Insurance companies/medical practices are getting tricky. It may have to do with something called "Best Practices" Certain conditions requires very specific medications to be prescribed for certain medical conditions or very specific guidelines to follow for high blood pressure, for instance. Insurance companies may give the insured a whole brochure of doctors who use these "Best practice doctors " and they prefer you go to them first. In my opinion, it gives the patient a false sense that these are the best doctors to use when actually it is the doctor who adheres to the guidelines put forth by the insurance company or medical practice. All this information is gathered by someone and reviewed. For instance, if a patient of that doctor has documented high cholesterol, the guidelines say that the patient has to be on cholesterol medication. So when your chart is audited, that doctor gets sited for not using best practices even though it is not his/her fault. I don't know all of how it works but this is a general explanation and my facts may not be correct completely, but that is how I understand it. I have gotten the brochures myself of specific doctors to use for any specialty for best practices in the past and get a discount if I use those doctors instead. In the past , I actually don't use those doctors because if I want to get a MRI for a neck problem, a best practice doctor would never order one for me unless I went through more simple diagnostic tests first such a neck X-ray, then Physical therapy, medications etc. If they ordered an MRI as a first step, it would show up on the audit. I am in the medical profession and I sometimes just want to get certain tests done and skip the beginning steps and go right to the best diagnostic test I know that will give me an answer quick. So that may be part of the reason. I don't know how it works for Medicare, as I am not Medicare age yet, but I am sure Medicare has something similar but may call it something different. There is something called HEDIS: Medicare does use HEDIS guidelines. The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by more than 90% of America's health plans to measure performance on important dimensions of care and service. ... HEDIS consists of 81 measures across 5 domains of care. It is all very complicated but health care is all carefully tracked and monitored. Not simple like years ago where you and your doctor decided what you needed, instead of the insurance companies.
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