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Behavior Modification for Doctors: How Insurance Companies Do It

Posted 05/06/2012

You don’t see those billboards anymore, the ones advertising health insurance companies (HICs) with some form of this message: We don’t tell your physician how to practice medicine—we let your doctor take care of you.

I guess it was too cynical even for the HICs, an industry in much disfavor these days. Even they had to draw some sort of line about truth in advertising. Tell us how to practice? We doctors are micromanaged by them.

As you must know, every possible aspect of your health care has been entered into the information system of your own HIC and then shared with other HICs. With this data, HICs can track doctors’ billing patterns, lab tests ordered, prescriptions written, referrals made, and surgical procedures performed. And because every day there are virtually millions of physician-patient encounters, you may be curious to know how a HIC uses behavior modification to keep doctors in line with “acceptable standards.”

Those quotation marks are deliberate.

Unsurprisingly, so-called acceptable standards are geared to maximizing HIC profits, having absolutely nothing to do with physician performance or with you getting the best health care. Acceptable standards generally means short and efficient visits, few lab tests, cheapest generic drugs, and as few patients as possible admitted to the hospital. Your HIC also tracks those dreaded pre-existing conditions, and by blocking your access to future health insurance also maximizes its bottom line. But you knew that already.

Physician “outliers”
The key tactic HICs use for behavior modification of physician outliers (a HIC industry term describing doctors who don’t play by their rules) is to place hurdles in front of physicians that waste time on irrelevancies. Time is, for all of us, a precious commodity. HICs know this all too well and lay it out like this: Doc—if you don’t want to waste your time on the phone getting prior authorizations for brand-name drugs, writing letters to justify a lab test, or having to copy and fax your medical records for our review, just play it our way. We could make it simple and send Rocky over to break your kneecaps, but really that’s not necessary. Just follow our rules, we’ll leave your kneecaps alone, and you can spend more time with the wife and kids.

Having related this, let me tell you how I’ve been spending my mornings.

Each day I arrive in the office about 30 minutes early to write a letter to a HIC in response to a letter I received from them the day before. Most letters begin “We welcome the opportunity to be of service to you,” a phrase frightening enough to tighten anyone’s stomach. It seems the HIC wants “additional information,” a “narrative report,” “patient progress notes,” and so forth.

They want my reasons for ordering a specific test that, in this series of letter requests, measures food allergies. Testing patients for sensitivities to foods they’re eating is “out of the box” thinking to them, making me a dreaded outlier and their computers smoke.

Why would I–or any competent physician–want to know what foods his patients are allergic to?

If you’ve been following the health tips and remember the two-part article Toxic Food Syndrome, you could probably write this letter yourself. Perhaps in my own letter I’ll  relate the story of:

  • A patient who suffered through four utterly useless sinus surgeries over a period of ten years until she was found to be sensitive to dairy.
  • A man diagnosed with Crohn’s Disease, which not only terrorized his immune system but for which he took a $5,000-monthly immune-modulating drug until he eliminated gluten from his diet and his Crohn’s mysteriously disappeared.
  • The young woman with rheumatoid arthritis, or one with fibromyalgia, or with chronic fatigue, each of whom improved by eliminating “culprit” foods.

I suppose I could mention also how “outlier” thinking actually pays off for everyone, including the HIC. Certainly I make no claim that eliminating toxic foods is a cure-all, but really, I say to the HIC, “You’ve already forked over more than $200,000 in useless sinus surgeries. Why are you arguing with me about a test that costs less than $500?”

Well, I don’t put it quite that way. After all, the HICs do keep us doctors financially afloat.

Waste my time, delay honest payment
Understand that this letter-writing business is not simply a behavior-modifying time waster, but also a delaying tactic for the payment the HIC owes me and my staff. Not only are hours slipping away writing these interminable letters, but the dollar amount our practice is fairly owed for these tests keeps increasing.

I’m sure they hope I’ll eventually get the picture (oh, have I gotten the picture!), cry uncle, and stop ordering food allergy testing. Not a chance. They’ll have to send Rocky to get me to do that.

One other interesting point: I don’t think anyone at the HIC is actually reading the letters I write. After we’d sent off a stack of them, we called the phone number indicated on their inquiry letter. No one at this extension knew about the letters. Someone quite pleasant promised she’d call back, but no one ever has.

So I’ve lately taken to tucking little parenthetical messages in the middle of a paragraph. At first it was “Is anybody reading this?” and later, “If you’re reading this, call this phone number and receive a free Target Gift Certificate.”

So far, no one has claimed it.

So tomorrow morning, I’ll place my latte next to my laptop and compose yet another letter. The process takes about 20 minutes. Twenty irretrievable minutes, gone forever. Makes me want to call them, ask for Rocky, and just get it over with quickly.

Be well,

David Edelberg, MD 

Leave a Comment


  1. Leah says:

    Things will get much worse if Obama Care goes through, Can you image the government controlling everything??

  2. Don Schoenbeck says:

    Health insurance companies have about as much to do with providing good medical care as political parties have to do with good governing and patriotism.

