Some of the nation's largest health insurers employ or employed physicians who have a history of malpractice or have been reprimanded by state medical boards, according to a Dec. 15 report from ProPublica and The Capitol Forum.
The reporters behind the piece were not able to find a single database listing physicians who work for large insurers. Insurers often hire physicians under the title of medical director, which most states require to hold a medical license, according to the report. Beyond that requirement, payers can decide who is best for the job. Medical directors working for insurers can overrule a patient's physician and deny coverage for services.
Using regulatory and legal documents, social media profiles, interviews with industry experts, malpractice databases and information from state licensing boards, ProPublica and The Capitol Forum identified 12 physicians employed by payers who have a "history of multiple malpractice payments, a single payment in excess of $1 million or a disciplinary action by a state medical board."
Cigna, Aetna, Highmark, UnitedHealthcare and Optum are all named in the report for employing or previously employing the identified physicians. Pinnacol Assurance, a nonprofit insurer specializing in workers' compensation, is also named.
A Cigna spokesperson told the outlets its medical directors are board-certified and credentialed physicians who are held to the same standard as physicians in its network. "We use a comprehensive suite of materials and discussions to assess how our medical directors support patients efficiently and effectively," the spokesperson said. "... Malpractice claims against physicians are common, particularly in high-risk specialties such as surgery, and the settlement of malpractice claims does not necessarily mean that malpractice occurred."
A UnitedHealth Group spokesperson told the outlets, "Medical directors go through a rigorous hiring process to ensure they are qualified for the roles for which they are being considered. We review individual performances regularly and provide ongoing training to help them with their various responsibilities."
A Highmark spokesperson told the outlets, "Medical directors use evidenced-based guidelines and the unique clinical picture of each member's case to render medical necessity decisions only, which is agnostic of cost."
An Aetna spokesperson told the outlets its medical directors are licensed and board certified, and that all accreditation requirements and state and federal regulations are followed.
A Pinnacol spokesperson told the outlets it did not directly employ a physician named in the report and said, "Our mission as a not-for-profit, state-chartered carrier is to serve the workers and employers of Colorado, and we would never, nor do we support denying necessary medical care 'to save our clients money.'"
Read the full report here.