ProPublica stated in its December 15, 2023 report entitled Doctors With Histories of Big Malpractice Settlements Work for Insurers, Deciding If They’ll Pay for Care that it and The Capitol Forum investigated how health plans refuse to pay for care by examining who insurers picked to make those determinations.
Health plans hire “medical directors” with the stated purpose of weeding out and denying unnecessary or risky care and expensive treatments for which there are less costly, equally effective alternatives. However, patients and their physicians maintain that health plans routinely, and wrongly, deny payment for critical lifesaving treatments because they are expensive, leading to patients having to pay for necessary medical care out-of-pocket or not receiving the necessary medical care. In a survey conducted by the American Medical Association, only 2% of the doctors who responded said that health insurance medical directors were “always” appropriately qualified to assess the requested treatment. More than a third said health plan doctors were “rarely” or “never” qualified.
ProPublica reported that a single medical director can rule on 10,000 cases a year, according to court testimony in a case involving Aetna, and some Cigna doctors have made health care determinations on more than 10,000 cases in a month without reviewing the patients’ medical chart.
ProPublica identified 12 insurance company doctors with either a history of multiple malpractice payments, a single payment in excess of $1 million or a disciplinary action by a state medical board: “One medical director settled malpractice cases with 11 patients, some of whom alleged he bungled their urology surgeries and left them incontinent. Another was reprimanded by a state medical board for behavior that it found to be deceptive and dishonest. A third settled a malpractice case for $1.8 million after failing to identify cancerous cells on a pathology slide, which delayed a diagnosis for a 27-year-old mother of two, who died less than a year after her cancer was finally discovered.”
And patients often have no idea who is reviewing their requests for approval of medical care – the identity of health plan medical directors are not made known to patients. ProPublica further reports: When an insurer shoots down a request to pay for care, the patient’s doctor can call the insurance company’s doctor to make the case for why it should be approved. This is known as a peer-to-peer review. But doctors often complain they’re not actually speaking with peers when they call an insurer. They get exasperated when an orthopedic surgeon weighs in on a procedure to treat an irregular heartbeat or a pediatrician questions an oncologist’s plan for an adult with lung cancer.
ProPublica reports:
Doctors turn to health insurance company work for many reasons. Some do it after burning out on clinical care or a change in circumstance, such as starting a family or retiring from a practice. Many find the work rewarding, saying they can help patients by flagging care that is unnecessary or even dangerous.
The job offers good pay with potential bonuses and a set schedule without weekend work or night shifts. The median pay for medical directors at insurers like UnitedHealthcare, Cigna and Elevance is around $300,000 a year, with the high end of the salary range over $400,000, according to the job site Glassdoor.
Despite this, ProPublica and The Capitol Forum found, insurance companies still wind up employing doctors who state medical regulators have rebuked for providing shoddy care or being dishonest.
A unit of Cigna called eviCore has employed Dr. Lorraine Driscoll as an associate medical director from 2006 through at least March 2022, according to records filed with the Maryland Insurance Administration. The New Jersey medical board in 2013 found grounds for disciplining Driscoll for “dishonesty, deception, and misrepresentation and/or … for engaging in professional misconduct.”
The board reprimanded Driscoll, an obstetrician-gynecologist, for altering patient records in ways that could help her fight a 2004 malpractice case involving a child born with Down syndrome. That case, which wound up settling for $700,000, was one of six that Driscoll settled, according to her application to be certified as a medical director by the Maryland Insurance Administration. (Maryland officials approved her application.) She reportedly did not respond to calls, emails or a letter with detailed questions sent via FedEx.
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