By Dr. Elisabeth Potter, MD
I’m sharing an actual recent peer-to-peer call that shows what physicians and patients face when trying to get a surgery approved. This call felt as absurd as it sounds.
The peer-to-peer call was to advocate for surgery to prevent and treat lymphedema for a patient with breast cancer. Her risk is high and we can perform a surgery to lower it.
The doctors from the insurance company on the call were an ophthalmologist with a subspecialty in oculoplastic surgery and a plastic surgeon who currently has a cosmetic practice. Neither doctor has ever performed lymph venous bypass…the surgery I was trying to get approved for my patient.
Neither doctor would provide their name or license number. At the conclusion of the call, the doctors told me that they didn’t have the power to make a determination or decision to perform the surgery. They were just there to inform me of United’s decision to deny it.
The Medical Decision was not up to the doctors on the call. It had already been made by United. So here I am, appealing again.
Medical decisions should be made by doctors who are well informed and patient-centered. Patients deserve access to the care that they paid for with their premiums.
Dr. Elisabeth Potter, MD 6818 Austin Center Blvd #204, Austin, TX 78731 (512) 601-4759 Website: https://www.drpotter.com/
ADDITIONAL COMMENTARY BY STACY MAYS:
The Perils of Prior Authorization: Time to Call Out the Right Party
Doctors and patients are going public with stories of absurd prior authorization denials—and the broken peer-to-peer processes behind them.
But there’s a critical piece missing in these conversations: They’re calling out the insurance company acting as a third-party administrator (TPA), not the employer—who is actually in charge.
📌 Under ERISA, the employer is the plan’s fiduciary—with ultimate authority and responsibility for all plan decisions.
➤ 29 U.S.C. § 1102(a)(1) – requires each plan to name a fiduciary who controls and manages the plan.
➤ 29 U.S.C. § 1002(21)(A) – defines a fiduciary as anyone with discretionary authority over plan administration.
➤ 29 U.S.C. § 1002(16)(A) – defines the employer as the plan administrator, unless otherwise designated.
That means employers are not just “buyers” of benefits. They are legally accountable for what happens inside their health plan—including what their vendors do.
🧾 Your company’s plan documents (check the legal packet you get at open enrollment) spell this out clearly. The employer is the Named Fiduciary and Plan Administrator.
So if you’re facing a denial that defies logic:
• 📧 Send the peer-to-peer notes or call recordings (if legal) directly to the CEO and HR executive.
• 🎯 Point out that the employer hired the vendor making these decisions.
• 🔁 Ask the CEO to override the denial—which they have the contractual and fiduciary authority to do. Make it a personal appeal.
Let’s be clear:
It’s not the “BUCA” plan (Blue, United, Cigna, Aetna).
It’s The ACME Manufacturing Health Plan, administered by [Insert TPA Name].
Time for accountability to match the authority.
FROM A PHYSICIAN
Bill, while this is definitely an egregious example, there are two sides to this story. As an employer, I was OK with Pre-auth, as long as it was done properly.
Several of our physicians found “moonlighting” jobs working in the peer review department at Aetna. They all cited multiple cases of egregious, inappropriate treatments. So, it happens more often than you think. Many physicians are financially incented to perform procedures that are suspect. Back surgeries are a classic example of that.
The peer to peer needs to be between physicians of the same specialty or subspecialty, especially if there is a denial. And the employer (as the fiduciary ought to be informed ahead of time, or at least contemporaneously with the decision.
And that’s the truth!!
