Full Transcript Sponsor Message: Gelt Tax Planning 0:03 Quick question. Are you [music] paying more in taxes than you should? 0:07 Most high-earning physicians overpay [music] by tens of thousands because 0:12 their CPA only looks backward, not forward. 0:15 Gelt is different. Dedicated CPAs powered by AI that work 0:21 year-round, [music] not just at filing time. 0:25 Tax strategy and proactive planning >> [music] 0:27 >> for practice owners, investors, and physicians with complex financial lives. 0:34 Built specifically for professionals [music] 0:36 who want to keep more of what they earn. Check out joingelt.com. 0:43 That's j o i n g e l t dot com. 0:52 If you work in healthcare, you already know this. 0:55 Conflict [music] is everywhere. In the OR, 1:00 in labor and delivery, in committee meetings, 1:03 between physicians, nurses, administrators, and teams that are all 1:09 trying to do the right thing. But here's the problem. [music] 1:13 Most of us were never trained to handle conflict well. 1:18 We learned procedures. >> [music] 1:20 >> We learned diagnostics. But we didn't learn how to navigate the 1:24 moments when two professionals strongly disagree. 1:29 That's why I developed the Spark framework. 1:33 Spark stands for stop, pause, 1:38 ask, don't assume, reflect and respond, 1:43 >> [music] >> and create a path forward. 1:46 It's a practical system designed specifically [music] 1:49 for high-stakes healthcare environments. Through keynote [music] talks, residency 1:55 workshops, and Spark masterclasses. I teach physicians, nurses, and 2:01 healthcare teams how to turn destructive conflict into productive [music] 2:05 conversations to strengthen teams and improve care. 2:10 If your hospital, residency program, or medical conference is looking for a 2:14 speaker on conflict, communication, and leadership in healthcare, I'd love 2:20 [music] to work with you. You can learn more in the show notes. 2:24 Because in medicine, conflict is inevitable.
Introducing the Scalpel and Sword Podcast 2:29 But handled well, it can [music] make teams stronger. 2:46 In every operating [music] room, in every ward, in every clinic, and 2:50 every team meeting, a silent battle brews. 2:54 Conflict, negotiation, identity. 2:58 Welcome to the Scalpel and Sword Podcast, where I, Dr. Lee Sharma, 3:02 physician and conflict analyst, explore the hidden negotiations behind modern 3:07 medicine. Let's trade burnout for boundaries 3:09 [music] and learn the art of healing with precision and power. 3:15 >> [music] >> Hello, my peaceful warriors, and welcome 3:19 to the Scalpel and Sword Podcast. I am your host, Dr. Lee Sharma, physician and 3:25 conflict analyst. And I'm going to ask that all of you who are followers of the 3:30 podcast, if you've already listened to episode 51, which is the invisible hand 3:36 on the scalpel, thank you for listening and thank you 3:39 for your feedback. And if you haven't listened to it, I'm going to ask that 3:42 you pause this one right now and go back and take a few minutes and listen to 3:46 that episode because that episode is going to play directly into what our 3:51 guest is talking about today. And my guest today is a practicing 3:55 surgeon who does utilization management work. 3:59 And they've chosen to remain anonymous so that our conversation can focus on 4:04 the work. We want to focus on the process, the potential, and we also want 4:09 to talk about how this affects the practice of medicine and what it means 4:13 for us as doctors, but even more broadly, what does this mean for
What Utilization Management Is 4:17 healthcare in general and how is this changing our environment and how can we 4:22 work within the system to actually make healthcare better? 4:27 So, thank you, guest, for being here. I'm really happy to have you. 4:31 Thank you for having me. I'm excited to be here and talk about this. 4:35 So, for those of us listening, cuz we do have some non-medical people who listen 4:39 to the podcast, explain to us what utilization management is. 4:43 Absolutely. So, we'll start out in broad strokes. So, 4:48 what happens is when you go to doctor sees you, they examine you, they maybe 4:53 think of that there's a series of tests that might need you to order or not, 4:56 come up with a diagnosis and a treatment plan. At any part in that process, 5:02 whether that's diagnostics or whether that's treatment, 5:05 they'll have to order something, whether that's a test or medication or a 5:09 treatment or even plastic surgery. And that service that they're offering 5:14 has to be paid for. There's a There's a fee for that in this country, the way 5:18 that our healthcare system is structured. 5:20 And who pays for that fee? In many cases, it's an insurance company. So, 5:24 the insurance company pays for the service, whether that's a test, whether 5:28 that's a procedure, whether that's a medication. 5:31 They don't pay for everything that's ever ordered, however. 