Once again, at 1 a.m., I was knee-deep in patient charts and the cacophony of messages that our “user-friendly” EHR employs to allow various staff members to reach us. One of these was about a simple, inexpensive radiologic test I had ordered which the insurance company denied for my patient. Not surprisingly, I was exhausted, and I lost it.

With some minor edits, I wrote the following in response to this affront and demanded that it be immediately sent to the insurance company. Thankfully my nurse is acutely aware of my rising frustration, and her cooler head prevailed. She realized the trouble this would cause and never actually sent it. Thank goodness.

***

It’s been brought to my attention that your massive corporation — whose sole purpose for even existing should be to ensure that those suffering from major and minor medical conditions can affordably obtain the evaluation and treatment they so desperately need — has deemed it necessary to “reject” the above test which I recommended for my patient. Not only are you adding undue emotional and financial burden on my lovely patient with terminal stage IV breast cancer, but you are knowingly adding to an already exhausting and monumental bureaucratic burden on the very team who knows her best and is charged with making the appropriate medical decisions that can alter the course of her life.

I’m going to assume you have little to no awareness of the diversion of resources/personnel necessary to answer all of the silly little queries to which you should already know the answer since you reportedly employ such a vast array of talent. Because daring to assume the alternative would imply a well-orchestrated strategy on your part to ensure that the medical offices with which you contract suffer from the administrative fatigue wholly necessary for your multibillion-dollar organization to reap even more profits. I imagine you to be not unlike the famed Gollum clinging to the ring and while appearing absurd to those around him, not once realizing how much the love of that ring has ruined him. In that vein, you likely believe most of us will just throw up our hands and relent, thereby saving you a few more precious dollars.

Well, to that I say: Dear Sir/ Madam, I “reject” your rejection!

This exact test is germane for this particular woman with this constellation of symptoms, and you may be shocked to learn this determination is made by none other than yours truly. Let me explain. After college I voluntarily spent the next 10 years in medical training, acquiring 4 board certifications, amassing hundreds of thousands of dollars of debt, passing dozens of national exams, sitting for thousands of hours of study, and spending years sacrificing time for family/friends/sleep/leisure. This was followed by another 15 years of experience practicing oncology and treating over 5000 patients with breast cancer, so please be assured there are few more suited than me to make this decision for my patient.

Oh, and please spare me the audacity to suggest that the laughably ill-informed “physician medical subject experts” you’ve employed to lend a theatre-like air of credibility to your ever more brazen denials are somehow as well equipped as me to counter my decisions. They are filled to the brim with your homemade poisonous kool-aid, which they have assuredly drunk to excess. It is only every leap year or so that I have the distinct pleasure of speaking to one who may have been awake during medical school. For those rarified competent few, I’ve always suspected if I played our recorded conversations backward, I would hear him/her imploring me to rescue them from their own Dante’s 4th circle.

The burden to connect the dots between the diagnosis stated in my note and those precious numbers and letters you call an ICD code should be yours and yours alone to bear. If there was even a shred of concern for the very people who pay these exorbitant premiums to keep you in business, you would employ just a few semi-literate cubicle dwellers to wade through the muck and mire of the 68,000 tragicomic ICD 10 diagnosis codes to find just the right fit.

Neither we as physicians nor our overworked staff should be combing through this nonsense, and we certainly shouldn’t be spending one additional second on the phone performing what you generously call a “peer-to-peer.” Let me be clear, your henchmen/women are not my peer because if they were, we wouldn’t be in this mess to begin with, and my patient would be receiving the testing they need.

If anyone reading this particular claim has even one iota of medical knowledge, it would take a mere fraction of the time it takes to navigate your preposterous phone menus to realize that swelling of an extremity in a patient with cancer is all you need know to instantaneously provide my diligent administrative staff with the canonical blessing of an “approval #” without which she can’t obtain a doppler ultrasound to rule out a potentially life-threatening thrombus. And surely the hematologic virtuosos in your indoctrinated medical army are keenly aware that underlying metastatic cancer markedly increases the risk of said thrombus, particularly when dealing with an older woman.

In summary, the diagnosis code already provided to you, coupled with my meticulous documentation, is more than sufficient to pay for the said study. Please ask no more of us, as we the treatment team are weary and people are dying.

The author is an anonymous physician.

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