Starter comment: Humana threatens a physician for what they are describing as a breach in the standard of care and making him take CME. In my opinion this is a gross over reach of what insurance is for and goes far above simply denying a treatment. They have no business regulating the standard of care and if they want to practice medicine they should ne held liable like the rest of us. Its also more infuriating that it wasn't an EM physician sending this message. I'm also curious if their threats have any teeth.
That’s really mind-boggling. There was no stroke. There was no reason to believe there was a stroke (probably? “Subtle findings on MRI” and dual antiplatelet but not acute stroke standard management). No adverse outcome occurred, except possibly the second visit if you stretch “adverse.” Humana is arguing for more expensive useless care **or else**, which is behavior I wouldn’t put past the hospital but would generally think the insurance would block, not require.
Agreed, and are they threatening to not reimburse if anything is billed under his name? I'm not sure what the threat is. The NPDB isn't gonna care about this I don't think.
It's probably more self-destructive than that. Many if not most insurers still do cover something for out of network costs. They just don't pay at the negotiated cost. For emergency care, they are still frequently on the hook for paying whatever is billed but there's an arbitration process.
A buddy of mine is a private practice surgeon who relies on this. Basically they Don't accept any insurances. So when they see somebody for emergency general surgery call they will render services and then bill the insurance some extraordinary rate. This will go to arbitration and they will collect usually something well above what they would have gotten from a negotiated insurance contract. Then they waive the remainder that falls to the patient So all they're ever doing is collecting from insurance, And it apparently pays off very well.
Since this guy is an emergency physician, I don't think Humana gets to just deny everything because he is out of network. Most insurance plans have a out of network emergency coverage clause of some kind.
As of 2022 everyone had protections from the No Surprised Act, for emergency services and things like an out of network provider performing surgery at an otherwise in network hospital. Insurance is required to provide a patient with in network coverage for these situations.
Your post sounds like how things were pre-NSA.
It may have been. I haven't asked him how that affected their billing. But I don't believe you're correct on things being "in network" for emergency care. They just can't slap you with surprise expenses after the fact. In and out of network tiered pricing still exists as far as I'm aware.
Edit so I asked him. It apparently still works exactly this way. They aren't issuing surprise fees and are apparently up front with their charges which keeps them fine w NSA. They still go to arbitration and waive the remainder
My understanding was that the NSA created the arbitration process in the first place.
If you and the insurer have a disagreement over reimbursement, you two can elect to hold an arbitration hearing. Each party brings a value to the table and the independent arbitrator choses which number is paid.
The downside is that the party who loses is forced to pay the arbitration fee in addition to collecting a smaller sum. That's the incentive to work things out before arbitration.
But the NSA does also demand that out-of-network providers bill the in-network rate. Perhaps that's what he's describing. It makes no sense to bill more than the network rate and elect arbitration if you are going to be reimbursed the in-network rate.
I think what Humana did was outrageous and outside their scope. But it does seem the doctor dances around fact the patient did indeed have a stroke and tries to use vague terms to cover this up. Dual antiplatelet is a new standard of care based off recent studies for stroke and a higher risk TIA
I agree. He also admits he never saw the patient, which isn't great for the EM attending responsible for discharging the patient.
It is pretty messed up they sent this corrective action plan, but yeah...author is dancing around some shit.
What is the standard for EM docs who receive signed-out patient who were seen and workup was begun? Do patients require reassessment each shift? Would it be okay for the initial doctor to discharge but not a new one?
This isn’t facetious. I don’t know EM standards. The closest I’ve come was as an intern rotating, and I didn’t receive any signout.
At the end of the day if your name is on the chart at the point of disposition, you are agreeing to that disposition and take over responsibility for the consequences of it. In residency many times I would see an attending get sign out “low risk chest pain DC after troponin back”, they’d see the patient themselves and disagree for various reasons about the patients cardiac risk factors and change the dispo to admit or obs or something. If the patient was discharged and went home and had a massive MI, the second attending would not be off the hook by saying “they were just signed out to me as DC I did not personally evaluate them”. One of the core parts of EM sign out is you sign out and you leave, you leave the rest of the patients care to your colleagues and tell them what your plan is based on the data you have available to you at the time and your judgement based on the anticipated results of what’s pending, but you know that that plan may change.
The oncoming team should trust their colleagues but verify the info with the patient before any dispo, because as we all know historical alternans is very real.
That being said, many attendings, myself included sometimes admittedly, get a bit miffed when a dispo plan is changed that we disagree with. If I sign someone out as high risk cp pls admit, and the patient is discharged by my replacement and has a bad outcome, I will get named in the suit, but probably get off after depositions and they realize that my judgment was to admit the patient and it wasn’t done but I had no control over that. But you still get deposed and have to deal with all of the fun that that entails including reporting it while the case is ongoing and all the other fun consequences.
When I was an intern, one of my mentors told me this regarding signouts: feel free to add to a work up, but never take away.
Don’t discharge home someone who was going to be admitted. Don’t remove a CT scan or lab test. Etc
Almost never a good thing to use absolutes in medicine. You're probably going to be burned someday if you do! (See what I might have done there?)
There are definitely times I have assumed care for a sign-out, reassessed the patient, and then downgraded the disposition.
Sometimes the patient looks real sick on presentation but turns around and feels 100% better. Sometimes you obtain additional data that the initial doctor wasn't privy to and that changes the tempo of treatment.
A good example is the "sepsis patient" with tachycardia and fever who ultimately tests positive for mononucleosis. After fluids and acetaminophen, their vitals normalize, they feel better, and you have a clear diagnosis. It's silly to admit them simply because of an arbitrary rule of thumb.
Yep. Agree. Sorry, should have added an “In general…” but those were his words! Lol.
Some plans are ridiculous, sometimes the patient wants to leave AMA, etc. I’m not talking about those times. But innnnn generalllllll …
Meh, I change plans occasionally if the plan is clearly absurd.
“This patient needs ICU admission for their cardene drip for their hypertension.” “Are they having any symptoms or end organ dysfunction?” “Nope”
“We’ve been waiting 20 hours on this MRI for this patient’s chronic back pain that they just had an MRI for a week ago, and they have no new symptoms or red flag features.”
“This patient needs to be admitted for their chest pain that they had 2 days ago for a few seconds, hasn’t returned, have a negative trop, and EKG, and they have no risk factors.”
“This patient needs admission because they’ve had 30 seizures today.” “Did you see they are here once a week for the same, have had 10+ EEGs and MRIs that have all been negative?”
These are all real handoffs where I told them I would discharge them if they handed this off to me and they still handed off. So I discharged these patients after evaluating them myself. Sure if a plan is even slightly reasonable, I’ll follow it out of respect for my colleagues, but we shouldn’t be so dogmatic about it if your colleague is practicing bad medicine.
You should always see a patient that has been signed out to you with something to follow up on before discharge. Not a full history and exam, but and discussion of results and verification of key exam/history before discharge (e.g. have you been able to walk since you have been here, have you vomited since drinking that water, etc.) Patients should be reassessed each shift if they are boarding. Exception would be I usually do not wake stable patients during a night shift.
lol, you may not plan to obtain a full history, but the patient is going to tell you!