5:34 They pay for things that they deem are medically necessary. 5:38 So, the product, the insurance coverage, is regulated and it's regulated by the 5:44 payer. The payer in this case is not the patient. The payer is the insurance 5:48 company. So, there's that third party that lives in between the doctor and the 5:52 patient. And utilization management is essentially the review 5:57 of the process of payment for those services. 6:01 So, I think this is a great explanation because I think a lot of people who 6:05 patients, a lot of people in healthcare don't understand how this relationship 6:09 works. And one of the things I used to tell people when people come with come 6:12 to see me in the office and ask, is my insurance going to pay for this? And one 6:16 of the things I would say is when you go to the grocery store and you buy milk, 6:19 you don't ask the cashier how much money you have in your bank account to buy the 6:24 milk. You know how much is in your bank account. So, as patients interact with 6:28 the healthcare system, I think there is an expectation 6:31 that they think that we understand how that insurance works. That we are 6:34 somehow in control of those purse strings or have an understanding of 6:38 them. And so, I think one of the biggest things about understanding third-party 6:41 insurance, but especially what you're doing with utilization management, is 6:45 how this system is functioning. So, at what point in practicing medicine 6:51 did you decide to get involved in this process of utilization management? 6:55 That's a great question. It wasn't actually a decision on my part to get 6:59 involved in this. It almost happened and I can give you an overview of what that 7:03 was like. So, I had just started in a new position and there was a ramp up 7:07 period that was, let's say, a little slower than I expected. So, I had some 7:10 free time on my hands. Out of the blue, I noticed that a recruiter from 7:14 utilization management company reached out. Uh and they asked if I would ever 7:18 consider doing this kind of work, utilization review. Well, I was first 7:21 asked about it, I didn't even know what it was, like probably most physicians 7:25 who hear the first time, they don't know what that is. They hear UR, they don't 7:27 know what that is. And so, I initially I don't even know if I answered the first 7:31 time I got the message. But, it took me a little while, a few weeks here, a few 7:34 months to warm up to the idea and I did a little research uh and I figured out 7:38 what it was. And at that point, when I realized okay, 7:42 this is doing the review of cases that have already been denied 7:47 by insurance is going to pay for it and someone independent of the insurance is 7:51 deciding do they or do they not have to pay for it. That's 7:53 that seemed somewhat interesting to me and so I looked into a little bit and 7:57 started out really slow, picked up a let's call it a review stream where a 8:01 company will send you cases and it was a case here, a case there. Almost started 8:06 out like one of these little side hustles that you might do like medical
How the Surgeon Got Into Review Work 8:09 surveys or something like that. And then I realized that it could build into 8:12 something a little bit more meaningful once I started seeing more of it. 8:16 Wow, so this is one of those things that kind of almost fell into your lap and as 8:21 you had this time and you started getting this work, you could find 8:24 another way to put your medical expertise to work and so you were able 8:27 to do that. What were some things as you launched into this process that really 8:32 surprised you? Uh absolutely, that's a great question. 8:35 So, I would say one of the first things about it that surprised me 8:40 was how straightforward it is for the reviewer in some cases. So, there would 8:46 be some cases where and I've worked for several companies so this is just a 8:50 general observation about the industry but there are some reviews that a 8:53 reviewer might do where it comes across your desk and physician X wants to 8:57 prescribe medicine Y to patient Z and it then the question that you're asked as a 9:03 reviewer is basically is this medically necessary? And patient has a condition 9:07 that the standard of care treatment according to a litany of research would 9:11 be this medication that was prescribed and of course the answer is obviously 9:15 yes. That was a pleasant surprise to me because as I think a lot of docs have 9:19 heard about utilization management might think one of my initial hesitations 9:23 about doing this was oh, this is just going to be my name as a rubber stamp on 9:26 a denial. I'm not going to be able to overturn anything. This this is all just 9:30 going to be me being Dr. No all the time 24/7 as 365 but that was was a pleasant 9:35 surprise to me initially was that sometimes the review