC Detroit that prior authorizations are a needless hurdle that hurts patients.

“It's a very inefficient use of our time,” said Dr. Bobby Mukkamala, specialist surgeon and head of Michigan State Medical Society. “[It’s] really just a way to delay care in the hopes that some people will give up and just not do it.”

Everyone can understand the need for efficient and scientifically-based care decisions, but sometimes the incentives seem to be more about lower costs for insurers than anything else.

Insurance Technicalities Put Lives at Risk

When insurers delay a doctor’s decision about care or treatment, it can have an immediate and negative impact on a patient’s health. In fact, stories of patients suffering due to denied care can be heard from across the nation.

In one case, Edgar Allen Beem from Oregon was hospitalized for pancreatitis. Edgar’s insurer Aetna told his doctors to discharge him from the hospital — despite his losing 50 pounds and not showing signs of improvement.

“When I objected to being discharged against my will, they informed me that I would have to pay out-of-pocket,” Edgar said.

Edgar went home and suffered a massive internal hemorrhage the next day, which resulted in a 6-day stay in the intensive care unit. When Edgar was denied care, he nearly lost his life, and the insurance companies who tried to protect their profits were forced to pay even more.

In another case, Christopher McNaughton, a UnitedHealthcare patient from Pennsylvania, also suffered from the greed of his insurance company. He had a crippling case of ulcerative colitis, but with a special treatment designed by the Mayo Clinic, Christopher was able to ease his symptoms of arthritis, diarrhea, fatigue, and blood clots.

However, his medical bills were nearly $2 Million a year, which led UnitedHealthcare to begin denying McNaughton’s coverage. His family decided to fight back, and they uncovered the company’s long history of denying claims against doctor recommendations.

Patients Deserve Care, Not Bad Faith Insurance

When someone gets sick or hurt, they rely not only on their health care providers but also on their insurance provider to help them get better. Sadly, insurers often deny legitimate long-term disability claims from patients facing debilitating illnesses that disrupt their daily lives.

If patients with legitimate claims are denied by their insurance company, it could be considered bad faith.

Bad faith happens when someone fails to live up to the terms of a contract. An insurance policy is considered a contract between the provider and the patient. When insurance providers wrongfully deny coverage, they’re considered to be acting in bad faith.

Mental health conditions and COVID-related complications, for instance, may face unfair denials due, in part, to the high cost of care and general difficulty proving the severity of their conditions.

Medical conditions eligible for long-term disability that are unfortunately commonly denied include:

  • Anxiety
  • Arthritis
  • Bipolar disorder
  • Cancer
  • Crohn’s disease
  • Depression
  • Diabetes
  • Epilepsy
  • Fibromyalgia
  • Heart disease
  • HIV/AIDS
  • Lupus
  • Multiple sclerosis (MS)
  • Post-traumatic stress disorder (PTSD)

This puts far too much pressure and financial stress on those already suffering — but a legal advocate can make the difference between suffering and getting the care you need.

If your long-term disability insurance claim was denied in bad faith, it is not the end of the line. An experienced long-term disability denial lawyer can help you appeal the insurer’s decision and stand up for your rights in court if needed.

Call us at (800) 995-1212 now to see if we may be able to help you appeal your insurance company’s decision.

Insurance Providers Known for Bad Faith Practices

Some insurance companies that have a history of denying long-term disability claims and engaging in bad faith tactics include:

The profit earned by health insurance companies continues to grow. In fact, UnitedHealthcare had a record $17.7 Billion in earnings in 2021. How much of that was earned through bad faith tactics that left everyday people footing the bill?

What Is a Bad Faith Insurance Lawyer?

Bad faith insurance lawyers fight for those wronged by insurance denials. They have the experience and resources necessary to stand up to billion-dollar insurance companies.

At Sokolove Law, our bad faith lawyers have over 40 years of experience advocating for those put at risk by companies protecting their profits.

We’ve recovered over $127 Million for clients unfairly denied disability across the country.

If you need legal help after a wrongful disability denial, contact us today for a free, no-obligation case review.

Author:
Sokolove Law Team

Contributing Authors

The Sokolove Law Content Team is made up of writers, editors, and journalists. We work with case managers and attorneys to keep site information up to date and accurate. Our site has a wealth of resources available for victims of wrongdoing and their families.

Last modified: August 17, 2023

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