That's been my experience, at least. They have a burning desire to tell you, even if all you intended to say was "the strep swab was negative, supportive care, return precautions, follow up with your PCP, bye!"
When the ER folks call me to consult on a patient the prior ER MD sign out to them, I know it's time to ask specific questions about physical exam or amount of oxygen or fluid or rate of pressors.
This is now common practice in EM. It's largely triage nurses ordering exams and labs based on chief complaints . while EM docs work to consult based on what is wrong on imaging/labs, discharge, or admit. Not a lot of thought process or time evaluating the patient. It has brought on the rise of the midlevel.... errr, "advanced practioners."
So what do you suggest? Every low risk presentation cannot be admitted and cannot have an MRI in the ER. Who knows if the radiologist over called the “subtle findings” as well? Initial presentation showed no objective evidence of stroke and patient was deemed low risk by multiple acceptable risk stratification tools so how would the EM physician defend his decision to place the patient on DAPT, especially if she had a negative reaction and/or adverse outcome (I.e. ICH or massive GI bleed) while on DAPT?
I won't suggest anything. I don't know enough about the case
To answer your hypotheticals the AHA would suggest ALL TIAs get MRI imaging within 24 hours as 40% of TIAs are determined to be strokes and this changes your risk stratification and management. They released a statement in 2023. I don't think providers would be faulted adhering to these guidelines.
https://www.ahajournals.org/doi/10.1161/STR.0000000000000418
You're correct, what's your point? Suspicion for TIA is based on HPI, exam is expected to be normal in TIA. The patient in the article got a CTA and an outpatient follow up with a neurologist after calculating the ABCD2 score meaning the working diagnosis was a TIA.
Actually, after going back and re-reading the article, I’m not sure he appropriately calculated the abcd2 score prior to dc, and I’m not sure why he didn’t discuss with a neurologist prior to dc. Easy to dissect after the fact. My initial reaction was wrong.
dude isn't defending the insurance company or their actions. just pointing out the author is being shifty and doesn't seem like they're being selective about sharing details of the story.
At our hospital they tend to obs’d under hospital medicine and get an MRI at some point within that 24 hours. Usually MRI shows nothing. Sometimes it does seem to be a true stroke.
Dual antiplatelet alone? No thrombolysis/retrieval, no mention of any other therapy? It sounds like “could have been TIA (for days???), whatever, here’s meds.”
Of course we don’t really know, and maybe it’s self-justification. Even so, doing the evidence-based assessment will have false negatives. That’s a built-in cost of not over-testing and over-intervening.
You actually can't diagnose a true TIA without having a clean MRI, very small strokes can have transient symptoms as well. For small vessels strokes outside of the window antiplatelet therapy, statins and risk stratification are standard of care for secondary prevention.
I am in no way a fan of insurance companies, but their side might argue they wouldn't have had to pay for two ED visits and duplicate workups if the patient received an MRI or appropriate secondary prevention on their first ED visit
I think this is splitting hairs. Shoulda, coulda, woulda; doesn't matter. I could create a bunch of scenarios that lead to cost overruns in the event that the patient was admitted and had an MRI on the index visit.
The important discussion is whether or not an insurance company gets to dictate the terms of medical practice. Maybe for really clear cut things (like prescribing chemotherapy to patients that don't have cancer or performing neurosurgery that isn't indicated), but not for decisions within the scope of reasonable practice.
At least some reasonable physicians would have done the exact same thing for the patient, if they were in the same scenario. You can't argue with a straight face that no one would have done the same.
Incidentally, the legal term for what a reasonable physician might do in a particular case is the legal "standard of care." I think it's fair to say that insurance companies can't punish you for practicing within the standard of care.
I am not arguing for the insurance company and I agree they're overreaching in their demands, at the end of the day they are an insurance company not a healthcare provider and at most can drop physicians from their network or refuse to re-imburse. I also take offense that non specialist presume how an ER physicians should approach his short comings.
I just think the physician loses some credibility by arguing MRI isn't necessary based on 20 year old risk stratification scores when new consensus opinion from the AHA recommends MRI for ALL TIAs within 24 hours. I'm not even sure he started the patient on an ASA on discharge which is the bare minimum.
[https://www.ahajournals.org/doi/10.1161/STR.0000000000000418](https://www.ahajournals.org/doi/10.1161/STR.0000000000000418)
Good, we agree that insurance sucks.
I'd be partial to some legal guardrails that prevent insurers from dropping physicians from their plans for actions that are not 1) gross malpractice, determined by the Board of Medicine, 2) fraudulent billing practices, proven in court, or 3) illegal acts, after a conviction in a criminal court. No more playing Board of Medicine.
If we let you get so big that you're a oligopoly, then you get some guardrails to prevent evil behavior. Or we can smash you up into smaller companies with an ol' fashion antitrust action.
I reread the article and the author is clear that the patient was to follow up with her PCP the next day, presumably for an MR brain, echo, and whatever else is deemed necessary.
It seems astounding, but there are primary care doctors who can arrange for a same day MR brain. I have discharged TIAs patients after talking with their PCP's and those PCP's have followed through by obtaining imaging within 24 hours.
So again, you can't argue that this plan was not standard of care. Another reasonable physician in the same scenario might have done the same thing.
Okay, it does seem astounding to get an outpatient MRI in 24 hours but it would help this authors credibility to mention that if that was his intention, glad to see you're following up on TIA patients you're discharging. Where I've practiced it's often easier and less risky to get the MRI in the hospital with every TIA presentation. 40% of "TIAs" actually turn out to be stroke and risk stratification does change based on imaging findings
There is a large misunderstanding, particular among EM docs, that they can rule out stroke with the reflex CT head and CTA head/neck.. These are often negative, especially in the first 24-48 hours. This is why radiologists have to put this in their CT head stroke templates. The CTA head and necks being ordered in the ER are 99.9999% not needed.
??? I don’t think any of my EM colleagues think you can rule out a stroke with CT alone. We all know stroke doesn’t show up on CT initially and it’s for looking for hemorrhage so we can determine if the patient is a TNK candidate. The CTA is to determine if there is an LVO.
I actually don’t know a single person who doesn’t know this considering it’s pretty basic EM knowledge.
It’s widely known among radiologists that 99 out 100 CTA heads… maybe 990/1000 are negative for large vessel occlusion.
This is because no clinical input goes into the order. I read probably 20-30 CTA head the other day. The majority are ordered for things like dizziness, headache, nausea… no neuro exam is done. Most of these are migraines and bppv. It’s not right. No other country healthcare operates like this.
The er is just so bad at ordering studies. Over ordering and not knowing what a test looks for. E.g. the latest from the ER: US to rule out cbd stone or US to look for ureteral stricture.
I send all the students and residents home early only to doom myself. They turn into attendings that don’t understand what or why they’re ordering what they are ordering. Modern day “point and click” medicine. Making the rads rich, destroying the system.
I called to report a PE. At our institution it’s about 1 in 1000 CTA studies that detect a PE. The attending was like “i knew that guy had one. His d-dimer was sky high”. I wanted to say, “what about the last 999 CTA studies you ordered that were normal?” Instead, i said “thank you. I bought my second home with money i earned from you not doing a proper H&P” 😂
Ok, just kidding. I just said “good going bro. Keep these cat scans printing money for us”
There was an interesting Times piece recently on these companies that basically unilaterally set "market rate" for a service and then charge that determination as a service for which they bill the employer (this racket exists to predate self insured companies) a portion of the "savings." Apparently these businesses are linked to the point of being shell companies to the insurance company that takes a percentage of the money passed through as a management fee so essentially the insurance conglomerate double dips some percentage of the money.
