2 Doctors Go Public With Managed Care Complaints

Among the responses I’ve received to recent columns about the issues raised by managed care, there have been a smattering from doctors, usually requesting anonymity.

A radiologist in Long Beach first wanted to go public with an account of medical insurers who, he said, are interfering with his practice. But after conferring with colleagues, he said he feared repercussions at his hospital if his name were used.

I also received a call from a physician in Ridgecrest telling me about the willingness of Blue Cross to fund certain expensive surgeries in breast cancer cases.

But then he found that Blue Cross didn’t want to talk publicly about it. So, he begged off.

Now, however, I have two doctors who are both acting on their grievances and agreeable to having their names used. One is 78 and the other 86. They remain in practice but in a limited way.

They feel that at this stage of life, they probably can’t be hurt by reprisals. They both have fond memories of the old days of practice without insurer interference or oversight--depending on your viewpoint.

Murray C. Zimmerman, 78, of Whittier, a dermatologist and clinical professor of medicine emeritus at USC, is suing Aetna U.S. Healthcare in small claims court for payment for the time he spent researching an appeal to Aetna to allow him to prescribe Lamisil for a diabetic patient.

Aetna, on his third try and 39 days after its initial rejection, finally approved the prescription. Earlier, it had insisted on other medicines to which Zimmerman objected.

Zimmerman says he is owed $3,700 in fees for the time he spent obtaining a power of attorney from the patient to make the appeal and for eight hours compiling information supporting the use of Lamisil to treat the patient’s foot ailment.

Aetna had itself suggested twice that Zimmerman could “submit additional information such as articles from peer review literature” to support an appeal.

So, Zimmerman said, he went ahead, and he is entitled to be compensated at the rate of $400 an hour, which he customarily charges.

“All I’m doing this for is to show they’re a bunch of a-------,” he said. “I don’t need the money.

“I actually gave my patient the Lamisil out of a supply I had. If I weren’t semiretired and a hostile old fart, I wouldn’t have spent eight hours on an appeal for a single patient.”

I went with Zimmerman to the small claims court. On the way, he reminisced about how medical practice has changed.

“It’s a different world,” he said sadly. “Doctors have to see so many patients for HMOs and PPOs, there’s not enough time for proper diagnosis.”

Zimmerman had arranged for Aetna to be served with his complaint on Aug. 20. But he still wondered if it would bother to be represented at the Sept. 9 hearing.

Yolanda Snyder, an account manager from its El Segundo office, showed up for the company. But she told Court Commissioner Gerald N. Mansfield she knew nothing about the matter and asked for a continuance.

Mansfield set a new hearing for Sept. 30, remarking tartly, “I will grant the defendant no further continuances.”

Responding to me later for Aetna was Dr. Andrew Burgoyne, one of the company’s patient management medical directors.

Burgoyne suggested that the whole dispute over whether to approve the prescription could have been shortened dramatically had Zimmerman called him or someone on his level to discuss it.

“We’re trying to be very flexible and to have an open dialogue, not just to arbitrarily say no,” he said. “Usually, we can work this out.”

As for Zimmerman doing eight hours of research, Burgoyne said, “I’m surprised that he felt he had to go to the library and do a major search. Usually, a doctor will say, ‘I have two articles available and I will send them to you.’ ”

But Zimmerman answered that far from ever being told he could send only a little supportive information, Aetna actually had requested him to send more after his first 10-page justification.

And, he pointed out, the rejection letters did not suggest a call to a higher level. Instead, they said, “If you wish to appeal this decision, you may provide a written notification within 60 days.”

The second doctor to allow use of his name is Leonard Asher, 86, an internist who has long practiced at Cedars-Sinai Medical Center.

He has been trying to collect a 3-year-old bill for his services to Cigna Property and Casualty.

Complaints that insurers pay slowly are common with the doctors who have contacted me. But usually, the payment is for treatment of patients, not for work done to defend the very insurer.

Asher said he had been retained by an attorney doing work for Cigna, Stephen L. Halpern of Woodland Hills, to do defense examinations on disability claims.

He did the work, received an initial payment, but persistent efforts to collect the rest of the money owed, about $3,000, from Halpern over a 2-year period were unavailing, Asher said. The attorney finally told him he should go directly to Cigna for the payment.

Halpern said he had been told by Cigna to say nothing to me.

Jim Ely, a spokesman for Cigna, said that the first Asher invoice to appear at Cigna came in a little more than a year ago and that the reason it had not been paid was that it was not properly coded.

“It’s a state requirement that workers’ comp invoices need to have proper codes,” he said, “and we communicated that to Dr. Asher.”

The state Division of Workers’ Compensation confirmed there are such regulations.

But, later, Ely said, steps were being taken to pay Asher.

“We’re going to try to process this as best we can, even without the codes,” he said.

Asher soon received a call from a Cigna representative indicating that at least $2,400 would shortly be paid. Maybe queries from a newspaper got attention an individual doctor’s plea never would have received.

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Ken Reich can be contacted with your accounts of true consumer adventure at (213) 237-7060, or by e-mail at ken.reich@latimes.com