[monkburger]

I frequently have to deal with this, particularly peer-to-peer (P2P) authorization. I have never been assigned a practising oncologist as a peer. Often a retired unrelated speciality (paediatrician, psychiatrist) or a non-practising insurance doctor. They are unfamiliar with any of the data in the field, and they read off cards provided to them by their "third party" employer to deny care, even care that falls within national guidelines. I had to escalate this to the CMO of the insurance company before, at which time they admitted that the treatment should have been approved from the beginning. Their goal is to make the process frustrating ("just call this number..." it's a phone tree), introduce delays ("please fax your appeal to this garbage can and we will consider looking at it between 72 hours and never"), require multiple layered appeals ("so I'm just the peer to a peer reviewer, and my guidelines say to deny this, but you are welcome to appeal to a panel that might read the references you already sent in"), and anything else to ensure that patients stop pursuing care and die before getting expensive drugs.

It is never based on quality care, but on increasing friction and pain in the system in order to minimize payments out of money already collected from patients. It is a criminal racket and nothing makes me angrier in my entire practice.