There are numerous stories of physicians getting embroiled in issues of ethical nature or not a crime but seriously putting their career at stake by a medical insurance auditor. Consequently forcing many of them to deal with matters that they were not liable and damaging their practice. The undeniably meddling and regularly illogical managerial, administrative review and paperwork troubles are being set on patients and doctors by the payors and insurance companies. These pestering issues result in situations where physicians feel less open to patients and being skeptical of insurance providers’ intentions. Patients are denied insurance benefits for necessary treatments, and as doctors discover their jobs changing from patient supporter to overseer for the insurance agencies. Here is one such story when a physicians’ career was put on stake by a medical insurance auditor. It’s an obvious fact that currently, insurance agencies are adjusting with a fast-changing healthcare sector. Insurance companies are the final examiners who scrutinize whether a treatment or procedure was valid for a patient. In such a case, a physician got entangled by an insurance agency auditor.
According to the physician’s narrative, it all started about two years ago, when his father who also was a doctor with whom he was practicing at that time, he started the day in the routine on a busy weekend. As it was the beginning of flu season and there were a huge number of patients waiting for the flu shot. Nervousness about this season’s flu virus was running high everywhere, after the demise of a local young lady from an especially destructive strain of the infection. The parents were anxious to get their children vaccinated as early as possible. As per Washington law, grown-ups don’t have to see their specialists get influenza shots. They can get vaccinated even by a pharmacist. But since kids under nine are progressively defenseless to uncommon yet hazardous allergic reactions, they should be vaccinated by a physician.
That specific Saturday went off easily, with the two physicians seeing and vaccinating around 60 patients in a 12-hour long shift. A quarter of a year later, a delegate from the insurance agency inquired to see a couple of the patient charts from that influenza center as an audit requirement and to inspect insurance fraudulent activities by double-checking clinical records. Insurance companies hire these auditors to uncover the best conceivable number of anomalies and in this manner helping them to ensure their interests. Auditors take away their commission, probably being paid a slice of the monies they recover.
The medical insurance auditor responsible for this case was unable to turn up any inconsistencies in their documentation. Still, the auditor issued a stern caution to physicians, directing them not to open the practice on a workday for routine flu shots. This was the first shock they received and it was that this restriction was unfair, considering their facility is a private unit where they set their own hours and timetable as suited. Be that as it may, rather than withdrawing, the female auditor also restricting the practice from analyzing the patients before immunizing them. Both the physicians were stunned by this unusual behavior. Vaccination of newborn children and little kids is a serious responsibility, requiring appropriate alert and care, so the physicians denied the undue restrictions imposed by the auditor. Following this concise conversation, the auditor threatened to report it as a violation of the Medical Quality Assurance Board.
The allegation against the physicians was of not following an insurance company compliance directions and which she thought is unprofessional. It didn’t make a difference that the charges against him were absurd. The potential results were quite genuine and conceivably disastrous. Had the State Medical Board ruled against him, he could have lost his medical license. He hired a legal counselor, drowning more than $8,000 into legal charges. He was cleared after all by a unanimous advisory group vote.
However, different doctors confronting similar circumstances may not be as fortunate. The year and a half of agonizing pressure that pursued the dispute with the auditor made it obviously certain that insurance agencies exercise and display way too much power. Insurance agencies will keep on hurting and hunting medical specialists and patients alike if nobody realized the seriousness of the matter.