When I joined CIMRO in late 2018, I was not entirely sure what to expect. I had been involved in plenty of peer review through my various hospital committees and leadership positions, so peer review I knew well. But the insurance review portion would be new to me. I love case reviews, but don’t we all? Don’t we all love to chat with our colleagues and doctor friends about interesting cases we’ve seen, hard cases we solved, and those cases that absolutely astound us? Don’t we love to ask the question, “So what would you do if…?”
Even among non-physicians, which one of us has not been asked to entertain a crowd with some good anecdote from our medical experience? I hear regularly from friends and family, “So, what good stories do you have to tell us?” However, as much as I love to entertain a crowd with my storytelling abilities, it is much more fun to have a discussion among my peers – those who can understand the nuances, relate to the details of the case, and offer tidbits of their own advice. My own brother is a trauma surgeon, and we could talk for hours just about medicine.
Insurance review was all new to me, but turns out, it is not much different than peer review. It is similar, but instead of saying a case is appropriate or not appropriate, the decision is to uphold the insurance company’s ruling or overturn it. As it happens, emergency medicine is a great background for both peer review and insurance review.
Because my job is to be sure reviews are complete, I don’t have to be the expert. You are the expert, carefully screened and chosen. As I review your reports and make sure you are answering all questions carefully and providing quality medical decision making in the report, I learned so much. As an EM doc, I like to refer to myself as a “Jack of medicine” – well, really, I am a “Jill of medicine.” I have a very broad medical education about all specialties, all organ systems, and all medications. I do specialize in emergencies – cardiac resuscitation, sepsis resuscitation, joint reductions, complex laceration repairs – and I am an excellent diagnostician who feels very lucky to not be bound by the “yes” and “no” of insurance companies. In emergency medicine, we are specifically taught to not look at insurance before making medical decisions, but this is not the case for the rest of medicine. And we know insurance companies, like the rest of us, like their money to stay in their own pockets.
I am grateful for you all, my fellow physicians who are willing to review cases for patients trying to get the care their physicians think they need. I am grateful for all your varied expertise, experiences, and wisdom. I have learned so much reading your reviews. I have learned a great deal about genetic testing and seen the shift from such testing being investigational to FDA approved for various cancers. I know when I see certain genetic testing, particularly with melanoma and prostate cancer, the claim will be denied. I know when an orthopedist requests sequential compression devices for home postoperatively, the claim will be denied. I appreciate the consistent support you all give to patients who have been on a particular medication for years and suddenly the insurance company denies coverage – usually due to formulary changes. Each time I read about something I don’t know about, I am provided with an opportunity to learn. I typically investigate the illness, testing and/or procedure being requested to expand my own knowledge base.
But the time has come for me to turn my job over to another as I pursue other opportunities at my local hospital system and college of medicine. Dr. Brad Weir will be taking over as chief medical officer as of Jan. 1, 2024. I have known Dr. Weir for 13 years and have every confidence in his ability to lead in his new role.
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