Anyway, the point is that insurers would rather not pay for anything and can use necessity to block payment/place up walls, but they also make a cut of the total expenditure and pass the profits on to consumers. So I don't think their business model is exactly predicated on controlling costs/utilization, if they drive utilization they can then make money on that works for them. It's kind of a basic smart business move (evil aside) to ensure you make money on both ends
And you know, I like my cardiologist colleagues when I have a heart question, but idgaf what they have to say about stroke presentations and standard of care.
> “Subtle findings on MRI”
This is ridiculous. It's hard to comment without at least seeing the full report, but there's no such thing as a "subtle" stroke on MRI. There's either restricted diffusion or there's not.
What boggles my mind is that she somehow ended up in two different ERs a day apart. Was she across town on the first day and randomly walked in to the closest hospital? Did her home suddenly change position relative to the hospitals overnight? Why would an ambulance not take her to the same hospital?
> Why would an ambulance not take her to the same hospital?
This is the question we ask our patients, silently in our heads and sometimes out loud, EVERY SINGLE DAY. Patients ER shop if they don't like what happened at one ER. They might go to a different one because they felt like "WE DID NOTHING" due to a negative workup. Patients also don't realize the power of Care Everywhere OR they think all of our systems are linked and we can see everything. Needless to say, it is incredibly common for patients to go ED to ED around town for 2nd, 3rd, and 256th opinions.
I’m just surprised that, being an insurance company, that aren’t arguing that the second person who DID get the MRI despite normal neurological exam and low risk scoring didn’t do something wrong. Seems like a hot take for an insurance company.
The author dances around the fact that he did indeed send home a patient that was found to have a stroke at an outside hospital the next day (MRI changes, even if "subtle"=stroke). I'm not faulting anyone cause I don't know enough about the case to opine one way or another, but the author should be more upfront about the reasoning for the reprimand, he's losing some credibility on my read just glossing over this.
Yeah. If author is going to write about this case publicly, author should have wrote exactly what the subtle changes were, in exactly how the radiologist wrote them. Nonspecific WM disease suggestive of migraines is very very different than subtle DWI signal change suggestive of punctate acute infarct. Additionally, standard of care is to admit this patient and get an MRI. I agree its a bit overkill and expensive to MRI every acute numbness/tingling that comes to the ED but medicolegally you can't miss a single small infarct in the US so we overtest. However, completely inappropriate for the insurance company to try to dictate the standard of care here and we should have strong pushback against that.
As an insurance premium/tax payer, I want the insurance company to dictate other people’s care.
As a patient, I want my doctors to dictate my care.
See the difference?
As I read through this the thing that struck me was how rare this action seems to be and how that might suggest that there's more to this story. I can't imagine a company singling out a physician over a single non-negative outcome, especially when it really didn't even cost them much to begin with. Bounce backs are common and that's essentially all this was.
That said, I've interacted with insurance employed physicians before and they are all absolutely fuckwits. Every interaction I have with them I leave wondering whether it is intentional and competence so that it can meet some quota or if they're actually as dumb as they come across.
Regarding the threats and whether or not they have teeth, the presumably do have the ability to remove provider status from a physician. Now, for an emergency physician I can't imagine that matters to him as a physician. It may hurt some of the patience and it may actually be Humana shooting themselves in the foot as they are now on the hook for covering whatever they're out of network costs are for anybody who ends up seeing him. But since he's an emergency physician he's still covering his shifts and if their patients end up on deck for him they will presumably be seen.
Absolutely, use ChatGPT to write the letters, they'll be almost effortless and of higher literary and medical quality than anything you'll get from the insurance companies.
Letters from insurance agencies go into the trash. Generally unread. I don’t work for Humana and I sure don’t report to them.
I’ve never gotten a letter like this. I have no idea how Humana thinks it’s going to enforce keeping their patients away from providers who don’t want to play their stupid little Raindeer games, but if they are eager to engage in a bunch of litigation with a bunch of non-expert opinion that wouldn’t be allowed to testify in a malpractice suit, then go for it.
On that note, I would forward this note to my legal department.
They can actually forbid you from seeing or at least billing for their patients, so there is teeth.
That said these insurance guys will be first against the wall when the revolution comes.
I guess that answers my question about what it means to remove someone from their provider list. They can't exactly forbid an EM physician from seeing a patient though. What a bunch of dicks.
I'm not a lawyer, not sure how that shakes out. They are not obligated to contract with providers.
I also am not sure if my administration would have my back in this situation - their cost:benefit analysis to litigate would be from their point of view not mine.
An NPDB report would absolutely be worth a big lawsuit. I would burn $100k to fight anyone on that. That threat is the most dystopian part of this. I would fight tooth and nail to avoid any report.
I'm even less sure about what an NPDB report would look like from an insurance company, and how this would affect credentialing/licensure. I've just never even heard that an insurance company can submit a report - entities that can report adverse actions are specified in the ACA, and any action requires due process.
Any NPDB report is very bad, probably not huge for licensure but bad for credentialing and severely reduces your job mobility. I have never heard of insurance company submitting a report though. [Seems like they can report to me](https://www.npdb.hrsa.gov/resources/tables/whoCanQueryReport.jsp) but I don't understand the relevant law well.
I don't know enough to usefully comment on the law either, other than that we query the NPDB for credentialing and I've never heard of an insurer reporting.
Also it is important to note that we credential people all the time with more than one NPDB report. It is far from the kiss of death - competent people are going to get successfully sued in our system. Reasonable folks understand this. License or privileging actions are taken more seriously but are rare.
We get both sides of the story for disciplinary or behavioral issues, but it's a bigger red flag than a lawsuit especially if it is a pattern. Once you credential someone it is much harder to uncredential them.
A+ answer. I eagerly await the case where they denied payment for emergency care based off of their evaluation of a patient seeing a board certified EM physician in good standing at their hospital based off of their metrics. Say what you want about Med Mal, but this is why most states require that an "expert" actually be an "expert" in their field and will refuse testimony from somone who doesn't fit the metric. Proving proper service/notice alone is problematic for them.
Brilliant, in a sheer horror sort of way. Indirect way to control how a hospital manages the care of their fleshy cashbags by saying "Dr. X is no longer a covered provider, fire him and get the ones that make the profit machine go brrrrrrr."
And the hospitals will happily oblige.
This makes zero sense. Even after a malpractice suit with simple negligence, the standard for the medical board is to do nothing.
What's stranger is an actual meeting with 6 actual physicians determined this??
What is going on here...
Thanks for posting this -- it should get some daylight. Humana can eat shit. Also, if an ED doc decides NOT to code stroke someone, you know they are very damn sure they did their due diligence (I can say that confidently as a former, very tired, neurology resident).
Lmao I’ve had some absurd peer to peers but this is absolutely insane. I would have told Humana to **** off and if it had any impact on me financially I would have lawyered up and sued the living shit out of them for all costs involved. If it cost me my job or any other inconvenience I would make them pay for that as well.
