Published with permission from Dr. Kris Held M.D.


Insanity reigns, and we must dethrone it. Today, a precious new patient sought my care. She is 28 and was perfectly healthy until 10 days ago when she developed a headache and then rather suddenly started to lose vision in her left eye. She was scared and waited a day or so hoping things would get better, but they’re not, they’re worsening. She confided in her mom who brought her in to see me, based on the recommendations of friends. I’m an M.D., a board certified ophthalmologist, having completed 4 years of college, 4 years of medical school, an internship in internal medicine, a three year residency in ophthalmology and ophthalmic surgery, 5 years on faculty as an attending physician at the medical school, and 23 years in private practice.


The patient and I engaged in a patient-physician relationship, and I obtained her medical history and examined her. This dear patient needs an immediate work up to make a definitive diagnosis, so that appropriate treatment can be implemented before she loses her vision or worse. She is worried, and so are her mom and I. According to standard practice, I arranged for her to have an immediate MRI scan of her brain. This is where the where the obstruction to her care began. The obstructionist is Blue Cross Blue Shield (BCBS), her “insurance company.”


BCBS will not authorize her MRI, because she is an HMO patient and has not seen her assigned “PCP” (primary care physician). If you have a BCBS HMO plan, you must see your PCP before BCBS will cover anything- even if deemed indicated by a board certified specialist. Your designated PCP is your gatekeeper, and there are no exceptions. She has not seen her PCP since having the BCBS HMO policy, because she is 28 and healthy. Apparently BCBS randomly assigned her a PCP, but the physician listed could not be located today, and no one was “on call” for her. In fact, the number listed seemed to be out of business. It just rang and then disconnected time after time. Sadly, there is a scarcity of PCP’s, and it can take months for a patient to get an appointment. Often, PCPs listed by the insurance companies are not actually “in network”, not accepting new patients, not in town anymore, not even in business, or not even practicing medicine anymore. My staff spent hours today trying to ascertain this PCP’s status and obtain authorization for the MRI, to no avail. I called and spent over an hour on hold and talking to various levels of BCBS employees working my way up the ladder through non medical personnel to finally speak to a nurse (God forbid I should get to speak to an actual physician colleague), who tried to get her manager to approve my patient’s MRI. This was all a massive waste of time as BCBS was unyielding. I was told all the usual things, sorry, this is policy, there’s nothing we can do, and even “maybe next time she won’t get the HMO plan.” I was informed all our conversations were being recorded for quality purposes, and I was glad. No one would believe the irrational nonsense I had to endure at the hand of these non-physician BCBS obstructionists without the recordings to prove it. At the end of the day, in spite of my pleas and appeals for rational behavior and ethical care, BCBS said NO, AKA- patient be damned, and screw you while you’re at it.


My patient can go to the emergency room tonight, and get the MRI at thousands upon thousands of dollars extra and hours upon hours of waiting and NOT seeing a specialist, and that will be covered. What a waste of valuable resources and abuse of the patient. The MRI I, a specialist, scheduled for this afternoon will not be covered. Further, BCBS negotiated a fee for the MRI of over $4000.00. The patient’s deductible is high. She will have to pay thousands. Ironically, I am an “out of network” physician. I will not enter into agreements with “insurance companies.” I only enter into agreements directly with my patients. I negotiated directly with a local imaging center a fee for the MRI at a fraction of the cost- $350.00. Much to my surprise, the radiologists’ practice has just been purchased by a 3rd party venture capitalist group, and the fee has increased to $550.00 and growing. Still, $550.00 is much less than the $4000.00 BCBS negotiated. This is all on big hot mess.


My patient went home with her mom. She is worried sick and asked me for sedatives to get her through the night. I refused, tried to reassure her, and gave her marching orders. If she suddenly gets worse, she will got to the E.R. BCBS will pay thousands of dollars extra, but the MRI will get done, and she will get actual medical care. It’s all a crapshoot now. God willing, she will make it through the night, and I will literally beg a colleague who is listed as a BCBS “in-network” provider to see her tomorrow to sign off on my (the specialist to whom he would have sent her in the first place) orders for the MRI. We’re hoping it helps that her mom went to high school with him, and I can name drop that to get her in before a few months. Then BCBS will hopefully authorize the MRI. It will most likely cost the patient significantly more money, but will at least “apply to her deductible.” Again, this is all convoluted, irrational, and unethical.


I am fed up. I can’t play this game. Patients will be harmed, and no doubt patients will die needlessly, because of insurance “policy.” For the second year in a row, the life expectancy in the USA has gone down- what does that tell you about the corporate practice of medicine? I accused BCBS of malpractice and the unethical obstruction of indicated patient care. I can’t sleep, because I am worried about my patient and angry that the tail is wagging the dog in the name of “universal coverage,” which is a scam, garbage, especially if you bought the HMO plan. And just know this, the ACA, MACRA, and the cascade of failed federal “healthcare” laws, rules, and regulations are all part of a top-down, government scheme for HMO’s on steroids, now called ACO’s (accountable care organizations) or APMs (alternative payment models). It is one giant insane mess. This mess benefits the insurance companies and the central planners. I will continue my fight for this patient in a few short hours. I pray she will get through this ordeal- a medical fiasco, pot stirred and fire stoked by BCBS, and its unethical, rigid, nonsensical, wasteful policies.


I call on my physician colleagues to refuse to put up with this anymore. They can’t do it without our consent. I call on my patient colleagues (we are all patients, I have cancer among other things- how about you?) to demand the insurance companies deliver. We are paying these companies thousands upon thousands at the individual and family levels and hundreds of billions at the national level to do what- obstruct, delay, deny, ration our care for their bottom line? Just think of the money from interest alone they make on a month of delays and denials. This insanity must stop. If all physicians would give the few remaining insurance companies a 90 day without cause severance notification tomorrow this would end in short order. Patients must stand up to the insurance companies too. Patients must read the fine print and know what they have signed up for and agreed to. Lawsuits against the obstructionist, rationing insurance companies will be essential. The time is now.