Tuesday, June 22, 2010

It's Official: Guidelines for Care Are Now Mandates for Care

Want a pacemaker or defibrillator on your dying UnitedHealthcare patient with complete heart block? Sorry, in many states you must first ask permission from the insurer beginning 1 July 2010:
UnitedHealthcare claims this protocol is not a pre-certification, pre-authorization program or medical necessity determination. A notification number must be obtained in accordance with the Cardiology Notification process prior to perform EP implant procedures. Failure to complete the notification process will result in an administrative denial. All procedures require notification regardless if they are elective or emergent. (Emphasis mine)

Prior notification may be obtained online, by telephone or fax:

■Online: UnitedHealthcareOnline.com (User ID and password are required)
■Telephone: +1 (866) 889-8054
■Fax: 1 (866) 889-8061
Cardiology Notification process? WTF? Where, exactly, do we place this "notification number" in patient patient's chart? In their operative report?

I can see it now as P waves are dancing across the screen:
"Hold on there, Ms. Smith! Just trying to place this temporary pacing wire... Um, give me a minute, okay.... Uh, which insurance do you have?.... er, please ma'am, don't talk right now - I might hit your lung.... It wouldn't be Unitedhealthcare, would it? Wait, don't talk.... okay, which one? Yes? Does anyone have UnitedHealthcare's Cardiology Pay-to-Play number???..."

"Okay, Ms. Smith... Ms. Smith????... Ms. Smith???...."

(gurgling noises hard in background)
And will the service will be 24/7/365?

Of course not!
If notification is required on an emergent basis or notification cannot be obtained because it is outside of UnitedHealthcare’s normal business hours, the service may be performed, and notification can be requested retrospectively. Retrospective Notification requests must be made within 14 calendar days of the service. Rendering physicians should follow the same notification process outlined for a standard request. Documentation must include an explanation as to why the procedure was required on an emergent basis or why notification could not be obtained during UnitedHealthcare’s normal business hours. If a claim is submitted prior to the Retrospective Notification Process being completed, it will receive an automated denial for lack of notification; however, the claim will be reprocessed if Retrospective Notification is received within 14 calendar days of the date of service, and it meets criteria as an emergent procedure.
Just think how many hours upon hours of doctors' time will now be spent holding online waiting for a college dropout to tell us our notification number!

Damn, what a waste of resources.

This is our "guidelines" for care are now mandates for patient care and will be used against us in our new era of health care reform.

Deviate from them and your patient will pay...

... and pay dearly.


Addendum: Dr. John Mandrola, another EP, shares a similar story, even before these new mandates go into effect.


Anonymous said...

How is that different then Blue Cross Blue Shield Policy. bivent implant with defibrilator for me last year, after the procedure was completed and when they got the big bill, they ask for documentation and complete medical history from Univerity of Chicago. They did approve everything at the end. But they kept sending me copies of the letters of denial and asking for additional documentation from UCMC and that was the last thing I needed instead of recovering from the procedure and gaining strength. I would have felt better if everything was done before and pre certified. Plus I could do nothing, the billing department of university of chicago was dealing with it, and I felt bad calling my EP's office as they are not equipped to do anything. Truthfully they should not do that. They told me not to worry that they do these things on a daily basis and almost on an auto pilot basis.

In cases there is a concern for high risk of caridac arrest, there is always the option of life vest for that patient until paperwork is completed. I do understand where you are coming from though, medical decisions should be kept to doctors and not to bureaucrats in an insurance company. All the EP's and cardiologists I dealt with (too many for my young age :))follow the same guidelines as mentioned by the insurance company very closely anyway as they do not want these claims to be rejected and get the patients pay for these claims.

Always a pleasure to read your posts,


Anonymous said...

I don't understand. Is this mandated by United Healthcare, a health insurance company, or is it a federal government mandate? If it is the policy of the insurance company, why are you castigating the federal government? It seems to me that health care reform was an effort to eliminate such practices by insurance companies and this is a loophole that the company is using to its advantage while it can. Perhaps once we get over the hysterics over this bill, Congress will make adjustments to eliminate such practices. If you find further regulation repugnant, then I leave you to the "free market" and its pre-existing conditions...

DrWes said...


This new effort at covert rationing of medical devices is mandated by the insurance company. Entire blogs have been written on the insidious nature of covert rationing to divide the doctor and patient. This is but one more example.

We should only wish health care economics were a free market, but they are not. We have conveniently divorced the patient from the costs of just about everything, justifying the fleecing of the patient's health care dollar by gargantuan systems that work to assure they get paid before the patient gets theirs. Ask yourself, why are defibrillator's and pacemakers still priced as high for the past 10 years, despite the maturity of the players in the field and you will see why it's not just the government, but our system of providing health care, not the doctors, that is to blame.

Bureaucrats add no value in terms of direct health care delivery to our health care system and by doing these hoop-jumping shenannigans, cost us all even more.

Anonymous said...

I know cardiologists are aggressive in treating lipid disorders, but now, apparently, you're melting so much fat you're a "rendering physician."

Keith said...

Some of the problem can be blamed on inappropriate overuse of these devices as well. How are insurers to address costs if they cannot weed out these unnecesary and very expensive procedures and devices? Tell me there is not overuse or inappropriate use and I can see your point.

Of course, this penalizes all the good cardiologists that do things the right way. I think that what we need to do is go back to the insurers each time they slap some beuracratic mandate on physicians and demand compensaton for the time and trouble of providing the additional information they require. These are unfunded mandates, and as long as insurers can save expense without bearing the whole cost, they will continue to use this tool to control utilization.