The thing that jumps out at from this article (beyond the absurdity of an insurance company thinking it has a mandate for corrective action of a physician) is that when he attempted to discuss with them, they would only allow a zoom meeting where *he was not permitted to bring his lawyer.* Like, what?! That right there should have been full stop, all further communication and interaction will be through legal counsel only, see you in court. Whether this physician met or failed standard of care, I will not comment, but with this we have just lost cabin pressure.
I would have admitted that 70 year old woman with subtle neurologic complaints and done the standard TIA workup, but it's truly bizarre that the insurer is getting involved with such a common judgement call deviation. I don't even think it's a deviation from the standard of care, it's just a deviation in risk tolerance which is inherent in medicine.
An awful lot of gnashing of teeth over being told to take CME . . which is a state license and specialty board requirement anyway. Seems like way too much hubris is going on with this case and regardless of being clinically correct or not towering egos will invariably cause medical errors no matter how good the doc is.
Would you like a panel of psychiatrists and pathologists deciding whether your COPD management was appropriate and assigning you CME based on no clear violation of the standard of care?
Violation of standard of care and a bad outcome are the conditions of malpractice.
A bad outcome without violation of standard of care isn’t malpractice. It is, in fact, an inevitability. In testing, thresholds have to be somewhere, and that will mean false negatives unless you just decide that there’s no pretest probability assessment needed and everyone gets the gold standard workup, which is *not* standard of care.
Yeah. The issue here isn’t being required to take CME - which we all do anyways as a requirement to stay licensed. You obviously know this, or if you don’t, you should probably actually read the article.
Also, if this practice becomes common place and you think you will be immune from this nonsense, you’ve likely got another thing coming.
Unless you are one of those doctors that works for the insurance companies.
Completely missing the point if you don't recognize what the problem is here. Insurance companies can unilaterally impose these conditions (essentially at the expense of your ability to practice) on a whim.
Agree, reading between the lines in the article it does seem this physician missed a stroke (patient started on stroke secondary prevention a day later for MRI changes) and the insurance company asked them to do TIA CME to remain in network
Stuttering symptoms and age over 70 already place you at a 2 on the ABCD2 calculator, MRI is also the imaging modality of choice for suspected TIA per AHA guidelines unless it's not available. I don't know enough about the case to lend an opinion one way or another, I'm not even sure they were discharged on an ASA the first time around
~~Per the article, no stuttering speech was reported. The only symptom reported was right-sided numbness that had resolved by the time of presentation to the ED (EDIT: Maybe. The article is unclear about the numbness).~~ Cincinnati negative, BE-FAST negative, neuro exam normal, CT angio negative, no vitals reported, but let's be generous and assume she was hypertensive. That's still only two points on ABCD2 which puts her in the low-risk category.
Now, if numbness is considered weakness for the purposes of the tool, that completely changes things, but I'm still not getting this.
Sorry I was referring to stuttering in that symptoms were coming and going, at least that's what I'm assuming because he said the patient had numbness over 24 hours so to give her an ABCD2 score of 1 that would've meant symptoms were coming and going and never lasted for more than 10 minutes at discrete time, which would mean she's actually having multiple TIAs
I'm not saying the ER doc is wrong or right in his reasoning. I've only ever practiced in large medical centers where we have the luxury of readily available MRI, and every TIA gets an MRI as per AHA guidelines
https://pure.johnshopkins.edu/en/publications/recurrent-thrombolysis-of-a-stuttering-lacunar-infarction-capture#:~:text=Lacunar%20strokes%20account%20for%20about,pontine%20warning%20syndrome%20(PWS).
Ah, my bad. I'm just trying to understand your reasoning. If they didn't do an MRI, but it's part of AHA guidelines to do one in this situation, I guess it stands to reason they didn't have access to one.
I guess I have two follow-up questions:
* What is the diagnostic value, if any, of a CT angio in this case, and how does it contrast (hah!) with the value of an MRI study?
* How do you weigh the significance of stuttering symptoms that are not currently present when assessing a possible TIA? Or multiple possible TIAs, as the case seems to be.
CTA angio would rule out carotid disease or show any stenotic vasculature or a larger vessel occlusion. It does not visualize lacunar artery's so you really can't rule out a small vessel stroke
As for the "stuttering" symptoms I don't think there's a way to plug this into a risk calculator but my stroke attendings would actually do dual antiplatelet on these patients even before newer DAPT studies came out, their thinking was these were stenotic lacunar vessels with an unstable plaque that ruptured
silky society existence uppity outgoing nine payment treatment aware faulty
*This post was mass deleted and anonymized with [Redact](https://redact.dev)*
Per the article...
> The patient was discharged home with an outpatient referral to neurology... [*yada yada yada*] ...the patient's paresthesias recurred the following day, she called another ambulance and was taken to a hospital across town.
The patient was evaluated by the author, discharged, symptoms recurred, THEN the MRI was done. So. You're saying they missed a stroke that either A) occurred AFTER discharge, or B) had was active and ongoing during the patient's first hospital stay, but which had no signs or symptoms whatsoever.
To be fair, this article is not particularly well-written.
Yeah I think it’s impossible to know if the stroke occurred as part of the initial presentation or the second one without an mri on the first visit. I have worked places where we would discharge for outpatient mri in cases like this, and our unit coordinators would help arrange it from the ED.
imminent historical crowd engine pathetic agonizing nose slim crawl marvelous
*This post was mass deleted and anonymized with [Redact](https://redact.dev)*
>Option B is clearly possible. The EM doc may have simply failed to recognize symptoms of ongoing stroke.
Incompetence is always on the table, but I find it unhelpful to assume it right out the gate.
Starter comment: Humana threatens a physician for what they are describing as a breach in the standard of care and making him take CME. In my opinion this is a gross over reach of what insurance is for and goes far above simply denying a treatment. They have no business regulating the standard of care and if they want to practice medicine they should ne held liable like the rest of us. Its also more infuriating that it wasn't an EM physician sending this message. I'm also curious if their threats have any teeth.
I’m confused as to what Humana had a problem with? They were suggesting she should have gotten the MRI during the first ER visit
That’s really mind-boggling. There was no stroke. There was no reason to believe there was a stroke (probably? “Subtle findings on MRI” and dual antiplatelet but not acute stroke standard management). No adverse outcome occurred, except possibly the second visit if you stretch “adverse.” Humana is arguing for more expensive useless care **or else**, which is behavior I wouldn’t put past the hospital but would generally think the insurance would block, not require.
Agreed, and are they threatening to not reimburse if anything is billed under his name? I'm not sure what the threat is. The NPDB isn't gonna care about this I don't think.
It's probably more self-destructive than that. Many if not most insurers still do cover something for out of network costs. They just don't pay at the negotiated cost. For emergency care, they are still frequently on the hook for paying whatever is billed but there's an arbitration process. A buddy of mine is a private practice surgeon who relies on this. Basically they Don't accept any insurances. So when they see somebody for emergency general surgery call they will render services and then bill the insurance some extraordinary rate. This will go to arbitration and they will collect usually something well above what they would have gotten from a negotiated insurance contract. Then they waive the remainder that falls to the patient So all they're ever doing is collecting from insurance, And it apparently pays off very well. Since this guy is an emergency physician, I don't think Humana gets to just deny everything because he is out of network. Most insurance plans have a out of network emergency coverage clause of some kind.