will come across my 9:39 desk and it's just the course. This absolutely isn't indicated and I would 9:42 overturn it and I'd wait a few days and see if someone sent me an email said, 9:45 "No, you can't do that." And that didn't happen. And it was like, "Okay, I'm 9:48 making something happen. I'm working within the system. We're making positive 9:52 change here." I love that you said that because and I 9:56 think that is a perspective that so many people have about and a lot of that I 9:59 think is some of that's bolstered by personal experience that we've had as 10:02 physicians having to work with denials or work with peer-to-peers. And I do 10:06 want to put this commercial in here that as I have dealt with that 100% of the 10:11 time and where I see it again, you're a surgeon, you probably see this as well 10:14 is when we're getting surgeries denied. We're applying for patient having a 10:17 hysterectomy and she has fibroids and she's anemic and she's tried medical 10:21 therapy and nothing's worked. This is a fairly clear-cut process applying for 10:26 surgery and we'll get a denial and I'll ask for a peer-to-peer 10:31 and I get on the peer-to-peer and I ask if this person is in my specialty and I 10:35 get a name and an NPI and then once we've had that, I just usually 10 10:39 seconds of fibroids, anemia, failed medical therapy and they go, "Yeah, 10:43 you're good." And I think that's been the majority of my experience.
Surprising Benefits of Doing Peer Reviews 10:48 But I do think you have a lot of people and I think on social this is becoming 10:51 more common of doctors who have talked about their negative experiences with 10:54 where they've gotten denials that are egregious in terms of people applying 11:00 for, let's say, lymph node dissections after breast cancer surgery having 11:03 reconstruction. But you you do hear some of the negative. Did that affect your 11:08 decision or did you feel like that was something that made you more invested in 11:12 being positive in this process? You mean seeing the negative feedback, 11:17 social media? Yeah. Uh I would say yes, although I'm not the 11:22 most social media present individual. I'm not super into that world 11:27 intentionally, but I do know that exists and I have seen that. But I'm also aware 11:32 of the negativity bias, and so a lot of people will report negative 11:36 interactions, and those will get more eyeballs because of the way the 11:39 algorithms work. And so, if somebody has a positive interaction at peer to peer, 11:43 I don't think that they're going to be posting about it on social media. And if 11:46 that even is the majority, you probably won't hear about it. So, certainly those 11:50 negative stories do occur. But, yeah, like you said, those positive stories, 11:55 that's often the majority of the cases when I'm getting on the phone with a 11:59 physician. And a lot of times, what happens is there's some sort of clerical 12:03 mix-up. Whether the documentation was incomplete, or the documentation wasn't 12:07 all sent over, so maybe the surgeon who was evaluating this patient did all the 12:11 right steps, did all the right workup, has tried the step medication and 12:15 everything, but the note didn't get sent to or the fax got lost or it was tied up 12:20 or it didn't get to the third-party review, and so it was denied. And then a 12:23 lot of times you get on the phone with that doctor, and just like you said, 12:25 same specialty, understand what you have, you tried X, you tried Y. Oh, of 12:30 course this is indicated. Absolutely, 100% approval. So, 12:33 it's sometimes a little frustrating being on this side of it because 12:36 sometimes I'm on that side of it, less so now that I do more of this work, but 12:40 still sometimes I am. And I understand, oh, I wrote that. No, I wonder why you 12:43 don't have that as the reviewer, and you just don't always know. One of the 12:47 things that you just said I want to drill down on because I think it's 12:49 really interesting. The you said that since you've been doing this work as a 12:53 reviewer, that when you actually have to submit 12:57 and you're going to you're getting trying to get approval for a treatment 12:59 or a procedure, that this is less so of a problem for you now since you've been 13:05 doing this work. Why is it less of a problem now? Absolutely. You're touching 13:10 on a great point there. It's definitely and this is obviously anecdotal, I don't 13:14 have numbers, but it's definitely less so now. I will say that the UNM 13:17 experience that I have has, in addition to being meaningful to just staying up 13:21 on literature, and seeing what's out there, seeing what 13:25 other procedures we staying up on what other procedures are occurring what 13:28 other surgeons are doing and helping patients get what they need paid for. 13:32 I'm also learning how to write better notes. So, the more cases that I do the 13:37 more policies that I'm exposed to, the more cases I review, the more that I 13:41 know that okay, if I'm going to try to recommend procedure Y for my patient or 13:46 if I think the medication X is indicated, I've got to try this first, 13:49 I've got to try that first. And I should document that I tried that first. A lot 13:53 of times I've seen cases where a doctor will write on their note, "Patient has 13:58 tried conservative treatment, failed, indicated for surgery." 