Funhouse mirrors everywhere.

Thanks for denying this surgery, Aetna.

My patient has severe leg pain and buttock pain. She’s suffered for years. See the MRI below: severe stenosis.

She tried physical therapy 3 times. She tried a different place each time. She gave it 2 solid months each time. No relief. Eventually, PT started making things worse.

Then she tried epidural injections. No relief.

Then she tried medications. No relief.

Finally, she came to see me. The pain was getting worse. She was having trouble walking.

I recommended a lumbar decompression. Outpatient… no metal involved… in and out.

Aetna’s decision: NOT approved.

Actually, that’s incorrect. Aetna doesn’t do its own pre-authorizations. It typically outsources that to Availity.

The reason for the denial? She hasn’t tried PT in the last 6 months.

So I got on the phone. Peer-to-peer… my favorite thing. I explained that she’d tried PT three times. I explained that PT made her worse.

They said they need proof. They needed documentation, from a PT within the last 6 months, stating that she was being discharged and shouldn’t continue.

Really? You don’t trust the patient. You don’t trust the doctor. I shouldn’t be surprised.

ProPublica called it out: “Denials for Dollars”

A company called Evicore runs pre-authorization for 100 million patients in the US. Evicore’s pitch to insurance companies: a “3-to-1 return on investment.” They reduce claims payouts by $3 for every dollar spent on Evicore’s services. Deny, deny, deny.

And it gets worse. In some cases, EviCore takes on the financial risk for approved claims… and in return, they get to keep any extra savings they create. Talk about perverse incentives.

I wonder if Availity plays the same game. All the while, my patient suffers. What is Aetna’s role in all this, anyway? My patient has a self-insured employer. So…

Aetna is NOT the payer.

Aetna is NOT managing pre-authorizations.

Aetna is NOT managing risk.

Aetna is NOT providing insurance.

It’s all a funhouse mirror. I’m frankly getting tired of the nonsense. Surgeons’ reimbursements are plummeting. We’re trying to so hard to contain our costs.

Meanwhile, all these intermediaries are siphoning money out of the system. It’s pure rent-seeking behavior, through and through.

We need tools to bypass these interlopers. All the money they’re stealing should go back to patients, employers, and physicians.

Are we ready to re-imagine and reboot?