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  • Writer's pictureTheresa Barta

Are Medical Directors who work for health plans and insurance companies Medical Doctors (M.D.s)?

The answer is, “Kind of.” While Medical Directors have a medical degree, their focus is not on providing patient care. Instead, they focus on the cost of health care to their employers: Health plans and insurance companies. In other words, Medical Directors focus on their profits, not on patients.

Medical Directors provide the following services:

  • Developing and approving policies and procedures that govern how other doctors can provide health care

  • Reviewing data and directing how to more quickly and cost-effectively (for the insurer) move patients through the health system

  • Providing authorization for which medical providers, and at which facilities, patients can receive their medical care

  • Determining whether medical services that the patients’ doctors provide is “medically necessary”

Medical Directors are most certainly not focused on patient care—and are not even qualified to do so. Here are two cases I’ve handled involving patient care that illustrate this point:

  • Life-threatening heart conditions: Insurance company A’s Medical Director determined that medical care provided to twin 10-year old boys who suffered from life-threatening bradycardia (a heart condition) was “not medically necessary”. His specialty, which he had practiced over ten years earlier, was sports medicine (in adults only) with a focus on ankles. He admitted to having no training, no experience, and no knowledge of pediatric cardiology.

  • Emergency medical care provided by a board-certified physician: Insurance company B’s Medical Director determined in hundreds and hundreds of cases that medical care provided by a board-certified emergency and family practice doctor were “not medically necessary”. During trial he admitted that he had not actually practiced medicine in 35 years and that his specialty “back then” was OB/GYN. The Medical Director said he had retired because he “didn’t like being bothered by his patients during the night.”

The bottom line: there are two kinds of M.D.s: those who take care of and focus on patients (Medical Doctors); and those who take care of insurance companies and health plans, and focus on profits (Medical Directors).

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