Are Health Insurers Practicing Medicine Without A License?

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By NIRAN AL-AGBA, MD (43)

It’s no secret that in today’s health care market, insurance companies are calling the shots. As a pediatrician in private practice for almost two decades, I’ve seen insurance companies transform into perhaps the single most powerful player in today’s health care landscape—final arbiters whose decisions about which procedures or medications to authorize effectively end up determining the course of patient care.

Decisions made by insurers, such as MassHealth, have arguably killed patients. But it was only when I got caught in the crosshairs of an insurance company auditor with a bone to pick that I fully appreciated their power to also destroy physicians’ careers.

My own nightmare began around two years ago, when my late father, also a physician with whom I was in practice, and I opened our Silverdale clinic on a Saturday. It was the start of flu season, and we’d just received 100 doses of that year’s flu shot. Anxiety about the flu was running high following the death of a local girl from a particular virulent strain of the virus a year before, and parents were eager to get their kids immunized as soon as possible.

Under Washington law, adults don’t even need to see their doctors to get flu shots. They can get them at Walgreens, directly from pharmacists. But because children under nine are more susceptible to rare but life-threatening allergic reactions, they must be immunized by a physician. This meant that, for convenience sake, parents often scheduled their kids’ annual checkup on flu shot day, thus allowing them to condense much of their routine care into a single visit.

That particular Saturday went off without a hitch, with my father and I seeing and immunizing around 60 patients between the two of us over a 12-hour day.

Three months later, a representative from Regence insurance company requested to see some of the patient charts from that flu clinic as part of an audit. Aimed at rooting out insurance fraud by cross checking doctors’ records, these audits have become a routine fixture in medical practices today. To incentivize their auditors to ferret out the greatest possible number of irregularities, and thus boost the corporate bottom line, auditors work on commission, being paid a percentage of the funds they recover.

The Regence auditor in charge of my case, Anke Menzer-Wallace, failed to turn up any irregularities in our documentation. But, still, Ms. Menzer-Wallace issued a stern admonition to my father and me, ordering us not to open our clinic on Saturdays to administer flu shots.

This struck me as an outrageous restriction, considering our clinic is a private entity where we set our own hours and schedule accordingly, and so I called Ms. Mezner-Wallace. But instead of backing down, she ratcheted up her rhetoric, saying she was also forbidding me from examining my patients before immunizing them—clearly, a bid to save her employer even more money. I was shocked. Ms. Mezner-Wallace’s directive amounted to practicing medicine without a medical license—which is of course illegal in the state of Washington and many other states across the nation.

I shot back that immunizing infants and small children is a serious undertaking, requiring proper caution and care, informed her there was no way I would be complying with her mandate. Following this brief exchange, Ms. Menzer-Wallace took it upon herself to report me to the Medical Quality Assurance Board–the government-backed body charged with shielding the public from unqualified or unfit doctors. The accusation levied against me? Not following an insurance company mandate—which, in her opinion, amounted to unprofessional conduct.

It didn’t matter that the charges against me were ludicrous. The potential consequences were only too real, and potentially catastrophic. Had the State Medical Board decided against me, I could have lost my license. I hired a lawyer, sinking more than $8,000 into legal fees. I was cleared last month by a unanimous committee vote. But other physicians facing similar situations may not be as lucky.

The 18 months of excruciating stress that followed my altercation with Ms. Menzer-Wallace made it patently clear that insurance companies wield far too much power. Bureaucrats are making life-and-death medical decisions without a single minute of medical training, and their auditors are terrorizing physicians, by coercing state medical boards to act as their henchman. Unfettered by any consequences for enforcing policies that fly in the face of rules protecting patient safety, insurance companies will continue to harm doctors and patients alike if no one can stop them.

Niran Al-Agba, MD is a pediatrician in private practice in rural Washington state.

43 thoughts on “Are Health Insurers Practicing Medicine Without A License?

