3 ways doctors can take on insurers

Physicians don't have to remain silent if they feel a health plan is wrong.

By — Posted May 21, 2012

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Trying to persuade a health insurer to change a policy, fix a problem or reverse a bad decision can be frustrating for physicians. But it can be done — with persistence, and by gathering strength in numbers.

It’s challenging for doctors to find the time to fight with insurers, said Gene Ransom, president and CEO of MedChi, the Maryland State Medical Society. He said physicians are more likely to take the time to ensure that a patient’s treatment is covered than to make sure they as physicians are being treated and paid fairly.

Whatever the goal, Ransom and others say the best way to get insurers to listen and make changes is to become bigger than one physician: Gather a group of doctors who want the same thing; forge an alliance with government authorities who have the power to force insurers to change; or get the issue wider attention using media — both the old and new varieties. The strategies don’t always guarantee success, but often will get insurers’ attention, which is the first and often toughest step toward getting a satisfactory solution.

Organized medicine is often the first place to find allies who share the same values and challenges. The American Medical Association, along with specialty societies and most county and state medical societies, have resources devoted to getting insurers’ attention and finding lasting solutions to persistent problems.

Mary Jean Sage, a health care consultant based in Pismo Beach, Calif., said that whether a physician is best served by a county, state, specialty or national medical society depends on the problem. A local problem may be best approached locally, while a problem that appears to be specific to a single specialty may be best approached by the specialty’s association. The objective is the same no matter which part of organized medicine is the first stop — finding other doctors with the same frustration.

“If it’s a policy you’re trying to get changed, the more colleagues you can find who are having the same problem, the better” the chances of showing insurers the problem isn’t just you, Sage said.

Peter Rappo, MD, a pediatrician from Brockton, Mass., said he understands that some physicians may be reluctant to call on someone else to help with a fight. “We [physicians] have always been rugged individualists, but you need to be part of something bigger, and something bigger translates into organized medicine,” he said. “I think insurers are going to be more attentive to larger groups.”

Dr. Rappo said he and other pediatricians with the Massachusetts chapter of the American Academy of Pediatrics have succeeded with an idea he said originated with Texas physicians. It’s a pediatric council that advises the state’s insurers. In Massachusetts, Dr. Rappo said physicians frustrated with hassles were considering creating a report card for the state’s health plans, detailing the degree of problems they caused for doctors. Insurers countered with something akin to what Dr. Rappo called, “Why can’t we all get along?” Dr. Rappo said both sides settled on the idea of the council instead.

“We can’t talk about fees, but we can talk about what’s best for kids,” he said. “We’re able to bring a certain educational perspective to the plan in terms of what we feel is appropriate.”

Dr. Rappo said working through organized medicine is successful, because usually insurers have established relationships with medical societies. So it’s a quick route to getting a seat across the table from insurers’ medical directors.

Yarnell Beatty, director of the Division of Legal and Government Affairs at the Tennessee Medical Assn., said many large medical societies, including the TMA, have a staff member whose job is solely to help resolve problems physicians have with health plans, while smaller societies’ legal departments handle those problems. He said in most cases, the physician should be able to ask for the person who deals with health plan or private payer complaints.

Beatty advised physicians to gather any correspondence from a health plan over the issue and to have available claims and any explanation of benefits or explanation of payment forms. It helps to be able to give a timeline of events, Beatty said.

It’s crucial for practices to act quickly when a medical society asks them for that documentation, he said. “Often we’ll be on a roll with a payer, they’re beginning to see the light, and we’ll ask for a document and the practice takes a while getting back to us, and it slows down the process.”

Beatty said the TMA and other medical societies look for patterns in complaints, but it doesn’t take more than a handful of calls to give them a sense of a large-scale problem.

“We have what we call the ‘roach rule’ — if you see a couple, there’s probably a couple hundred behind the wall. If we get five or six calls from different areas of the state, we can say, ‘We’ve got a problem.’ We assume that dozens or hundreds of physicians are having the same problem.”

For physicians unsure of where to start, the AMA has a long list of resources available, including an online Health Plan Complaint Form.

“The AMA stands ready to help physicians resolve concerns with third-party interference, delayed and denied payments, inappropriate downcoding and bundling, unfair contract practices and any other hassles faced by physicians,” AMA President Peter W. Carmel, MD, said in a statement.

2. Getting government assistance

Another AMA website can identify legal protections available in their respective states, as well as government officials who may be able to offer assistance.

When insurers appear to be going beyond just creating hassle, state officials are the best choice for physicians trying to fight health plans, Ransom said.

He stood alongside Maryland’s attorney general at MedChi’s house of delegates meeting April 30 and unveiled a dedicated website where physicians can report illegal or unfair practices by health insurers. The “Insurance Watch” portal will allow physicians to submit complaints to the Health, Education and Advocacy Unit of the attorney general’s office as well as the Maryland Insurance Administration.

Though most states don’t have such a portal, all have offices within their insurance departments that will deal with complaints about health plans.

