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Opinion: Insurance companies second guessing physicians is no way to run our health care system
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An ambulance in parked at the Northeast Georgia Medical Center emergency room Thursday, Oct. 17, 2019, after bringing a patient into the hospital. - photo by Scott Rogers

I believe if you asked my husband, Tommy, about me, he would say that I am usually a mild-mannered individual with relatively conservative views who has developed a “live and let live” attitude over the course of my 60-plus years. 

Reading the Nov. 8 edition of The Times moved me to share firsthand how Anthem and other large insurers are assuming the roles of treating physicians in today’s health care arena. Though I understand from 35 years as a human resources practitioner that there are usually at least two sides to any argument, I would like to weigh in on the state of the Anthem issue from the standpoints of a concerned caregiver of both of my parents and as a former employee of NGHS.

In 2012, as managed care was taking its toe hold in our nation, I came out of retirement to develop an analytical denials taskforce team whose job was to appeal denied claims for services and in-patent hospital stays of former patients at NGMC. 

For six years, I have seen the health insurance industry use their “Monday morning quarterback” analyses in deciding if treatment of their insurance members was medically necessary. Time after time our team would cite patient symptoms, medical chart data, lab values, plan of care and subsequent diagnoses and outcomes toward patient stabilization only to have the insurance company(ies) deny over 70% of all the appealed claims! 

The Times article stated that rules are changing, and nothing could be more true as it relates to hospitals and health care providers having contracts altered mid-term by insurance companies.

As technology improves and enhances the speed and efficiency of diagnosis and treatment, that same technology and subsequent treatment is deemed “not medically necessary” by the insurer’s medical director. It is as if the insurance companies of our nation want to review the medical file after the fact only to second guess the treating physician who, in the heat of the moment, makes life-altering decisions for medical care and treatment. 

How is this outlandish scenario allowed to happen in our society? What is remotely fair about an outside physician who works in the best interest of his employer, the insurance company, making after-the-fact decisions about your health care and your well-being?

For the capable and professional medical teams, managed care personnel, and revenue staff that strive every day to compel insurers do the right and fair thing for their members, I applaud your efforts. 

Sadly, the battle with Anthem may prove to be the tip of the phenomenal iceberg as more insurers expect a bigger portion of the health care and treatment pie. Since most of us pay a substantial amount annually for health care coverage for ourselves and our families, it might behoove us to explore what our insurers are giving back to our medical service providers and hospitals on our behalf. 

Shame, shame, Anthem. It’s time to come back to the bargaining table with an open mind and a less greedy heart.

Joan Sheffield 


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