14:01 Now, that'll get you by with you're trying to defend yourself in a case 14:05 conference or at M&M or something like that or even on your boards. If you 14:09 write, "We tried conservative treatment for for a while, it didn't work, etc." 14:13 Unfortunately, in some cases that to standardize things, the policies 14:18 will say "Conservative treatment of X, Y, and Z 14:22 must be tried for X, Y, and Z weeks or months or etc." So, you might have to 14:27 specify that and if you don't as as frustrating as it can be, 14:32 sometimes that can be the reason that it's denied. So, even though you may 14:35 have even done that all that step therapy and all that required 14:39 pre-therapy with the patient or pre-treatment and sometimes it's not 14:43 documented and that's the reason that the denial's made. 14:46 Wow. So, you really have gotten a much greater understanding of the system 14:51 and by getting this greater understanding of the system, you've 14:54 actually gotten more efficient at providing care for your patient. Because 14:58 you understand the system. And you've got little kids. I don't know how much 15:02 you guys watch movies, but that was a big thing with us and our kids. And we 15:05 love The Incredibles. We've probably seen that movie a billion times. And 15:09 there's a scene at the very beginning where our hero was working at an 15:12 insurance company. And he has a little old lady in front of him and she's 15:16 crying because the insurance company has denied her claim and he's writing down 15:20 for her specifically, "Go to this floor, talk to you person, and tell them you 15:23 have this, and then you will be fine. Then his boss comes and yells at him 15:27 because it's like, why is it that your clients have this intricate knowledge of 15:30 how our system works? But you can't get away from the fact 15:35 that because you have somebody like you that understands the system, ultimately 15:41 what's happening is you are facilitating getting that care for your patient. 15:46 Absolutely. It's a double-sided win. You get to help people on the other side of 15:51 it. So, I get to be the reviewer and help people get what they need approved. 15:54 And I can also help my own patients. So, I'm doing things more efficiently. I 15:57 don't remember the last time I've had a test or a surgery denied and had to do a 16:02 peer-to-peer. I honestly don't. Just because now I really know all the 16:05 policies that are relevant to my specialty. I'm familiar with all of 16:08 them. They're mostly similar from payer to payer, so I don't really have to, in 16:12 general, look up, "Oh, which insurance does this patient have? Do I have to try 16:16 X, Y, or Z treatment first?" Majority of the time, if I document what 16:20 I need to document in the note, it's going to go through. So, it's really 16:24 helped me to work within the system and help other 16:28 people, but also just to help me learn how to navigate the system better. 16:32 100% and look who's benefiting from that. Your patients are benefiting from 16:35 that. And I'm sure that benefits you, too, because that gives you less stress 16:39 at work. Already having knowing all of these things definitely 16:43 has to make your work day feel a lot better. Yeah, they always talk about the 16:46 administrative burden, the added extra time that peer-to-peers and prior
Documentation, Denials, and Better Approvals 16:50 authorizations will add to a physician's day. When you can minimize that, you're 16:54 you're hitting a home run. Yes, absolutely. And I think that's 16:58 eliminating something really important about the work that you're doing. And I 17:02 think this kind of goes back to episode 51. We have so many people trying to put 17:08 hands on that scalpel. We have so many people trying to get their hands into 17:13 healthcare. And as physicians, one of the things we always think about is how 17:18 do we get our seat at the table back? How do we actually start to bring some 17:24 of that control back into the hands of the clinician who's making the decision? 17:29 And I think so often we might think about this is we just have to blow up 17:32 the system, we have to just destroy how the system works and that seems we just 17:35 have to get rid of all of this. And unfortunately, that's just probably not 17:39 practical in terms of continuing care for the patients who depend on us. But 17:43 what you're doing, you are working within the system 17:48 and it's not only being I don't want to say secret agent, but you are in the 17:53 system that maybe on some level might have been designed to deny care or save 17:59 some money to the third-party payer. But what you're doing in that system is 18:03 you're actually facilitating care within a structure that already exists. 