Richard Lander, MD, a pediatrician from Livingston, N.J., is active with the American Academy of Pediatrics, particularly in helping his colleagues with the business of medicine and dealing with private payers. He goes said physicians should go to state insurance regulators at the same time they complain to organized medicine. “My advice to anyone would be to not be afraid to, from the very beginning, involve the local department of banking and insurance, because as a rule they are the only entity managed care will listen to and be polite to, since they regulate them.”

When dealing with government officials, particularly elected ones, Dr. Rappo said, it helps to share stories of real people and focus on how patients will be affected. “There’s a saying, ‘The plural of anecdote is policy.’ ”

Physicians should keep in mind, however, that change made through government policy can be slow.

“Most legislative changes have a longer gestation than an elephant,” Dr. Rappo said. “But sometimes it works the other way — [legislators] do seem to respond when they feel insurers are being unfair. Consumers are also voters.”

Sage said it often makes sense to start with organized medicine before going straight to regulators. Typically a medical society already has contacts at a regulator’s or legislator’s office.

3. Using media

Sometimes the best “person” to go to is everyone — at least everyone reading a newspaper, watching television or using the Internet.

As with legislators, traditional media outlets like local TV news and newspapers are often most interested in how insurers’ actions affect patients, experts said. Judging from what ends up on television, Sage said, the media tend to be most interested in health coverage from a consumer’s perspective, not necessarily a physician’s. “They’ll latch on when it becomes a consumer issue.”

John Tedeschi, MD, went online with his complaints after he received a letter from Aetna saying he would be eliminated from its network in 90 days.

Dr. Tedeschi, a family physician in Robbinsville, N.J., produced a video he described as “a discussion of how insurance companies have ‘taken over’ the direction of health care and, in many cases, dictate to doctors how the practice of medicine should be done.” One of his patients, a broadcast producer, volunteered his services to record the video, which lasts a little over 6½ minutes and is available on YouTube.

As of mid-May, the video had logged 3,850 views and 33 comments, many of them supportive from his patients.

Aetna spokeswoman Susan Millerick said that because the company is not obligated under its contract with Dr. Tedeschi to give a reason for its decision, it has opted not to disclose one. “We have taken steps in several markets to reduce the size of our network, to make it more cost-effective for our customers,” she said.

In response to Dr. Tedeschi’s video, Millerick said his approach was “clearly his decision and right — but I do not believe it has or will change our decision in this matter.”

Dr. Tedeschi said he wasn’t as much interested in whether he remains in the Aetna network as much as raising awareness of the problems he sees with insurers’ practices. The video did get some wider attention, including an article the Hartford Courant, the newspaper in the Connecticut city where Aetna has its headquarters.

“I look at life this way — my duty is to act in good conscience. I don’t expect anything,” Dr. Tedeschi said.

Physicians and their advocates say that regardless of how they raise the alarm about insurance company behavior, doing it is preferable to remaining silent.

Dr. Lander said it’s key for physicians to stand together.

“We all have to not be afraid of managed care, to answer them back and not to take the nonsense they throw our way,” he said. “If you’re doing it alone, you’re never going to succeed. If more physicians would not be afraid to stand up to them, they would be forced to change their tune.”

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Physicians’ voices heard: success stories

Sometimes it has taken a judge’s order to seal the deal, but physician complaints have led to health insurance industry reform.

Major insurers agree to change business practices

Physician complaints about chronically late payments, routine claims denials and improper downcoding led to a group of class-action lawsuits filed between 2000 and 2004 against nearly every major health plan in the country, from Aetna to WellPoint, under federal anti-racketeering laws. Most of the lawsuits were settled between 2003 and 2008, with insurers agreeing to make systemic changes to the way they do business. Settlements included pledges to make fee schedules available, work toward automated claims adjudication, create company physician advisory councils, pay promptly and allow for a fair appeals process. The original settlements have expired, but many of the insurers pledged to continue to abide by the agreements.

Out-of-network rate-setting comes out of the “black box”

Physicians were frustrated by the lack of transparency and consistency in insurers’ payment rates for care provided outside an insurer’s network. Those complaints led state societies and the American Medical Association to sue insurers in 2000. The New York state attorney general’s office took up the cause in 2009, resulting in large-scale changes to the way physicians are paid for out-of-network care. The New York attorney general settled with multiple insurers, and many of the same insurers settled the class-action lawsuits filed by the state medical societies and AMA. Physicians covered under the $350 million settlement received checks for their share in the spring of this year.

Sources: American Medical News archives; Physician Advocacy Institute’s HMO (link)

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External links

American Medical Association health plan complaint form (No login required) (link)

American Medical Association National Managed Care Contract (Member login required) (link)

MedChi, The Maryland State Medical Society’s Insurance Watch (link)

National Assn. of Insurance Commissioners: maps of states and jurisdictions (link)

National Assn. of Attorneys General: list and links to offices of state attorneys general (link)

“A Conversation with Dr. John Tedeschi,” YouTube video, March 21 (link)

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