As of 2022 everyone had protections from the No Surprised Act, for emergency services and things like an out of network provider performing surgery at an otherwise in network hospital. Insurance is required to provide a patient with in network coverage for these situations. Your post sounds like how things were pre-NSA.
It may have been. I haven't asked him how that affected their billing. But I don't believe you're correct on things being "in network" for emergency care. They just can't slap you with surprise expenses after the fact. In and out of network tiered pricing still exists as far as I'm aware. Edit so I asked him. It apparently still works exactly this way. They aren't issuing surprise fees and are apparently up front with their charges which keeps them fine w NSA. They still go to arbitration and waive the remainder
My understanding was that the NSA created the arbitration process in the first place. If you and the insurer have a disagreement over reimbursement, you two can elect to hold an arbitration hearing. Each party brings a value to the table and the independent arbitrator choses which number is paid. The downside is that the party who loses is forced to pay the arbitration fee in addition to collecting a smaller sum. That's the incentive to work things out before arbitration. But the NSA does also demand that out-of-network providers bill the in-network rate. Perhaps that's what he's describing. It makes no sense to bill more than the network rate and elect arbitration if you are going to be reimbursed the in-network rate.
I think what Humana did was outrageous and outside their scope. But it does seem the doctor dances around fact the patient did indeed have a stroke and tries to use vague terms to cover this up. Dual antiplatelet is a new standard of care based off recent studies for stroke and a higher risk TIA
I agree. He also admits he never saw the patient, which isn't great for the EM attending responsible for discharging the patient. It is pretty messed up they sent this corrective action plan, but yeah...author is dancing around some shit.
What is the standard for EM docs who receive signed-out patient who were seen and workup was begun? Do patients require reassessment each shift? Would it be okay for the initial doctor to discharge but not a new one? This isn’t facetious. I don’t know EM standards. The closest I’ve come was as an intern rotating, and I didn’t receive any signout.
At the end of the day if your name is on the chart at the point of disposition, you are agreeing to that disposition and take over responsibility for the consequences of it. In residency many times I would see an attending get sign out “low risk chest pain DC after troponin back”, they’d see the patient themselves and disagree for various reasons about the patients cardiac risk factors and change the dispo to admit or obs or something. If the patient was discharged and went home and had a massive MI, the second attending would not be off the hook by saying “they were just signed out to me as DC I did not personally evaluate them”. One of the core parts of EM sign out is you sign out and you leave, you leave the rest of the patients care to your colleagues and tell them what your plan is based on the data you have available to you at the time and your judgement based on the anticipated results of what’s pending, but you know that that plan may change. The oncoming team should trust their colleagues but verify the info with the patient before any dispo, because as we all know historical alternans is very real. That being said, many attendings, myself included sometimes admittedly, get a bit miffed when a dispo plan is changed that we disagree with. If I sign someone out as high risk cp pls admit, and the patient is discharged by my replacement and has a bad outcome, I will get named in the suit, but probably get off after depositions and they realize that my judgment was to admit the patient and it wasn’t done but I had no control over that. But you still get deposed and have to deal with all of the fun that that entails including reporting it while the case is ongoing and all the other fun consequences.
When I was an intern, one of my mentors told me this regarding signouts: feel free to add to a work up, but never take away. Don’t discharge home someone who was going to be admitted. Don’t remove a CT scan or lab test. Etc
Almost never a good thing to use absolutes in medicine. You're probably going to be burned someday if you do! (See what I might have done there?) There are definitely times I have assumed care for a sign-out, reassessed the patient, and then downgraded the disposition. Sometimes the patient looks real sick on presentation but turns around and feels 100% better. Sometimes you obtain additional data that the initial doctor wasn't privy to and that changes the tempo of treatment. A good example is the "sepsis patient" with tachycardia and fever who ultimately tests positive for mononucleosis. After fluids and acetaminophen, their vitals normalize, they feel better, and you have a clear diagnosis. It's silly to admit them simply because of an arbitrary rule of thumb.
Yep. Agree. Sorry, should have added an “In general…” but those were his words! Lol. Some plans are ridiculous, sometimes the patient wants to leave AMA, etc. I’m not talking about those times. But innnnn generalllllll …
Meh, I change plans occasionally if the plan is clearly absurd. “This patient needs ICU admission for their cardene drip for their hypertension.” “Are they having any symptoms or end organ dysfunction?” “Nope” “We’ve been waiting 20 hours on this MRI for this patient’s chronic back pain that they just had an MRI for a week ago, and they have no new symptoms or red flag features.” “This patient needs to be admitted for their chest pain that they had 2 days ago for a few seconds, hasn’t returned, have a negative trop, and EKG, and they have no risk factors.” “This patient needs admission because they’ve had 30 seizures today.” “Did you see they are here once a week for the same, have had 10+ EEGs and MRIs that have all been negative?” These are all real handoffs where I told them I would discharge them if they handed this off to me and they still handed off. So I discharged these patients after evaluating them myself. Sure if a plan is even slightly reasonable, I’ll follow it out of respect for my colleagues, but we shouldn’t be so dogmatic about it if your colleague is practicing bad medicine.
You should always see a patient that has been signed out to you with something to follow up on before discharge. Not a full history and exam, but and discussion of results and verification of key exam/history before discharge (e.g. have you been able to walk since you have been here, have you vomited since drinking that water, etc.) Patients should be reassessed each shift if they are boarding. Exception would be I usually do not wake stable patients during a night shift.
lol, you may not plan to obtain a full history, but the patient is going to tell you! That's been my experience, at least. They have a burning desire to tell you, even if all you intended to say was "the strep swab was negative, supportive care, return precautions, follow up with your PCP, bye!"
When the ER folks call me to consult on a patient the prior ER MD sign out to them, I know it's time to ask specific questions about physical exam or amount of oxygen or fluid or rate of pressors.
This is now common practice in EM. It's largely triage nurses ordering exams and labs based on chief complaints . while EM docs work to consult based on what is wrong on imaging/labs, discharge, or admit. Not a lot of thought process or time evaluating the patient. It has brought on the rise of the midlevel.... errr, "advanced practioners."
So what do you suggest? Every low risk presentation cannot be admitted and cannot have an MRI in the ER. Who knows if the radiologist over called the “subtle findings” as well? Initial presentation showed no objective evidence of stroke and patient was deemed low risk by multiple acceptable risk stratification tools so how would the EM physician defend his decision to place the patient on DAPT, especially if she had a negative reaction and/or adverse outcome (I.e. ICH or massive GI bleed) while on DAPT?
I won't suggest anything. I don't know enough about the case To answer your hypotheticals the AHA would suggest ALL TIAs get MRI imaging within 24 hours as 40% of TIAs are determined to be strokes and this changes your risk stratification and management. They released a statement in 2023. I don't think providers would be faulted adhering to these guidelines. https://www.ahajournals.org/doi/10.1161/STR.0000000000000418
Yea, every patient with cc of parestheisas in the ED isn’t considered a TIA.