18:09 Yeah, we're using it to make things better. It's unbelievable turning it a 18:12 little bit on its head sometimes if you look at it from that perspective, which 18:15 honestly, I hadn't until now. So that's a remarkable statement and I really like 18:18 how you phrase that. I'm and I think this is one of the 18:22 things I loved as we were talking about these forces that shape medicine 18:26 is that we can we all understand it. We can understand that these are forces 18:29 that are shaping what we're doing. How do we use those to actually improve 18:34 the face of medicine and improve how we provide care? You are doing it. You're 18:38 actually absolutely doing that in real time, which I love. 18:43 It sounds like you do feel as you're working through this because you've 18:47 definitely got a lot out of this process. Did you feel sometimes maybe 18:50 that peer-to-peer is legit? It's a good thing to have peer-to-peer kind 18:55 discussion. Oh, I think it's good. I almost always 18:58 still dread it. I've been doing this for years already and I always dread when I 19:02 get a case and it says you're going to have to do a peer-to-peer if you deny 19:05 this case and I say, "Okay, I'll I guess I'll take I'll talk to the doc." And I 19:09 don't like it because it hurts. I don't I don't I like I don't like to call a 19:12 doc and say, "Hey, listen, I here are the here are X Y and Z reasons why I 19:16 can't approve this test or this procedure, but I will say that in in 19:20 retrospect over 90% probably almost all of the 19:25 cases where I do they're very congenial calls. I'm 19:29 speaking to a physician who is a peer. They're happy enough that I'm a peer in 19:32 their same specialty and often even their same subspecialty field. I totally 19:37 understand they're not I get everything that they're saying. I know the 19:40 evidence. I'm familiar with the same studies they're some I I've even cited a 19:43 study to a doctor who published that study one time. Wow. Yeah, I said, "I've 19:48 read your paper on X Y and Z and I understand why you're indicating this 19:52 procedure." And so it's nice to get to do that. But I still something it's time 19:57 I still still dread it every time I have to make one of those peer-to-peer calls 20:00 there's still a little part of me that says, "I don't know if it's going to go 20:02 well." It always does go well, but it's very rare that somebody flies off the 20:05 handle or something like that. But it's interesting to look at it like I said in 20:09 in hindsight I get Yes, the peer-to-peer conversation can 20:13 be very uncomfortable, but usually it's pretty rewarding. 20:17 That's it really does sound like you feel like the majority of the time even 20:22 though I think in the sort of this era where we're talking about prior auths 20:26 and gold cards and this is a kind of a very big discussion in the national 20:30 questions with medicine that it sounds like you feel like this the peer-to-peer 20:34 process in general or your process in general works or at least it provides 20:39 something that's beneficial. It can. Now, I will make generalizations 20:45 about the industry. I'm not going to speak about any particular service or 20:49 or company or anything. We talk a lot about the positives of you as in any 20:54 industry there are things that work really well and there are things that 20:57 perhaps there's room for improvement. I wouldn't say that every case that comes 21:01 across my desk is a win is positive. There are sometimes there's where I get 21:06 it and I look at this case and I say, "There's just zero chance that I can 21:10 overturn this. There's no way that this insurance company's going to pay for 21:13 this on this review." So, often I'll know that I have to do something that 21:18 it's a policy-based review or whatever the case may be that at this level of 21:22 review it's not going to be overturned. 21:26 But, to understand that fully, you need to understand the process of appeals. 21:30 Now, the way that these appeals for claims work is that the patients have 21:33 multiple layers of appeal so they can have a first appeal, there can be a 21:37 second appeal, and then there's an external appeal, which is a 21:40 federal-level appeal. On those final appeal levels 21:44 there is no internal policies, so no individual insurance company policy can 21:49 be used. This is just standard of care. You have to use evidence. You have to 21:51 look at the textbooks. You have to look at the published literature, and you 21:54 have to find an evidence-basis for the question, yes or no, approve or deny, 21:59 overturn or uphold. And so there's always that last avenue that 22:03 exists. In some of the lower levels of appeals
