SUMMARY: Summarize this content to 100 words: AUSTIN (KXAN)—An Austin surgeon and insurance company UnitedHealthcare are going head to head, over a dispute between a cancer patient’s overnight hospital stay after a procedure.

Dr. Elisabeth Potter, a plastic surgeon, said the patient’s claim for the overnight stay last month was initially denied.

UnitedHealthcare said this was due to an error on Potter’s office end, and is now accusing the surgeon of defamation after a series of her videos on TikTok and Instagram, have gotten millions of views and comments.

The day of the surgery

“I’ve never had this happen before,” Potter said in a Jan. 7 video she posted out of frustration after a stacked day of surgeries. “I got a phone call into the operating room saying that United wanted me to call them about one of the patients…who was actually asleep having surgery…said I had to call them right now,” Potter said in her video. Potter, who was performing mastectomies and reconstructive surgery on her breast cancer patient said she worried the call could have meant her client’s claim was being denied. So, she says scrubbed out, and another surgeon in the operating room took over.

“It was just so absolutely ridiculous that I was called out of the operating room to answer administrative questions for UnitedHealthcare,” Potter said. “I’m thinking…she might get stuck with a huge bill.”

UnitedHealthcare’s response

United Healthcare denies Potter’s claim.

An attorney representing the company sent a 6-page letter, which Potter posted. In part, the attorney demanded Potter retract what she said, telling her to delete her posts and post a public apology to UnitedHealthcare.

UnitedHealthcare provided KXAN with a statement.

“Intentionally spreading misinformation over social media is irresponsible and dangerous, and any physician who jeopardizes patient safety for social media clout undermines the trust in both the physician-patient relationship and health care in general.

There are no insurance-related circumstances that would ever require a physician to step out of surgery, as doing so would create potential safety risks and we would never ask or expect a physician to interrupt patient care to return a call. These allegations by a plastic surgeon that UnitedHealthcare denied coverage for the care that a breast cancer patient received are false and UnitedHealthcare had previously approved coverage for the care, including an overnight stay.”
UnitedHealthcare Spokesperson

Potter said she doesn’t plan to take down her posts.

“This is the way they operate, and it’s gone too far,” Potter said.

She admits the backlash from UnitedHealthcare was initially intimidating, she feels she owes it to the community to speak on what she experiences as a physician working with insurance companies.

“The truth is an absolute defense to any liable claim, and I have the truth on my side,” Potter said. “I’m good. I’m not here to create drama. I want to actually have a conversation about why this happened and why this is wrong.”

A history of physicians expressing difficulty working with insurance companies

Potter’s message is echoed by physicians across the state, according to the Texas Medical Association (TMA). “We know physicians are spending sometimes, 10 to 20 hours a week dealing with insurance companies pursuing prior authorization denials,” Dr. Ezequiel “Zeke” Silva III, council on legislation for TMA said.

Silva III said this impacts patient care, and in some instances, patients’ willingness to seek and follow through with the care they need when they’re worried about whether claims will be approved. TMA has worked with legislators to improve the insurance process. During the 87th Legislative session in 2021, TMA helped create a bill called the Gold Card Act.

“The Gold Card Act enabled physicians to achieve 90% of approvals for specific health care services to receive a Gold Card exemption from prior authorization going forward,” Silva III said. “It was one of the most meaningful prior authorization legislation in our state, and actually proved to be a model for the rest of the country, including other states.”

Silva III said there’s still work to be done, since the passing of this bill.

“We’ve learned since that time, regrettably, the percentage of physicians who have achieved this status is relatively small,” Silva III said. “The last number we saw referenced by the Texas Department of Insurance was around 3% which suggests to us that there’s opportunity there. There’s a chance to improve that law in a way that allows more physicians to achieve that status and patients to receive the care that they deserve.”

Open conversations

There is an appeals process physicians and patients can go through. Still, Potter hopes more conversations around improving the healthcare system can happen.

“I want to actually have a conversation about why this happened and why this is wrong,” Potter said. “It’s clear that United is not even ready to have that conversation. They don’t see any of this is wrong. Now I’m just waiting for the opportunity to have the constructive conversation where we actually start to talk about how we’re going to change health insurance in America because this isn’t going to continue.”

UnitedHealthcare told KXAN, “The provider incorrectly submitted a bill for an inpatient admission. The service provided was for outpatient care that included overnight observation and had been previously approved. Per the explanation of benefits, there is no liability for the member.”

United Healthcare says the patient wasn’t charged anything for the procedure, and that Dr. Potter has been paid for the services as well.

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The post Austin surgeon, UnitedHealthcare dispute over cancer patient's hospital stay appeared first on www.kxan.com