Mad Velocity

I literally have to spend WEEKS teaching our team made up entirely of non clinicians (no formal medical training) how to read and interpret/understand prior visit notes, prior imaging reports and impressions for ALL radiology modalities (X-ray, DEXA, Mammo, Ultrasound, CT, MR, PET/CT, etc.), raw pathology reports, lab reports, and literally anything that’s in a patient’s clinical history and also look up the specific ICD-10 code for the diagnosis/reason for exam.

There are THOUSANDS of ICD-10 codes and they’re not always clear what each code covers based on the description alone IF ITS EVEN A VALID AND BILLABLE CODE. For example, R51.9 is “Headache, unspecified” so that one is pretty obvious. We use that when we’re trying to figure out why a patient is having headaches. R42 is “Dizziness and Giddiness”. You know what that one is used for? Vertigo Not Otherwise Specified (general vertigo but you don’t know what’s causing it). But if you just google “Vertigo ICD-10” you get H81.4 which is a DIFFERENT and VERY SPECIFIC TYPE of vertigo. And if you pick the wrong ICD-10 code to use, you’re probably going to get a denial.

THEN we have to take all of that and see if it meets clinical necessity by looking up the Clinical Guidelines specific to the test requested for the specific RBM the patients insurance uses. Each RBM has different guidelines. Once we find the guidelines for the right exam for the right diagnosis, we now have to read through intentionally over complicated checklists to see if we have everything we need. If we do we can finally start the request.

But wait, that’s just the beginning. NOW we have to figure out how to submit the request because each insurance has different rules. Major insurances like Aetna and Cigna use one designated RBM (EviCore in this case) and usually have an online portal. Blue Cross Blue Shield has hundreds of plan specific RMBs, some have portals, some require phone calls only, some are fax submission only, and SOME require you to go through the health plans Utilization Management Department directly and don’t use an RBM. Good luck figuring out which is which without sitting on hold for no less than 2 hours for each patient though. United Healthcare doesn’t use an RBM and authorization requests are done through them directly. UNLESS it’s UHC Oxford which goes through EviCore OR it’s UHC Medicare Advantage for some (not all) PET/CTs in which case that goes through Optum.

And that’s just the four major insurances. Third Party Administrators and state Medicaid/ Managed Care Organizations and other smaller insurances? You might as well just give up because even when you call to ask what to do they’re just going to laugh at you and say “good luck figuring it out because we aren’t allowed to tell you.”

After you figure out HOW to submit the request, you have to answer questions about the case. Like in the video it starts off with patient name, DOB, insurance info, doctor info, facility info, CPT (exam) code, ICD-10 code, etc.

Then you get asked questions about the case. And like in the video, sometimes the questions asked don’t match up with what is actually required because SURPRISE SHAWTY, if you answer even ONE question incorrectly the rest of the questions change. The questions are like the worlds most stressful choose your own adventure book because they’re intentionally worded to be confusing AND you can’t go back and change your answer because they think you’re trying to commit fraud.

After you submit the request, it either gets instant approved (almost never happens) or it goes to review. If it goes to review, you have to fax in the clinicals that support your request or call and speak to the nurse reviewer. After the nurse reviews it, a medical director reviews it if the nurse can’t approve the case. The medical director then approves or denies the request.

If they deny it? You get to now read the denial letter to see why and sometimes they’ll deny the case because “there’s something missing” when it’s very clearly in the clinical notes. So you have to go through the appeals process for THEIR MISTAKE.

And this is just ONE SMALL FRACTION of what we have to do for EVERY. SINGLE. PATIENT. each and every day. And this is for typical cases. If anything goes wrong (like the RBM can’t find the patient in their system but the home plan says authorization is required through that RMB) it gets so much more tedious and could take hours to solve the problem for just one patient.

I cannot wait for the day my job becomes redundant and I have to find another career because we now have Universal Healthcare.

Because I am tired.

I am tired of playing these stupid games set by these insurances.

I am tired of watching my trainees have legitimate panic attacks when they realize their income is now dependent on how well they play these stupid games.

I am tired of watching my trainees have meltdowns because they have to have near Physician level knowledge of everything in Radiology to essentially fill out a form correctly and get paid barely more than minimum wage.

I am tired of having to know even more than my trainees so I can support them while they grow their own skills and knowledge in a safe space.

I am tired of having to call patients and tell them we have to cancel the exams that will give them answers, improve their quality of life, fix their pain, or possibly save their life just because their insurance didn’t like the fact that they only took medication for 5 and a half weeks instead of a full 6.

I am tired of patients taking out their frustrations, anxieties, and fears on us because of shitty insurance practices when I make sure we know how to do everything we possibly can to make sure they can have their exams.

I am tired of watching my patients go through this entire ordeal just to have to cancel the exam because they cannot afford their Financial Responsibility.