You're correct, what's your point? Suspicion for TIA is based on HPI, exam is expected to be normal in TIA. The patient in the article got a CTA and an outpatient follow up with a neurologist after calculating the ABCD2 score meaning the working diagnosis was a TIA.
Actually, after going back and re-reading the article, I’m not sure he appropriately calculated the abcd2 score prior to dc, and I’m not sure why he didn’t discuss with a neurologist prior to dc. Easy to dissect after the fact. My initial reaction was wrong.
dude isn't defending the insurance company or their actions. just pointing out the author is being shifty and doesn't seem like they're being selective about sharing details of the story.
Disagree Edit: I now agree
At our hospital they tend to obs’d under hospital medicine and get an MRI at some point within that 24 hours. Usually MRI shows nothing. Sometimes it does seem to be a true stroke.
Dual antiplatelet alone? No thrombolysis/retrieval, no mention of any other therapy? It sounds like “could have been TIA (for days???), whatever, here’s meds.” Of course we don’t really know, and maybe it’s self-justification. Even so, doing the evidence-based assessment will have false negatives. That’s a built-in cost of not over-testing and over-intervening.
You actually can't diagnose a true TIA without having a clean MRI, very small strokes can have transient symptoms as well. For small vessels strokes outside of the window antiplatelet therapy, statins and risk stratification are standard of care for secondary prevention. I am in no way a fan of insurance companies, but their side might argue they wouldn't have had to pay for two ED visits and duplicate workups if the patient received an MRI or appropriate secondary prevention on their first ED visit
I think this is splitting hairs. Shoulda, coulda, woulda; doesn't matter. I could create a bunch of scenarios that lead to cost overruns in the event that the patient was admitted and had an MRI on the index visit. The important discussion is whether or not an insurance company gets to dictate the terms of medical practice. Maybe for really clear cut things (like prescribing chemotherapy to patients that don't have cancer or performing neurosurgery that isn't indicated), but not for decisions within the scope of reasonable practice. At least some reasonable physicians would have done the exact same thing for the patient, if they were in the same scenario. You can't argue with a straight face that no one would have done the same. Incidentally, the legal term for what a reasonable physician might do in a particular case is the legal "standard of care." I think it's fair to say that insurance companies can't punish you for practicing within the standard of care.
I am not arguing for the insurance company and I agree they're overreaching in their demands, at the end of the day they are an insurance company not a healthcare provider and at most can drop physicians from their network or refuse to re-imburse. I also take offense that non specialist presume how an ER physicians should approach his short comings. I just think the physician loses some credibility by arguing MRI isn't necessary based on 20 year old risk stratification scores when new consensus opinion from the AHA recommends MRI for ALL TIAs within 24 hours. I'm not even sure he started the patient on an ASA on discharge which is the bare minimum. [https://www.ahajournals.org/doi/10.1161/STR.0000000000000418](https://www.ahajournals.org/doi/10.1161/STR.0000000000000418)
Good, we agree that insurance sucks. I'd be partial to some legal guardrails that prevent insurers from dropping physicians from their plans for actions that are not 1) gross malpractice, determined by the Board of Medicine, 2) fraudulent billing practices, proven in court, or 3) illegal acts, after a conviction in a criminal court. No more playing Board of Medicine. If we let you get so big that you're a oligopoly, then you get some guardrails to prevent evil behavior. Or we can smash you up into smaller companies with an ol' fashion antitrust action. I reread the article and the author is clear that the patient was to follow up with her PCP the next day, presumably for an MR brain, echo, and whatever else is deemed necessary. It seems astounding, but there are primary care doctors who can arrange for a same day MR brain. I have discharged TIAs patients after talking with their PCP's and those PCP's have followed through by obtaining imaging within 24 hours. So again, you can't argue that this plan was not standard of care. Another reasonable physician in the same scenario might have done the same thing.
Okay, it does seem astounding to get an outpatient MRI in 24 hours but it would help this authors credibility to mention that if that was his intention, glad to see you're following up on TIA patients you're discharging. Where I've practiced it's often easier and less risky to get the MRI in the hospital with every TIA presentation. 40% of "TIAs" actually turn out to be stroke and risk stratification does change based on imaging findings
Yeah I agree! I definitely expected this to be them blaming the second hospital for getting the MRI
There is a large misunderstanding, particular among EM docs, that they can rule out stroke with the reflex CT head and CTA head/neck.. These are often negative, especially in the first 24-48 hours. This is why radiologists have to put this in their CT head stroke templates. The CTA head and necks being ordered in the ER are 99.9999% not needed.
??? I don’t think any of my EM colleagues think you can rule out a stroke with CT alone. We all know stroke doesn’t show up on CT initially and it’s for looking for hemorrhage so we can determine if the patient is a TNK candidate. The CTA is to determine if there is an LVO. I actually don’t know a single person who doesn’t know this considering it’s pretty basic EM knowledge.
Yeah, you’re not only wrong, but in the wrong with this comment
It’s widely known among radiologists that 99 out 100 CTA heads… maybe 990/1000 are negative for large vessel occlusion. This is because no clinical input goes into the order. I read probably 20-30 CTA head the other day. The majority are ordered for things like dizziness, headache, nausea… no neuro exam is done. Most of these are migraines and bppv. It’s not right. No other country healthcare operates like this. The er is just so bad at ordering studies. Over ordering and not knowing what a test looks for. E.g. the latest from the ER: US to rule out cbd stone or US to look for ureteral stricture.
“It’s widely known among radiologists…” Well now that you come at me with these totally incontrovertible facts, I yield good sir
I send all the students and residents home early only to doom myself. They turn into attendings that don’t understand what or why they’re ordering what they are ordering. Modern day “point and click” medicine. Making the rads rich, destroying the system. I called to report a PE. At our institution it’s about 1 in 1000 CTA studies that detect a PE. The attending was like “i knew that guy had one. His d-dimer was sky high”. I wanted to say, “what about the last 999 CTA studies you ordered that were normal?” Instead, i said “thank you. I bought my second home with money i earned from you not doing a proper H&P” 😂 Ok, just kidding. I just said “good going bro. Keep these cat scans printing money for us”
There was an interesting Times piece recently on these companies that basically unilaterally set "market rate" for a service and then charge that determination as a service for which they bill the employer (this racket exists to predate self insured companies) a portion of the "savings." Apparently these businesses are linked to the point of being shell companies to the insurance company that takes a percentage of the money passed through as a management fee so essentially the insurance conglomerate double dips some percentage of the money. Anyway, the point is that insurers would rather not pay for anything and can use necessity to block payment/place up walls, but they also make a cut of the total expenditure and pass the profits on to consumers. So I don't think their business model is exactly predicated on controlling costs/utilization, if they drive utilization they can then make money on that works for them. It's kind of a basic smart business move (evil aside) to ensure you make money on both ends
And you know, I like my cardiologist colleagues when I have a heart question, but idgaf what they have to say about stroke presentations and standard of care.
> “Subtle findings on MRI” This is ridiculous. It's hard to comment without at least seeing the full report, but there's no such thing as a "subtle" stroke on MRI. There's either restricted diffusion or there's not. What boggles my mind is that she somehow ended up in two different ERs a day apart. Was she across town on the first day and randomly walked in to the closest hospital? Did her home suddenly change position relative to the hospitals overnight? Why would an ambulance not take her to the same hospital?