Peer-to-Peer Calls and Appeal Levels 22:08 it's not exactly that way. So, sometimes you can't really bring in literature. 22:12 So, there are cases where I know that any reviewer's desk that this case comes 22:16 across, this will be denied, whatever the physician says, whatever letter they 22:20 write. I've seen some very heartfelt appeal letters written by patients, 22:24 written by physicians, and they they're very emotional, they're very strongly 22:29 worded. Some of them are very ferociously worded, even, which is not a 22:32 great strategy, but some of them are. And unfortunately, at certain levels of 22:36 appeal, that's just not going to work. It just won't. But, I do know that in 22:40 those cases, the way or what I tell myself anyway is that listen, that case, 22:43 that's an automatic loss. That's the cost of doing business. Being in this 22:47 position and overturning the cases I'm able to overturn comes at the cost of 22:52 the cases that I can't win. We don't overturn every case, and that's just a 22:55 fact of life. I can't I have to accept the fact that there will be cases where 23:00 that's just how it goes, and I have to stay in the game in order to do the ones 23:03 where I can do what I want to do. And I think that's such a great point is 23:07 that as you're working within the system during this work that you are picking 23:12 your battles. That you really it's like there are things that I'm able to I'm 23:16 going to be able to help patients, I'm going to be able to help clinicians, but 23:19 maybe not every single person on every single day. But you're still moving the 23:23 needle in a way that you can and I think there's huge value in that. 23:26 Yeah, you certainly have to pick your battles in this field. You cannot win 23:29 them all. If you do, I think you'll burn out very quickly. You get a lot of 23:32 emails probably that say, "Did you look at this or did you look at that?" 23:38 And since you do this for multiple organizations, 23:42 I think this is another thing that's really important to talk about is that I 23:47 think we sometimes and some of this is going to be more popular news and things 23:52 like that right now in terms of certain third-party payers maybe doing more 23:56 denials, maybe doing AI denials, and then maybe certain ones that are not. 24:00 But it sounds like you consistency across most of these as you're working 24:05 through these. In some ways, yes. I will say that some of these different streams 24:10 and some of the insurance companies as well, there is consistency. It's often 24:13 hard to know what the internal policies are cuz again, I don't do any work 24:17 directly for any insurance company. So all of this is independent work. So I'm 24:20 not always It's a black box sometimes before it gets to my desk what has 24:24 happened in this case. A lot of times I can see the previous denial clerical 24:29 documentation. Why was it the denial issued? Sometimes it can literally be 24:33 just We don't have any notes from your doctor. And then in the appeal process, 24:37 I have 400 pages of notes from the doctor. I've got plenty of information. 24:40 So sometimes it's just as much as that, but a lot of times I don't know exactly 24:44 what's happening behind the curtain. So I can't tell you for sure that I that's 24:47 the case. I think that's a really important point 24:50 too because I think that's one of the misunderstandings about is that you have 24:53 access to those policies or you know what's going on and 24:57 you are strictly a another pair of clinical eyes 25:01 that's looking at this and you are giving your clinical opinion. And so I 25:05 think that's huge in terms of understanding how this work is and the 25:11 physicians that do it that they're not necessarily working for an insurance 25:15 company. And I think that's a huge misunderstanding people have about this. 25:19 Yes. Yeah, I can't tell you how many times I get on the phone with a 25:23 physician assistant or nurse practitioner or physician and I 25:26 introduce myself as I'm calling from we're doing the peer-to-peer. And then 25:29 they say, "So you work for Blue Cross or you work for this one or that one?" I 25:33 say, "No, actually I don't. Not at all. This is completely independent." So it's 25:37 a big misunderstanding. Yeah, that's for sure. I agree and I think that's one of 25:41 the misunderstandings that I think keeps from physicians from considering it. Is 25:47 like you said, it's an opportunity to actually change health care 25:52 from within in a way that you are actually improving 25:56 your own clinical skills. You're improving patient care and this 25:59 is outside the exam room or outside the operating room. And that's what makes 26:03 this so powerful is that you're able to do that. So if there were physicians 26:08 that were listening to this podcast today and said, "Oh my gosh, I didn't 26:11 know that this was a way that actually maybe I could get the doctor's hand more 26:16 on the scalpel than off of it by actually doing this kind of review 26:20 work." And let's say you encouraged someone was encouraged to try to do this 26:24 work after listening to this podcast. How would you advise them to start? 