I love my job. If there’s one aspect I could do without, it’s the insurance hassles. In this day and age of pre-certs and denials, I wish I could just take care of folks without navigating the gauntlet of insurance checkpoints in order to get approved.

‘Experimental’ procedure
I’ve been performing hip arthroscopy for more than 15 years and have helped many patients with this ever-evolving procedure. Yet, some insurers will deny coverage for this technique because they deem it experimental. Never mind that the patient’s hip has a bone spur the size of Boston or that their labrum is in more pieces than a box of Cracker Jack!

“All non-op measures were not exhausted, including physical therapy,” insurers will say when explaining a denial, some requiring a whopping 6 months of PT. Great, the labrum is so detached it is in the other room and I am going to subject my patient to PT and all its inherent twisting and probing and prodding for 6 months?

Denials are not unique to the hip. I’m lucky to get a biological cartilage knee resurfacing approved. When I do, I light 3 candles at church and throw a party. Here again insurers like to bandy about the “experimental procedure” line. So, the 3cm defect in the 20-year-old knee will respond to copper knee sleeves and gingko?

To make matters worse, the kneecap is not covered by some insurers, considered by some as a “non-major weight-bearing area.” Last I checked we humans do, in fact, walk on our legs.

I remember a patient with a knee chondral lesion so large, it had an area code. The only recourse for him was a biologic, cell-based cartilage transplant. I hoped and prayed for approval. Not! A little too “experimental.” Break out the copper knee sleeve.

Peer-to-peer calls
I loathe the dreaded phone calls from insurers (also known as peer-to-peer calls) regarding approval for a treatment plan. In essence, this scheme is to facilitate a dialogue between the treating physician and the insurance doctor (peer). Trouble is, my so-called “peer” is usually a 90-year-old retired proctologist who thinks “impingement syndrome” is constipation and whose favorite drink is Metamucil. My last peer was so old she had an airbag on her walker!

The ER admission workaround
In the past when a surgery was necessary and the denial was imminent or the patient was without insurance, you’d tell patients to come to the emergency room to be admitted for their “emergency surgery.” While appearing grossly unethical, for many this was the only recourse for treatment. I once witnessed the emergent admission and surgery for a non-healed stress fracture of the foot. Must have really hurt! I guess failure of Dr Scholl’s inserts justified approval. I have even seen shoulder and hip arthroscopies expedited “urgently” through admission via the ER. Lord knows how these patients got by the triage nurse. This scheming will hopefully be no longer necessary as more and more Americans gain coverage.

Worth the hassle
While I don’t see an end in sight for the insurance gauntlet, I still get to help people every day. And that, my friends, is still worth the hassle — even the dreaded peer-to-peer phone call. Next time I hope my peer still has a license.