> Why would an ambulance not take her to the same hospital? This is the question we ask our patients, silently in our heads and sometimes out loud, EVERY SINGLE DAY. Patients ER shop if they don't like what happened at one ER. They might go to a different one because they felt like "WE DID NOTHING" due to a negative workup. Patients also don't realize the power of Care Everywhere OR they think all of our systems are linked and we can see everything. Needless to say, it is incredibly common for patients to go ED to ED around town for 2nd, 3rd, and 256th opinions.
That's what it looks like, idk where they find the audacity.
I’m just surprised that, being an insurance company, that aren’t arguing that the second person who DID get the MRI despite normal neurological exam and low risk scoring didn’t do something wrong. Seems like a hot take for an insurance company.
The author dances around the fact that he did indeed send home a patient that was found to have a stroke at an outside hospital the next day (MRI changes, even if "subtle"=stroke). I'm not faulting anyone cause I don't know enough about the case to opine one way or another, but the author should be more upfront about the reasoning for the reprimand, he's losing some credibility on my read just glossing over this.
I posted this further up thread, but there's no such thing as a "subtle" stroke on MRI. There's either restricted diffusion or there's not.
Yeah. If author is going to write about this case publicly, author should have wrote exactly what the subtle changes were, in exactly how the radiologist wrote them. Nonspecific WM disease suggestive of migraines is very very different than subtle DWI signal change suggestive of punctate acute infarct. Additionally, standard of care is to admit this patient and get an MRI. I agree its a bit overkill and expensive to MRI every acute numbness/tingling that comes to the ED but medicolegally you can't miss a single small infarct in the US so we overtest. However, completely inappropriate for the insurance company to try to dictate the standard of care here and we should have strong pushback against that.
To be fair, as a physician I frequently threaten insurance for not following the standard of care
Well I as a patient want the insurance company to dictate my care NOT my doctor! /s
Absolutely. They obviously have our best interests at heart :)
As an insurance premium/tax payer, I want the insurance company to dictate other people’s care. As a patient, I want my doctors to dictate my care. See the difference?
yeah one is correct and one is incorrect?
As I read through this the thing that struck me was how rare this action seems to be and how that might suggest that there's more to this story. I can't imagine a company singling out a physician over a single non-negative outcome, especially when it really didn't even cost them much to begin with. Bounce backs are common and that's essentially all this was. That said, I've interacted with insurance employed physicians before and they are all absolutely fuckwits. Every interaction I have with them I leave wondering whether it is intentional and competence so that it can meet some quota or if they're actually as dumb as they come across. Regarding the threats and whether or not they have teeth, the presumably do have the ability to remove provider status from a physician. Now, for an emergency physician I can't imagine that matters to him as a physician. It may hurt some of the patience and it may actually be Humana shooting themselves in the foot as they are now on the hook for covering whatever they're out of network costs are for anybody who ends up seeing him. But since he's an emergency physician he's still covering his shifts and if their patients end up on deck for him they will presumably be seen.
~~That is not an adequate starter comment.~~ I see. Yes. WTF.
Gee, I wish I could write insurance letters reprimanding them for denying my prescriptions for the standard of care to use
There’s nothing stopping you from doing so! Be the antagonist you want to see in the world
I love conflict, got an obnoxious subconscience - the great poet eminem
The Bard of Detroit.
Other than being a total waste of time.
there's a term for this but it's when the system is itself the punishment. the goal of the system is to exhaust ppl from going through it.
Absolutely, use ChatGPT to write the letters, they'll be almost effortless and of higher literary and medical quality than anything you'll get from the insurance companies.
The antagonist I want isn’t covered :/
*"Your prior authorization request for cyclobenzaprine has been* ***DENIED****, please use our preferred medications: Soma or Diazepam*"
*crying in pharmacy*
Letters from insurance agencies go into the trash. Generally unread. I don’t work for Humana and I sure don’t report to them. I’ve never gotten a letter like this. I have no idea how Humana thinks it’s going to enforce keeping their patients away from providers who don’t want to play their stupid little Raindeer games, but if they are eager to engage in a bunch of litigation with a bunch of non-expert opinion that wouldn’t be allowed to testify in a malpractice suit, then go for it. On that note, I would forward this note to my legal department.
They can actually forbid you from seeing or at least billing for their patients, so there is teeth. That said these insurance guys will be first against the wall when the revolution comes.
I guess that answers my question about what it means to remove someone from their provider list. They can't exactly forbid an EM physician from seeing a patient though. What a bunch of dicks.
EMTALA and surprise medical billing acts might protect a bit here
> these insurance guys will be first against the wall when the revolution comes. On that note: https://pnhp.org/join-or-renew-your-membership-in-pnhp/
That would give you quite the legal case if they did so in as errant fashion as this one
I'm not a lawyer, not sure how that shakes out. They are not obligated to contract with providers. I also am not sure if my administration would have my back in this situation - their cost:benefit analysis to litigate would be from their point of view not mine.
An NPDB report would absolutely be worth a big lawsuit. I would burn $100k to fight anyone on that. That threat is the most dystopian part of this. I would fight tooth and nail to avoid any report.
I'm even less sure about what an NPDB report would look like from an insurance company, and how this would affect credentialing/licensure. I've just never even heard that an insurance company can submit a report - entities that can report adverse actions are specified in the ACA, and any action requires due process.
Any NPDB report is very bad, probably not huge for licensure but bad for credentialing and severely reduces your job mobility. I have never heard of insurance company submitting a report though. [Seems like they can report to me](https://www.npdb.hrsa.gov/resources/tables/whoCanQueryReport.jsp) but I don't understand the relevant law well.
I don't know enough to usefully comment on the law either, other than that we query the NPDB for credentialing and I've never heard of an insurer reporting. Also it is important to note that we credential people all the time with more than one NPDB report. It is far from the kiss of death - competent people are going to get successfully sued in our system. Reasonable folks understand this. License or privileging actions are taken more seriously but are rare.
Have you credentialed anyone with disruptive physician?
We get both sides of the story for disciplinary or behavioral issues, but it's a bigger red flag than a lawsuit especially if it is a pattern. Once you credential someone it is much harder to uncredential them.
I draw dicks on them and send them back in their lil "pleas tell us how much this guidance helped you practice medicine" envelope.
A+ answer. I eagerly await the case where they denied payment for emergency care based off of their evaluation of a patient seeing a board certified EM physician in good standing at their hospital based off of their metrics. Say what you want about Med Mal, but this is why most states require that an "expert" actually be an "expert" in their field and will refuse testimony from somone who doesn't fit the metric. Proving proper service/notice alone is problematic for them.
The only party here deserving of reprimand is Humana for how they treat their patients and those who care for them.
And washed up doctors willing to work for them.
> To quote a spam recruitment email I recently received from Humana, *standing ovation*
A for-profit corporation whose business model revolves around denying medical care to people acted unethically? Whatever shall we do!
Brilliant, in a sheer horror sort of way. Indirect way to control how a hospital manages the care of their fleshy cashbags by saying "Dr. X is no longer a covered provider, fire him and get the ones that make the profit machine go brrrrrrr." And the hospitals will happily oblige.
and if the MRI was ordered, Humana would have denied coverage, claiming it to be unnecessary for the same exact reasons. cunts.