  1. I wonder if a lawsuit against the insurance company for recovery and damage to your reputation would be winnable? Robert DeAngelis, MD

    1. Unfortunately, probably not. I have won a recent settlement from a separate case where damage to my reputation occurred and proving defamation is extremely difficult. It has to involve making false statements “knowingly.” The insurer will say they support their auditor who still believed fraud was occurring despite passing an audit.

      1. Basically they can lie their asses off about lying their asses off and somehow that’s a double negative that becomes a positive. I run a medical clinic as an admin. We no longer bill insurance.

  2. When my son changed health insurers, they decided to cut one of his medications as necessary. He was forced to wean off it, and deal with the consequences. He had already tried a number of substitutes, to no avail. That a new and expensive drug worked was not relevant to the discussion.

    1. Basically, most of us — physicians and patients — are stuck with this insurance model for now. Even if the nation converts to a single payer, we still have one organization calling the shots. There is no power placed in the hands of physicians or patients. Every patient who needs a medication is taking dollars from the pockets of CEO’s and other executives. They really believe they have earned their millions in salary, which is a ridiculous notion, because they keep the company on track. Until we get legislative change, as I have written about here: http://peds-mommydoc.blogspot.com/2019/01/say-on-pay-legislation-giving-patients.html,
      we will be unable to influence this industry.

    2. My mother took Prilosec when it was still available only by prescription. When a cheaper generic form became available, her insurance company insisted she switch. She tried the generic, and it was about as effective for her as a sugar pill. She had to get her doctor to write a letter to her insurance company, insisting she be allowed to continue taking Prilosec instead of the generic. Of course, the insurance company tried to fight him on it, but her doctor eventually got his way and she was allowed to continue taking prescription Prilosec. Once it became available OTC, the prescription was no longer an issue.

  3. I run my own small private ObGyn practice and insurance companies are always after me because I spend a lot of time with my patients (and document the same). Patients love my practice— my Yelp reviews are great— but insurance companies couldn’t care less if their patients are happy and healthy.

    1. Rebecca, you and I are probably running similar practices. I spend time with my patients and document this and therefore charge accordingly. Good care takes time but exceptional care takes even more. Patients are worth it and those in my practice are not complaining either. Unfortunately my Yelp and Google reviews are filled with ghost “anti-vax” hit jobs but my patient satisfaction ratings are excellent. Being a physician is about listening, caring, and connecting. Insurance companies cannot really measure this intangible therefore they don’t care and do not want to pay for it. Time will tell if they continue to strongarm those of us on the front lines doing our job. In the meantime, keep up the good work! Your patients are lucky indeed!

  4. Have you taken your experience to State legislators or the board of the insurance company that harassed you?

    1. Any person who reports to the State Board of Health (or Medical Quality Assurance Commission) has whistleblower protection. I have spoken with State Legislators about narrowing the scope of MQAC however it is not a concept with teeth yet. I have not given up. As far as the insurer, they are paying these auditors to “find” fraud. I have been told insurers are often right when these make accusations like this. It is a scary thought if they are wrong and a physician is wrongly convicted.

  5. I just opened a private solo sub-specialty Maternal-Fetal Medicine practice and insurance companies don’t want to reimburse me for office visits on the same day ultrasound is performed. They will only reimburse me for the lesser of the two if they do choose to reimburse because they see my subspecialty consults as “global OB care” even though I do NOT perform the delivery. These patients are all referred to me for extremely high-risk conditions and I spend a lot of time with them…the exact reason I left hospital funded practice—to actually spend time with my patients. It’s a sad world we live in when insurance companies drive the quality of care a physician gives…and try to ruin the careers of those who are upholding the oath to do no harm.

    1. I am so sorry for the experience you are having. “Global” charges for outpatient care are not really conducive to keeping a private practice afloat. There is a facebook group for physicians in private practice and if you are not part of it, you should be. They have lots of ideas and suggestions for physicians facing these challenges. Please friend me on Facebook and I can add you. I believe insurance will continue to try and ruin physician careers, they believe doctors are just too expensive and getting in the way of their obscene executive and CEO salaries. We must keep holding insurers accountable when they target good doctors unfairly. Thanks for reading and commenting.

