May 26, 2017

Physicians as Reviewers vs. Providers of Care


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11/17/2008
Brian S. King
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This insight by Dr. Adam Wolfberg, an obstetrician, appeared in the Boston Globe earlier this week. It brings a different perspective to a dynamic I see a lot. In handling denied medical and disability claims I routinely run across the opinions of doctors who have been retained by insurers or other payers to review claim files and assist the payor in deciding whether or not to pay those claims. What obligations do these physician reviewers owe to the individuals whose medical records they are reviewing? Dr. Wolfberg talks about a specialist in the field of cerebral palsy who applies different standards for what he believes is medically necessary care when treating his own patients compared to what he believes is medically necessary when reviewing files for health insurers. Dr. Wolfberg refers to an American Medical Association ethical rule that states, “Physicians in administrative and other nonclinical roles must put the needs of patients first . . . The ethical obligations of physicians are not suspended when a physician assumes a position that does not directly involve patient care.” Provider versus payer tension regarding healthcare has existed as long as the two have been around. That tension has been made more acute in the last few decades with the advent of HMOs and thorough injection of managed care into the medical arena. Thus, Dr. Wolfberg’s concerns are not unique. But his personal perspective brings home the dilemma in a poignant way.

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