Skip to Content

Some insurance companies employ doctors with medical malpractice suits to review claims.

A recent investigation reveals that some disgraced doctors become medical directors who determine the fate of patient care.

Where do doctors with malpractice claims go?

In some cases, to insurance companies.

To be sure, not all doctors working for insurance companies have faced malpractice suits, nor do all who have wind up at insurance companies. But according to an investigation conducted by ProPublica and the Capitol Forum, many insurers hire doctors who have been rebuked by state medical regulators. In some cases, it’s for providing poor care; in others, it’s for dishonesty or professional misconduct.

Yet somehow, these disgraced doctors become medical directors who determine the fate of patient care. Here’s how it works: Insurance companies employ physicians-turned-medical-directors to review medical claims. When a patient receives a claim denial, it’s often because the medical director decided that their care was unnecessary.

These medical directors claim to be acting in the best interest of patients, because they prevent practicing doctors from performing expensive, needless surgeries or procedures. The denial comes in the form of three magic words: “not medically necessary.” But at the end of the day, they’re working for the insurer — and it’s in the best interest of the insurer to pay the minimum amount for patient care. Doctors working for health insurers can rule on 10,000 or more requests for care every year, notes ProPublica.

When an insurer decides not to pay for a patient’s care, that patient’s doctor can call the insurance company’s doctor to make the case on behalf of the patient in a process called a peer-to-peer review. But according to ProPublica, doctors often claim they don’t speak with a peer when they call an insurer. In other words, an orthopedic surgeon may be deciding on the care of a patient with an irregular heartbeat — when they arguably have no business doing so.

A doctor, often one who has never performed or is not allowed to perform a specific surgery due to malpractice claims, reviews cases for an insurer and gets to decide whether a practicing physician is allowed to perform that surgery. (Here at Uncovered, we think this is a bit backward.)

The investigation found that at least a dozen doctors working for health insurers were hired by the insurance companies after being disciplined by state medical boards or making multiple or outsized malpractice payments.

To be fair, the vast majority of doctors employed by insurance companies have not faced medical malpractice claims. But there are the select few cases that raise a plethora of questions: Where is the accountability for these medical directors working on behalf of insurers? At the end of the day, who is truly qualified to rule on medical claims? Who can make decisions regarding patient care — the doctor who is seeing the patient, or the one employed by the insurer with ample motive not to approve medical claims?

Original Article:

Subscribe to Un-covered Essentials

Insurer policies limit coverage and disrupt patient care, while producing record profits for corporate shareholders. Stay informed with the Un-covered newsletter.