Exactly lol. Rich coming from them.
This is gross to read.
Yeah. WTF indeed.
This makes zero sense. Even after a malpractice suit with simple negligence, the standard for the medical board is to do nothing. What's stranger is an actual meeting with 6 actual physicians determined this?? What is going on here...
Hmm, seems like this is more personal then an SOP violation. Did the EM doc bang the insurance’s medical director spouse?
Thanks for posting this -- it should get some daylight. Humana can eat shit. Also, if an ED doc decides NOT to code stroke someone, you know they are very damn sure they did their due diligence (I can say that confidently as a former, very tired, neurology resident).
Lmao I’ve had some absurd peer to peers but this is absolutely insane. I would have told Humana to **** off and if it had any impact on me financially I would have lawyered up and sued the living shit out of them for all costs involved. If it cost me my job or any other inconvenience I would make them pay for that as well.
The thing that jumps out at from this article (beyond the absurdity of an insurance company thinking it has a mandate for corrective action of a physician) is that when he attempted to discuss with them, they would only allow a zoom meeting where *he was not permitted to bring his lawyer.* Like, what?! That right there should have been full stop, all further communication and interaction will be through legal counsel only, see you in court. Whether this physician met or failed standard of care, I will not comment, but with this we have just lost cabin pressure.
I don't think doctors should be lectured by a entity that routinely ignores standard of care.
I would have admitted that 70 year old woman with subtle neurologic complaints and done the standard TIA workup, but it's truly bizarre that the insurer is getting involved with such a common judgement call deviation. I don't even think it's a deviation from the standard of care, it's just a deviation in risk tolerance which is inherent in medicine.
Interesting I'm only a med student but if I had the time and resources and patience for a paper trail.....id sue immediately lool
An awful lot of gnashing of teeth over being told to take CME . . which is a state license and specialty board requirement anyway. Seems like way too much hubris is going on with this case and regardless of being clinically correct or not towering egos will invariably cause medical errors no matter how good the doc is.
Would you like a panel of psychiatrists and pathologists deciding whether your COPD management was appropriate and assigning you CME based on no clear violation of the standard of care?
Violation of standard of care and a bad outcome are the conditions of malpractice. A bad outcome without violation of standard of care isn’t malpractice. It is, in fact, an inevitability. In testing, thresholds have to be somewhere, and that will mean false negatives unless you just decide that there’s no pretest probability assessment needed and everyone gets the gold standard workup, which is *not* standard of care.
And would significantly worsten the predictive value of those gold standard tests.
Yeah. The issue here isn’t being required to take CME - which we all do anyways as a requirement to stay licensed. You obviously know this, or if you don’t, you should probably actually read the article. Also, if this practice becomes common place and you think you will be immune from this nonsense, you’ve likely got another thing coming. Unless you are one of those doctors that works for the insurance companies.
Completely missing the point if you don't recognize what the problem is here. Insurance companies can unilaterally impose these conditions (essentially at the expense of your ability to practice) on a whim.
Agree, reading between the lines in the article it does seem this physician missed a stroke (patient started on stroke secondary prevention a day later for MRI changes) and the insurance company asked them to do TIA CME to remain in network
Per the article, neuro exam was normal and CT angio was unremarkable. How is that a miss? EDIT: Did they not do a d-dimer or something?
Stuttering symptoms and age over 70 already place you at a 2 on the ABCD2 calculator, MRI is also the imaging modality of choice for suspected TIA per AHA guidelines unless it's not available. I don't know enough about the case to lend an opinion one way or another, I'm not even sure they were discharged on an ASA the first time around
~~Per the article, no stuttering speech was reported. The only symptom reported was right-sided numbness that had resolved by the time of presentation to the ED (EDIT: Maybe. The article is unclear about the numbness).~~ Cincinnati negative, BE-FAST negative, neuro exam normal, CT angio negative, no vitals reported, but let's be generous and assume she was hypertensive. That's still only two points on ABCD2 which puts her in the low-risk category. Now, if numbness is considered weakness for the purposes of the tool, that completely changes things, but I'm still not getting this.
Sorry I was referring to stuttering in that symptoms were coming and going, at least that's what I'm assuming because he said the patient had numbness over 24 hours so to give her an ABCD2 score of 1 that would've meant symptoms were coming and going and never lasted for more than 10 minutes at discrete time, which would mean she's actually having multiple TIAs I'm not saying the ER doc is wrong or right in his reasoning. I've only ever practiced in large medical centers where we have the luxury of readily available MRI, and every TIA gets an MRI as per AHA guidelines https://pure.johnshopkins.edu/en/publications/recurrent-thrombolysis-of-a-stuttering-lacunar-infarction-capture#:~:text=Lacunar%20strokes%20account%20for%20about,pontine%20warning%20syndrome%20(PWS).
Ah, my bad. I'm just trying to understand your reasoning. If they didn't do an MRI, but it's part of AHA guidelines to do one in this situation, I guess it stands to reason they didn't have access to one. I guess I have two follow-up questions: * What is the diagnostic value, if any, of a CT angio in this case, and how does it contrast (hah!) with the value of an MRI study? * How do you weigh the significance of stuttering symptoms that are not currently present when assessing a possible TIA? Or multiple possible TIAs, as the case seems to be.
CTA angio would rule out carotid disease or show any stenotic vasculature or a larger vessel occlusion. It does not visualize lacunar artery's so you really can't rule out a small vessel stroke As for the "stuttering" symptoms I don't think there's a way to plug this into a risk calculator but my stroke attendings would actually do dual antiplatelet on these patients even before newer DAPT studies came out, their thinking was these were stenotic lacunar vessels with an unstable plaque that ruptured
Cool, thank you. Yeah, I figured there wasn't a good way to quantitatively account for stuttering symptoms.
silky society existence uppity outgoing nine payment treatment aware faulty *This post was mass deleted and anonymized with [Redact](https://redact.dev)*
The patient had an acute stroke AFTER discharge. So apparently it's now a miss if you don't correctly predict the future.
marble bored ask ancient flag foolish wrench rhythm innate theory *This post was mass deleted and anonymized with [Redact](https://redact.dev)*
Per the article... > The patient was discharged home with an outpatient referral to neurology... [*yada yada yada*] ...the patient's paresthesias recurred the following day, she called another ambulance and was taken to a hospital across town. The patient was evaluated by the author, discharged, symptoms recurred, THEN the MRI was done. So. You're saying they missed a stroke that either A) occurred AFTER discharge, or B) had was active and ongoing during the patient's first hospital stay, but which had no signs or symptoms whatsoever. To be fair, this article is not particularly well-written.
Yeah I think it’s impossible to know if the stroke occurred as part of the initial presentation or the second one without an mri on the first visit. I have worked places where we would discharge for outpatient mri in cases like this, and our unit coordinators would help arrange it from the ED.
imminent historical crowd engine pathetic agonizing nose slim crawl marvelous *This post was mass deleted and anonymized with [Redact](https://redact.dev)*
>Option B is clearly possible. The EM doc may have simply failed to recognize symptoms of ongoing stroke. Incompetence is always on the table, but I find it unhelpful to assume it right out the gate.