  6. Niran – You’re a great doctor! I can personally attest to that 🙂 Keep up and keep on providing exemplary care. I am so sorry for your ordeal. I feel your pain. I wish I had any manner of solution or advice so instead just know that the physician community stands with you and perhaps one day organizations like AMA/AAP/WSMA can effectively combat insurance industry excesses and abuses.

    1. John! So glad to see you on here. Thank you for your support. You trained me well 🙂 I am hoping that if Practicing Physicians of America prevails in the Racketeering lawsuit against ABIM and ABMS on MOC abuses, maybe we will have an organization that trains physician warriors en masse. Fingers crossed. Thanks for reading and commenting.

  7. I love this discussion about the insurance company abuses and challenges that we physicians face on a daily basis. I have run a solo private practice of dermatology for 20 years. I have often commented that insurance companies are practicing medicine without a license. They tell us what drugs to use before we can prescribe the medicines/treatments that will really help our patients. I have often said the medical director of the insurance companies should have office that we could send all he patients to when they deny the appropriate care, so they can then assume care and manage the patients with the same crap-care they are espousing, and they have to look the patients in the eye and explain the “money for me first, care for you second” approach to them. Niran Al-Agba, I will find you on FB, please add me to the private practice group. Thanks!

    1. Dr. Crutchfield, I added you to the group. You can search any topic you like and see that a variety of them are covered. There are about 2,600 docs, so it is a wealth of information as we all try to reclaim our profession. Thanks for reading and commenting.

  8. My husband and I started our pediatric office almost 15 years ago. We continue to fight the same battles with the insurance companies. Especially the flu shots without visits and the global charges. We are approx 80% medicaid, and have just recently became 100% EHR dependent after investing in 2 different systems over the last 7 years. Without being able to report, we have not been able to participate in any meaningful use stages and therefore not been eligible for any additional federal funding. We also have not become a PCMH due to the cost and manpower it would take to become JANCO certified. Ive spent the last year writing letters to congressmen, trying to convince them we deserve to be recongnized, and therefore funded as such even without a PCMH certfication. Our Quality measures are above that of our peers, as reported by post billing from our medicaid HMOs. I would be very interested in sharing ideas and strategies with others through your private practice group, as I have not come across any other group like that to date. I agree it is time that we, with independent practices still remianing, stand strong.

    1. I know. As a solo pediatrician (who used to be in practice with my father until his death one year ago) I have been there ad totally understand your challenges. I used to be 50% Medicaid but had to institute a waitlist and now am 10% Medicaid after Obamacare/ACA trickled down to primary care. I am still 100% on paper and that has helped me stay in business. I just figured I would accept the penalty and not mess with all those certifications. When GEHA wouldn’t pay for immunizations at all (they billed the patient instead) I wrote to both my Senators. I never got a reply, there is nothing they can do. My patient satisfaction ratings are one of the highest in the region and this is why I have survived this long. Feel free to friend me and pm me and I will add your hubby to the group. Feel free to contact me anytime, if you feel I can be of help. We have been in business 49 years and are on third generation patients.

  9. Thank you, Niran. I am an LMHC (Master’s level licensed counselor) and we see this sort of thing too, both in mental health care and, by report, for the medical care our patients receive. I appreciate your writing and hope to read more of it.

  10. Thank you for your courageous op ed. Regardless of the insurance model, it has become necessary to determine and decide that it is cost effective and morally just to shift the focus from high-tech medical care to an integrative and preventative model. That shift alone will take some of the power from the actuaries in the insurance industry. Questions will need to be raised about the cost/benefit of every procedure including the social as well as economic costs. We as a nation of people (We the people…) must take back the power to decide on the destiny of our heath care and our wellness…how we actually feel, think, and act. Otherwise, we are reliant on the AMA, Insurance providers, and the pharmaceutical industry.

