Cigna HealthCare's refusal to cover leukemia patient Nataline Sarkisyan's liver transplant until it was too late is out of the insurance playbook. My patients suffer similar fates every day.
Insurers always qualify their denial letters with a sentence to the effect that the doctors must provide whatever care is necessary and that the payment is a separate issue. Insurers never deny care only the authorization for payment. To stall the actual delivery of care, insurers hold out an insincere promise to authorize payment if the doctor provides more information. This leads the doctor on indefinitely, while insurers never say absolutely "no" until the patient gives up or dies. I agonize over having to choose whether to wait one more day for approval or to go ahead with the surgery and potentially damn the patient, his family, and the institution, to assuming the financial consequences. If I do go ahead without approval, no one comes to my defense when administrators ask me why so many of my patients' insurers are not paying. No one rescues the bankrupted families.
Calling a procedure "experimental" is another routine insurance industry stall tactic. Insurance contracts don't give the criteria for such a designation, but insurers still claim the right to define what is experimental. Such unilateral decision-making means the insurer is party to an unsustainable contract contracts should bestows rights and obligations on each party, and shouldn't include undefined terms.
Sarkisyan's procedure likely wasn't experimental because the outcome was known. Doctors treating her told Cigna that patients in similar situations have a 65% chance of living six months. A 65% chance of surviving six months does not preclude a 50% survival at five years. Furthermore, if consent is not required by the Institutional Review Board, and if others have already reported the procedure, it is not experimental. I helped introduced the radical abdominal trachelectomy in 1997 with IRB approval. It became the standard of care by repeated use as determined by individual doctor-patient relations ultimately, whether a procedure is experimental can only be decided by a clinician and individual patient.
The third predictable insurance industry stall is the "expert" review. I would define an expert as a doctor who did a transplant or took care of a transplant patient this week. Insurers that review my denials define any has-been, retired, unemployed failure with a medical license an expert, paid to deny care. This is practicing medicine without examining the patient or seeing all the data. In effect, the licensed nurse or doctor working for an insurer is practicing medicine unprofessionally and criminally.
Sarkisyan was killed when the insurer decided to stall. Her family is within its rights to expect coverage for what their doctor determined was necessary, as Cigna promises.
Giuseppe Del Priore is a gynecologic oncologist and associate professor at Weill Medical College of Cornell University.Copyright © 2015, Los Angeles Times