26:28 That's a great question. So some people think that there's some secret handshake 26:32 or of a locked door that you need to find in order to get into this, but 26:36 sometimes it's as simple as just scouring LinkedIn. It really can be that 26:40 mundane. Where you I found a couple of opportunities through that where I'm 26:45 just I'll sit there and browse through the opportunities remote. You could 26:49 there's a way to set filters so that you get jobs like that and then you can find 26:52 ones within your specialty. There's lots of companies that are hiring in many 26:56 specialties. I will say there are some specialties. So, each company will have 27:00 panels and mental medicine. They'll have general surgery. They'll have fibroid 27:04 and endocrine. They'll have rheumatology and pediatrics, neurosurgery, all these 27:08 different fields. And they'll have panels in each of those fields. And your 27:12 specific specialty, to the listener, may or may not be in demand. So, if it's an 27:18 in-demand specialty, you're a lot you're going to probably find a way to to get 27:22 into a review stream fairly easily. But if you happen to be in a specialty that
How Physicians Can Get Started in Utilization Review 27:27 is that doesn't have a lot of I would say 27:29 high-cost medications or procedures or something like that, things that are 27:33 going to commonly run into this, you may not see a lot of opportunities within 27:37 your field. And that's just the nature of certain fields. 27:41 Yeah. But that's a great way to for you to find opportunities. And then, as 27:47 they're finding these opportunities, let's say this specialty that's in 27:49 demand, then they can kind of get into those. Having some having the time to do 27:53 this, I think is important. But there's definitely, and I really love how you 27:58 talk about this, that doing this work has 28:01 really, not only changed how you document, but it's also making you very 28:05 aware of the literature and staying very current. We were talking off mic about 28:10 how doing this kind of work makes you stay current. And in all of our 28:13 specialties, no matter what we do, there are advances every single day. I just 28:19 got back from my state OBGYN meeting, and they're talking about doing these 28:23 special robotic films and products we can use in robotics, and it's just 28:26 incredible even in the last 5 years. So, it does make you stay current being able 28:32 to review. It absolutely does. And it highlights another side of this that I 28:36 meant to mention before, which was that sometimes you do these cases and you 28:41 learn that not everybody is staying current. That there are cases where 28:44 things are coming in and you know that may have been evidence-based 20 years 28:47 ago, but what this doctor is saying to you right now is not up to the bar of 28:50 current evidence. And because you say current and because 28:54 you're on this, you understand why this was tonight. And some of these 28:59 physicians have been practicing a certain way for a certain amount of 29:01 time, they might be very uncomfortable with the fact that you might say, 29:05 "Listen, the evidence doesn't show that. We don't do this anymore." If you go to 29:08 enough for meetings, they say, "Yes, we've stopped treating patients with 29:12 this is." And that to me uncomfortable discussion. Thankfully, that is very 29:16 rare situation. But you do see that. Not every single submission Not every single 29:21 request that is submitted does a reviewer actually think, "Oh, 29:25 yeah, this is medically indicated. We should do this." 29:29 Which is such a fascinating part of what you're doing. And I do think on some 29:36 level that's on the intent behind having you is that you are trying to stay at 29:40 that level. You We all want to practice at or above the standard of care. We all 29:44 want to practice at the top of our license. We all feel that's important to 29:48 us as physicians. But it sometimes is easier said than 29:51 done in terms of if you've done something for 29:55 a really long time in a certain way. I've used this antibiotic for this for 30:00 forever and now standard of care says we don't use this antibiotic for X anymore. 