    1. thank you for reading and commenting. You are right looking at health care from a systems perspective is our best bet, however I find relying on my patients and I working together is the best antidote. Every one of my patients affected by this investigation was informed and volunteered to write statements if necessary. It was closed before it was opened as a full scale investigation, however knowing I had their support helped me sleep better at night. The AMA, insurers and hospitals are out to help themselves.

  11. Physicians are not “stuck” with this model. Physicians CHOOSE this model because they like how much money they can make. Physicians could CHOOSE to run cash practices for affordable prices, Admittedly there would be less volume, but also much less paperwork and none of these headaches. I am an alternative medicine provider, and do just this. I keep my rates low, and am able to be completely free of this kind of meddling. If all you pompous ass physicians let go of your half-million dollar homes and lexuses and came down to the level of the people you serve this whole problem would cease to exist overnight. You’re only stuck because you don’t want to let go of the money. Typical simian instinct.

    1. So I am not sure your comments are all that kind or helpful except you are absolutely correct about cash practices and a great deal of what I do is cash-based. Now obviously, you don’t know me as most of the world seems to understand I am actually one of the poorer physicians in the country. Until very recently, I lived in a 3 bedroom, 1800 square foot home with my husband and four children. Now as for the minivan I drive, it is over a decade in age and kinda banged up but everyone in town knows its mine when they bring me their second hand clothes for my kids to use. I would say I am definitely below or equal to the economic living standard of the patients that I serve and it has never mattered to them or me one bit. My children go to public school with all my patients and many of my patients are friends as well.

      Now as for how you conduct yourself on social media, let me say this, you sound a little angry and I am not sure what that is about. If you are feeling burned out, please get help. Thank you for reading.

  12. Recently, a family successfully sued an insurance company after their family member died and they could prove it was due to delays in care caused by the insurance company denying treatment. There are several barriers to more families and physicians doing this. One is an affords lawyer willing to wage the war against insurance. Another is physician support for families as this is a time consuming and risky endeavor for a physician. The last is the very real harassment that insurance companies wage against any patient or provider who dare go up against them. We need many large class suits against very big insurance companies. Many times over. When it becomes more financially profitable for insurance to cease these behaviors is when we will see change. Until then, insurance companies win 100% of the time, so why change. Morally, we also need physicians and pharmacists and other specialists who work on medical management departments to cease their support of routine denials. State medical boards need to focus on insurance doctors who make life and death decisions without examining a patient or specializing in board certified specialties relevant, or without a true understanding of a patients medical records. In every other setting, a physician who decided to operate or not operate without ever seeing a patient, examining a patient or reviewing their medical records would face disciplinary action. Pharmacists have no prescription privileges, yet they make prescription decisions all the time for insurance.

    1. I wholeheartedly agree. I hope sharing my story inspires others to stand up and be counted. We can win. If we are honest, forthright and share with our patients what is happening. I could not have succeeded without the support and backing from my patients. You are right we should continue reporting insurance companies practicing medicine without a license, but first consumers need to understand what is happening to physicians.
      Some policy experts believe patients aren’t interested in the plight of physicians on the front lines. I am living proof (as are the 8,000+ shares of this article) that indeed, patients, physicians, and other healthcare workers DO care.
      More importantly, this experience is true, accurate, and a matter of public record. If what I went through inspires another physician to fight against big insurance to better serve patients, then it was worth it.

  13. I’m an alternative medicine practitioner, and part of the reason for that is I don’t want to be a slave to insurance companies. As a patient and a practitioner, I’ve struggled to understand how insurance companies have the right to dictate care when they haven’t even met the patient. If I were to do that, I would have my license taken away and be put in jail. I feel a big reason that more patients are seeking alternative care is because physicians are restricted in regards to how much time they can spend with a patient in order to be paid an amount of money that is actually significant, let alone be able to prescribe necessary procedures and medications. It’s a sham on their part and a huge disservice to our patients. I commend you for speaking out and trying to change this dynamic. It’s time to hold them accountable and remind them we are the professionals, not them. We have the knowledge base, they don’t.

