Exposing Bad Doctors: How Auto Insurance Companies Flag Them

Auto insurance companies have a variety of methods to identify fraudulent claims and bad doctors. They analyse claims history, looking for patterns in the frequency and type of past claims. They also use a checklist of suspicious loss indicators, such as a claimant who is calm and collected after submitting a large claim, or who adds insurance coverage shortly before submitting a claim. Private investigators are also used to research claimants' backgrounds and interview witnesses.

In addition, insurance companies use sophisticated computer systems to detect suspicious billing, especially in medical and auto repair claims. They also have special investigation units with employees who have backgrounds as detectives, police officers, or medical personnel, who are capable of performing tests and checks to assess suspected fraud. These units can, for example, conduct burn-pattern analyses on cars and homes damaged by fire to determine if the fire was accidental or intentional.

Insurance companies also try to prevent fraud by running credit checks on prospective employees, as fraud can also originate from within the company. For instance, claims adjusters may skim money off the top of insurance payouts.

Insurance companies use 'utilization management' to evaluate and overrule doctors

Insurance companies use utilization management to evaluate and overrule doctors. Utilization management is a set of techniques employed by insurance companies to manage healthcare costs by evaluating the necessity of medical treatments and services on a case-by-case basis. This process often involves a review of the patient's health insurance plan, the proposed treatment, and an assessment of whether the treatment is necessary and, if so, how much of it is needed. The reviewer then submits the proposal to the insurance company for approval.

There are three types of reviews available in utilization management: prospective, concurrent, and retrospective. A prospective review evaluates the necessity of a procedure and rules out duplicate treatments before treatment starts. It is used for routine or urgent treatment but not for emergency room cases. Insurance companies can overturn a doctor's orders for treatment during this type of review, which can cause resentment among patients and staff.

The second type of review is the concurrent review, which occurs if treatment is already in progress. This review monitors the patient's progress and the resources used during treatment. Reviewers may also stop treatment prematurely or discharge a patient earlier than planned. Concurrent reviews consist of three major areas: discharge planning, care coordination, and care transition.

The third type of review is the retrospective review, which is performed after the treatment is completed. It focuses on the effectiveness and appropriateness of the treatment and can be used to challenge the denial of claims or check the accuracy of reimbursements.

Utilization management aims to lower costs, improve patient care, and reduce the denial of claims. However, it can also create animosity between patients, healthcare providers, and insurance companies, especially when patients are left with the burden of paying for rejected treatments. Utilization management tends to favour safer and more cost-effective treatments, and insurance companies can overrule doctors' orders for treatment.

Insurance companies can request that patients visit their own doctors for an evaluation

If an insurance company requests an IME, it is typically to get a professional evaluation of the patient's injuries and to verify that the injuries are, in fact, a result of the accident in question. This does not diminish the assessments made by the patient's chosen doctors. However, patients have the right to refuse to undergo an IME and can instead supply the insurance company with the necessary documents themselves.

In some cases, insurance companies may try to control doctors' practices by requiring them to use "cost-effective" alternatives or withholding treatment altogether. This can result in doctors having to fight with insurance companies to secure the care they believe their patients need. Additionally, insurance companies often deny disability claims, dismissing the severity or legitimacy of the illness, which can leave patients feeling overwhelmed by rising healthcare costs.

To protect their rights and ensure compliance with legal procedures, patients can seek legal support when navigating insurance requests. It is important for patients to keep thorough records of all medical consultations, treatments, and communications with insurance companies.

Insurance companies can deny disability claims

• Insufficient medical evidence: To qualify for disability benefits, you must provide comprehensive medical documentation that proves your inability to work due to your medical condition or injury. Incomplete or insufficient medical evidence can lead to your claim being denied.
• Failure to meet eligibility requirements: Disability benefits are typically available to employees who meet certain criteria, such as the number of hours worked per week or the duration of employment. If you do not satisfy these eligibility requirements, your claim may be denied.
• Pre-existing conditions: Many disability insurance policies exclude coverage for pre-existing conditions. If your medical condition was present before you were covered by the policy, your claim can be denied. It is important to carefully review the terms of your policy to understand any exclusions or limitations.
• Failure to follow treatment: If you do not adhere to the prescribed treatment plan for your medical condition, such as taking medication or attending therapy sessions, your claim may be denied. Insurance companies may view this as a sign that you are not doing your part to improve your condition.
• Missing or incomplete information: Insurance companies often require a significant amount of information and documentation to process disability claims. If you fail to provide all the necessary details, your claim may be rejected.
• Surveillance evidence: In some cases, insurance companies may resort to surveillance tactics to investigate claimants they believe have exaggerated or enlarged their disability claims. They may follow you, take videos or pictures, or track your movements to catch you performing activities that contradict your claimed limitations. This evidence can then be used to deny your claim.
• Fraudulent claims: Insurance companies actively monitor benefits recipients to detect any signs of fraud or misrepresentation of a medical condition. If they suspect fraudulent activity, they will not hesitate to deny your claim.

It is important to remember that insurance companies prioritize their financial interests and will often look for reasons to deny claims. If you feel your disability claim has been unfairly denied, it is crucial to seek legal advice from a specialized disability lawyer. They can help you understand your rights, navigate the appeal process, and fight for the benefits you deserve.

Insurance companies can delay a doctor's decision about treatment

In the US, prior authorization (PA) is a health plan cost-control process that requires physicians to obtain approval for prescribed treatments or services before they can qualify for payment. PA requirements can cause delays in treatment, negatively impact clinical outcomes, and lead patients to abandon treatment. In a survey of 1,000 physicians, 92% agreed that prior authorization negatively impacts patients' clinical outcomes, and 61% said this impact was "significant". The same survey found that 92% of doctors reported that their patients experienced care delays due to prior authorization, sometimes, often, or always.

The time taken for prior authorization can cause patients to wait several days to receive their medication, leaving their condition untreated. In the survey, 30% of doctors said that they waited at least three business days for a prior authorization decision from a health plan in the previous week, and 64% reported waiting at least one business day.

The need for prior authorization can also discourage patients from following their doctors' recommended course of action. 80% of physicians said that patients sometimes, often, or always abandoned the recommended test or treatment due to issues related to prior authorization.

In addition to prior authorization, insurance companies use other utilization management strategies to control doctors' decisions, including step therapy, quantity limits, and nonmedical switching. These strategies can also lead to delays in treatment and negatively impact patient care.

Patients who feel they have been denied care or had their treatment delayed due to insurance company decisions can appeal the company's decision and have it reviewed by a third party. They can request an internal appeal or an external review by an independent third party.

Insurance companies can request access to your medical records

In the context of auto insurance, an insurance adjuster may contact you after an accident to request access to your medical records. While you do not have to authorize this access, it is advisable to speak with a lawyer to navigate the situation effectively.

• To verify that your injuries are from the accident: Insurance companies want to confirm which injuries were presented to the healthcare provider and when, as this helps determine their liability.
• To understand your estimated recovery timeline: Insurance adjusters want to know your prognosis and when you are expected to reach maximum medical improvement (MMI).
• To find reasons to deny or undervalue your claim: Insurance adjusters may look for inconsistencies in your statements or opportunities to argue that the accident did not cause the injuries you claim.
• To contradict your doctor's medical evaluation: Insurance companies have their own healthcare experts who will assess your records and may request that you visit one of their doctors for an evaluation.

It is important to carefully consider any requests for access to your medical records and seek legal advice if needed.

Frequently asked questions