30:04 I think those are really hard things to do, but that's why I love that and I 30:09 think we all have different avenues for doing what you're doing. That's why I 30:11 love that you're doing it in this way. Because I never thought of until we 30:17 really started having this conversation. The fact that doing was actually going 30:22 to make somebody a better doctor. But it totally 30:25 That was a big surprise for me. It really was. I was not expecting that 30:29 facet of it. I was just that's thinking, "Hey, this is a little thing I can do. 30:32 This is It's a little more exciting than medical surveys about this somehow 30:36 medicine for it. Hey, you, I think we'll pay you seven bucks for some of these 30:39 surveys." That's why I'm doing this. And I will say some of these cases that you 30:44 get for UN, they it's not like they're paid that much. These cases don't pay a 30:48 tremendous amount either. It's not that you would necessarily do this for the 30:52 money. But it's a nice thing to do just to supplement the way that you are 30:56 practicing in your spare time if you have that, which not everybody certainly 30:59 has that luxury. But but yeah, like I said, it's just a 31:03 phenomenal adjunct and you can fit it into your 31:07 day. I think we were talking about if someone has time for it. You can fit it 31:10 into your day or your week, however you see fit. So we didn't really get into 31:13 too much of the specifics of how this work goes. 31:16 But there for most of them they'll have like I said a stream. I used that word 31:20 before. And what that basically means is that they've got a whole list of cases 31:25 of denials that were already issued and they're appealed in this state. In this 31:29 stage. And so there's an endless an endless list at any point in time of 31:34 these cases. And they're sent from the insurance company to the third party and
Flexible Case Streams and Final Takeaways 31:38 the third party sends it out to their panel. And these cases can just appear 31:41 randomly at any time. And some of them will send you a text, some of them will 31:44 send you an email or some of them even have their own app. And they'll say, 31:47 "Hey, there's a case available. Do you want it?" It's not "Hey, there's a case 31:50 available. This is yours. You're assigned to it." It's "There's case 31:53 available. Do you want it?" Some streams are very busy. You might get several of 31:56 those days. Some of them are very quiet and then you get one a month or 31:59 something like that. And again, it's very specialty specific. But if you're 32:03 on vacation, if you're out of the country or something, you you'll think, 32:06 "Yeah, that's fine." You just no one's holding you accountable to that. It's 32:09 just Okay, someone else on the panel will grab it. So it's a very flexible 32:13 kind of thing. It's nice. You can build it up if you have a slow week, you can 32:15 turn it down if you have a busy week. It's really nice in that way. 32:19 That's huge. And I'm really glad you said that because that was not my 32:23 thought process. When I think about people doing medical reviews, I think 32:27 it's you sit down and you have six cases and you're having to go through all of 32:29 those. But that's so not what it is. It's something that you definitely have 32:34 a choice in terms of which you take and you can definitely play with that based 32:37 on your schedule. That's what >> Yeah, it can really be tailored. It's 32:40 very individualized. I love that. This has been a great conversation and a 32:47 fabulous insight into how utilization medicine it can really this idea of 32:53 looking at you it's not something that's evil and terrible. It is something that 32:59 within it has potential to make us better doctors also help us give better 33:04 care for our patients but it is a way to take back some control of that scalpel 33:10 and I cannot thank you enough for being here on the podcast and being giving of 33:15 your time. It really means a lot. Of course, yeah, like I said, thank you 33:19 so much for having me. I'm really glad that we were able to do this and I hope 33:22 that this inspires some of your listeners to look into you or think 33:26 about doing it or at least at the very least just to think a little less poorly 33:30 of those of us who choose to do it. 100% 33:35 For all of our peaceful warriors who have joined us today on the Scalpel and 33:39 Sword, thank you so much for being with us. If this episode resonated with you, 33:43 please share it with a colleague and until next time 33:47 be at peace. 33:51 Every episode is an invitation to speak, 33:55 >> [music] >> to negotiate, to choose. 33:58 I'm Dr. Lee Sharma. Join the dialogue by subscribing [music] 34:02 to Scalpel and Sword. Until next time peaceful warriors. May 34:06 your choices be sharp >> [music] 34:08 >> and your voice be even sharper. 34:14 This podcast is a reflection of lived experience and [music] research in 34:18 conflict resolution. The Scalpel and Sword is not intended as 34:22 medical [music] or legal guidance. For personal matters, please consult a 34:26 qualified professional.
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