    1. I want to like your comment 1,000 times! I wholeheartedly agree. I refuse to be restricted by insurers and my patients and I are on the same side. It is the only way. This unbalanced dynamic NEEDS to change. Thanks for reading and commenting.

  14. These reports to the Licensing Boards are common. I saw the first one in 2000 in a northern state. Helping that surgeon get justice started The Center for Peer Review Justice. He had sued the Board 6 times and lost every case. No such thing as Judicial Review. Fast forward 3 years and we were able to get every board member to resign or be fired. And, we did not use lawyers or the Courts.

    In the last 18 years, I have seen one outrageous attack at a physician and surgeon after another. That is why The Center for Peer Review Justice exists.

    Richard Willner
    http://www.PeerReviewJustice.org .

  15. Insurance companies and their enforcers have us at their mercy, and that needs to change.

    My son has a chronic disease, and requires a biological Q 8 weeks. He was delayed 3 weeks beyond his next due date because the insurer decided that after six years, he needed to be tried on the cheaper biological before he could be approved for the one he had been taking successfully for years. The company pointed fingers first at their contracted pharmaceutical provider, saying that my son’s physician had to submit documents to them, and they said they had the documents, but insurance denied the claim. Finally, the mid-level clerical type told me (knowing I’m a physician) that they had never paid a claim for the drug while they were my son’s PRIMARY carrier, and only paid as a Secondary carrier to follow his primary at the time. Which was an absolute LIE. They HAD been his primary carrier for a significant period of time, during which they DID pay, several times.

    I outlined this in an email which was sent to the CEO and VP of the company. I received an emergency override of their denial the next morning, although it took all day to actually activate it. We now have eight weeks to permanently straighten this out.

    In my communications with the infusion center, they tell me this happens every single day to multiple patients.

    As a physician, I have some knowledge in how to navigate this sort of thing, and I do not hesitate to go to the very top of a company when the underlings circle the wagons. In this case, catching them in an outright lie was probably quite helpful. That isn’t always so easy.

    I googled for previous class-action cases against this carrier, and contacted an attorney who had successfully brought such an action in the past. We’ll see what happens.

  16. Hello, your article is rather shocking, but (unfortunately) unsurprising. May I ask two questions (besides this one requesting permission to ask two questions)? First, isn’t the whistleblower-protection rule designed to protect complaints filed in good faith, and, if so, could this be considered a non-good-faith report? Second, as you say, she engaged in medical practice without a license, which is a crime…therefore, would it be our responsibility to report this to the relevant authorities? After all, if one of us finds a non-licensed “practitioner” selling snake oil on the street, that would be reportable. Thanks very much for your article, and I am very sorry for the emotional and professional toll (not to mention financial) that the situation likely caused you and your family.

    1. The whistleblower rule is designed to protect complaints filed in good faith, however how does one go about proving that report was not made in good faith? It is a rather subjective thing to prove. I doubt this would get very far trying to prove the auditor was angry and reacted out of that.

      So as far as the engaging in medical practice without a license, there is no law on the books that would include forcing a physician NOT to examine patients as qualifying. I did ask that she put this in writing (that would have provided evidence of such a thing) however she refused (with good reason.)

      What is more frightening is that insurers are subtly threatening physicians to stay in our place and not speak up for fear of losing our licensure for “fraud.” It is this veiled, insidious approach that I would like to call out and make known so other physicians are willing to fight.

      1. The “good faith” can be revealed in the discovery process when you examine the internal emails/texts of the insurers workforce. When they snark to each other “we’re gonna get this one” or something similar, you have your case. Happened here in Maryland at the Board of Physicians level. Unfortunately, it was a doctor who really deserved condemnation, but the Board Staff had a vendetta…

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