The only other way to effectively weed out wasteful use of this technology is to go to a capitated system where some accountable organization becomes responsible for bearing the cost for a determined yearly rate (welcome back HMOs). they could pay the cost of the device, but pay the cardiologist a set fee whether he/she puts in 0 or 200 devises per year. Then watch the numbers of pacemakers placed dwindle as it eats up the cardiologists time to keep installing them in every borderline situation. It just may be possible healthcare organizations will bargain down the price of the devices as well.

cynthia bailey md said...

I saw this coming. Physician's clinical judgment reduced to an algorithm. Hmmm, that's how machines work. I wonder what's next?
Cynthia Bailey MD

Jodi said...

While I am not opposed to some government regulations, every time the government tries to "correct" the behaviors of companies, consumers end up paying for it. Yet, the government continues to think their strong arm is needed to "protect us". Who is going to protect us from the government? When do we get to sue them for malpractice?

Rather than our government helping to create an environment where patients are protected from the bad behaviors of insurers by allowing them to shop around more easily when they are getting "scr@w#d", and actually making changes to the system that brings DOWN the cost of doing business and brings down health care spending, they decide to do the opposite.

Again, when can I start suing my politicians for malpractice. Class action lawsuit, anyone?

This is just the beginning....

Critical Care RN

Jodi said...


What about more transparency in health care? If doctors and hospitals had to post their amounts and uses of devices so that referring physicians, patients, and insurers can know who may be overusing, etc., then the "good" cardiologists will get more business when they're practicing more conservatively, and the "bad" ones will get less (via referrals). I realize that is easier said than done, as there are other things to consider, but shouldn't transparency be what we use to penalize the bad doctors, while rewarding the good?

Shouldn't we always be focused on "smart" consumer choices to bring down costs, and increasing competition to bring down costs?

Jodi said...


Wouldn't transparency in health care be a better way to penalize the bad cardiologist, while rewarding the good. If doctors and hospitals had to post stats on amounts of devices used, for what reasons, etc. then referring physicians, and insurers, would be much wiser in their choices (as well as, ideally, patients). The "good" cardiologist would get more business, the reckless one less.

I realize that is easier said than done, but shouldn't it be the goal to protect consumers through transparency, rather than increasing bureaucracy that we already know makes costs go up, not down? Competition, transparency, smart consumer choices is what brings costs down (and spending).

Anonymous said...

good post. Funny though that when they decreased Chemo payments, doctors administered more chemo and expensive Chemos for lung cancer patients in recent study. Profits and margins will always prevail when there is a business to run!

Keith said...


the trouble with your argument in the case of a pacemaker is that you really don't have the opportunity to shoop around for a pacemaker once you are told you need one. More often than not, patients are told they need to have it placed now, or potential dire consequences may occur. And when you pass out at home, you don't get to pick the hospital you are taken to either! So how will better consumer info help in this acute instance?

Jodi said...


That is the case for a pacemaker in an emergent situation. Bureaucratic hoops, government or otherwise, won't solve that problem either. If it's an emergency, it must be done.

Your earlier argument was that too many doctors are putting in too many devices. Then you said things have to be done emergently or patients will pass out. Which is your argument, doctors are doing too much, or they are doing things emergently to save patients?

When someone receives a pacemaker, there is a "referring" physician somewhere along the line. If that physician doing the referring knows which cardiologists are putting in the newest and most expensive pacemakers that have little or not added clinical value 90% of the time they may be less likely to refer to that cardiologist. OR, insurers may be less likely to approve placement by that cardiologist. Pacemakers are not always on an emergent basis, meaning hours. As a physician, you would be responsible for knowing the physician's in your area, and whom you care to refer to.

As for taking patients to what hospital...Again, in an emergency things must be done, bureaucratic limbos won't change that either. Not all medicine is "emergent" and if you can impact the non-emergent consumption, what a difference that could make.

Finally, as I said, I realize this is much easier said than done, but wouldn't it have been better if we had been talking about this kind of thing, rather than government interventions that drive up costs even further?

Keith said...


There is no discrepancy in my argument. Many of these devices are installed for the right purposes, but some are not. Patients in many institutions may not always be "referred" in the way you define it. If they show up at the ER off hours, it may be the cardiologist on call is the only choice. Many may also be referred by their PCP, but there are also PCPs who overutilize resources and do too much. They are unlikely to question the opinion of the expert in these situations anyways, although I usually take the tack of suggesting a second opinion where that option is availible.

Your idea of transparency is good, but I was simply pointing out that it doesn't help in many situations where patient choice is limited by circumstance. That is maybe why insurers need to overseee what indications are being used to place these very expensive devices since it is not a circumstance where you can always empower the patient with the necessary info to make the right decision. I personally think it would be better to incentivise the provider by not rewarding them on the perclick method of payment and instead compensate them for evaluating and making good clinical decisions as to when these devices need to be used.

Rogue Medic said...

There should always be too many pacemakers implanted, just as there should always be too many people transported to trauma centers.

The sensible position is to try to get it right, but we will always need to leave a margin for error, because patients do not always present with clear diagnoses and information about the way they will respond to treatment- the kind of information that will be available to the Monday morning quarterback.

If we try to prevent using too many, we will have more hospitalizations and fatalities.

Perhaps they will pay fortune tellers to predict which patients need pacemakers. If nothing else, it should make it clear that fortune tellers are only good at scamming people.