  3. Tim Wilkin says:

    Yikes – maybe we can send Rocky to the HIC for you! Keep up the good fight, there’s a reason you’re my doctor: I trust you and know that you’ll explore for the best remedy (prescription or not, preferably not). Thank you for your diligent and excruciatingly mind-numbing hard work on our behalf.

  4. Don Schoenbeck says:

    As a patient, Medicare is the BEST funding system that’s ever covered my medical needs. Unlike the parasitical inefficient insurance industry system, I haven’t been excluded, gouged or had my doctor/patient relationship interrupted by some faceless meddling bureaucrat. The major problem with the Affordable Care Act is that it falls far short of Medicare for all!

  5. Addie says:

    And everyone thought “Big Brother” referred to the government!

  6. Whitney says:

    As a consumer, yeah, I guess health insurance makes sense. But as a health care practitioner, it really doesn’t. As a physical therapist, if I write the word “prevent” anywhere in my note, (as in “to prevent falls” or “to prevent further degeneration”), then that day’s visit is not covered by insurance, because insurance companies don’t want to cover any “prevention” services. So they would rather pay for a total hip operation (>$40,000) than 10 PT visits for balance training (<$1,000). Can anyone explain this?

  7. S says:

    All I’m saying is Obama Care will be no better and eventually will be much worse. Once the governmnet gets it’s hands on anything it gets worse. My brother has cancer and is on public assistance and it is horrible. The wait for scans ect sre so long that his cancer advances while he waits for therapy. Look at Europe.

  8. Mery Krause says:

    Makes me glad I’m not a Dr., Dr……haha You said it plainly and humorously ,even though the whole mess is not funny at all. But laughter keeps us sane, right? Hope Rocky needs your services someday and repents on his knees.

  9. I’m having the same kind of problem w/Hancock re my long-term care insurance.Phoned so-called
    “customer service” about 5 times, finally wrote an honest-to-gawd letter on April 20; 18 days later no answer. Think I may Google to get CEO’s name!

  10. Ann Raven says:

    Brave Dr. Edelberg, fighting for Truth, Justice and the American Way!

  11. Beth says:

    Leah, see what Don Schoenbeck says, 3 notes down from you.

  12. Beth says:

    S, if we had the Obama Care that Obama wanted, your brother would be in a better position. I’ve spent time in two European countries and the difference in access if you have a chronic condition requiring a specialist is much better there, and the drug prices are MUCH cheaper.

  13. Barb says:

    Thank God there are Doctors like you that get it. It is bad enough we have to fight with the insurance companies all the time, but to waste your time as well is ridiculous. When will they ever get it that doctors like you are saving them money not costing them more. It is so frustrating on every level the state of health care in America.

  14. Dr. H says:

    I recently had a “utilization review” with a “doctor” at one of these organizations where he wished to just review some of my practices (Just a “friendly” discussion-wink wink). He stated “Well, you are at the 75% of the group for this procedure”. To which I replied, “If it is a distribution, then doesn’t somebody have to be at the 75%?” Their goal is of course to just keep pushing down that average. So maybe I do that procedure just a little less, then somebody else gets that call next time and they then do it less and eventually everyone wonders why their care is so bad…

  15. William Geldernick says:

    Hey all at WholeHealth!
    I resemble this blog! Lol. This I think is my wife’s story; and yeah the HIC in question is UMR, which actually is only a flexible spending account manager. MY MONEY, taken out of my check bi-weekly, and they are telling me how to spend it. I also called to see if they received your forwarded form via email, and they said they received nothing and would call me back later. I wonder which regulatory agency I could call to enforce the rule of law- Pft!!! I will follow up tomarrow and give them another fair chance as some ordinary people who work for these machines deserve that but I also am prepared to raise a conscientious stink with the Better Business Bureau. Keep up all the great work guys. It’s nice to know that some people out there still take the hippocratic oath seriously: “…try to prevent as well as cure disease…”

  16. cheryl says:

    why dont you save a template that you can just add the paitents name to, then it should only take a minute or so.

  17. sherrykay50 says:

    This is an excellent article. I have noticed another addition to the insurance game. They now hire ‘middle’ managers to do this dirty work for them. For example, if I want physical therapy, there is now another layer between the physician’s prescription and the PT-and this middle management company denies or allows the PT (this is not the HIC)-they require the PT to write these ‘narratives’ justifying why I need any more visits after 3 weeks, , despite my dr. writing “12 weeks.” I noticed this because the PT visits were shortened by 10.” And anyone who has gone to PT can see the rush of people in and out. If they have to do this for everyone, then they probably now need that time or 1/2 day for the paperwork.

    Another area I just found out about (and not because the insurance company cared to notify us) was durable medical equipment. I have used a CPAP machine for six years (and I use it diligently). I am supposed to get new ‘supplies’ (the face mask has foam parts that break down over time) every three months. I always used a local business-they had an office in town and I could either pick them up or they would mail a box to me. However, somehow,they got ‘off’ the approved list,” and replaced by….? I am still trying to find out-a national company, to be sure.
    I have not been able to get new supplies since January. My doctor has called and faxed information 3x (there is always some ‘information’ missing or new info they require), and no one can yet tell me who or when or how I can get the supplies.

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