Doctors Who Paid Big Medical Malpractice Settlements Now Decide Insurer-Approved Care

One might presume (or at least hope) that negligent doctors with a track record of paying large sums to settle multiple Florida medical malpractice lawsuits would have a tough time continuing to work in the health care industry. That person would be wrong.West Palm Beach medical malpractice lawyer

Not only is it rare for a doctor to lose their state-issued license to practice medicine in Florida, a new report by ProPublica revealed that several physicians repeatedly found negligent in providing patient care now earn healthy sums working for health insurers — approving or denying coverage for patient insureds.

The first example involved a surgeon who practiced for years in Brevard County, Florida — during which time he settled five Florida medical malpractice lawsuits for a collective $3 million. Among the patient allegations against him:

  • He negligently cut the aorta of a patient who underwent surgery for her gallbladder. She died just before her 40th birthday, leaving behind a husband and two teen daughters.
  • He negligently stapled and stitched a patient’s rectum to her vagina.

The surgeon denied these and three other claims against him, but ended up paying sizable settlements to each of those claimants for medical malpractice.

Those harmed might take comfort in the fact that he hasn’t worked as a practicing surgeon for a dozen years. However, he was hired to work as a medical director for a health insurance company, where he is a critical gatekeeper deciding which patient procedures will be covered by the insurer and which won’t. Not only that, he oversees more than a dozen other medical directors.

Although medical directors like him never see patients in person, they can overrule the doctors who do when they recommend medicines, tests, treatments, or procedures.

ProPublica reported that on average, a single medical director reviews 10,000+ patient claims for coverage a year. In a few cases, doctors astonishingly ruled on more than 10,000 claims in a single month. That breaks down to a single person ruling on more than 333 cases a day – and that assumes the doctor actually worked 30 days straight, which is unlikely.

Rubber-Stamping Health Insurance Coverage Denial

A longstanding major criticism of health insurers is that they routinely and automatically deny medically necessary and sometimes life-saving treatments due to the cost, rather than compelling proof that such treatments aren’t necessary. Patients can try appealing (which is arduous, time-consuming and often unsuccessful) or they can pay out-of-pocket and possibly go bankrupt.

Health insurance medical directors make major judgment calls that have a huge impact on patients’ lives. And yet, the identity, experience, qualifications, and professional backgrounds of these doctors isn’t made readily available for scrutiny. States can require medical directors be licensed physicians, but as our Palm Beach medical malpractice lawyers already noted, it’s rare for a state board of medicine to entirely strip doctors of their licensure – even if they’ve had multiple substantiated prior allegations of medical malpractice.

So it’s largely left to health insurance companies to decide whether a physician is qualified. Neither the patient nor the doctor treating them get transparency or veto power when it comes to the medical director who reviews their case.

But why would insurers want to hire a doctor with a questionable practice track record? Our guess is doctors with limited professional prospects may be more easily persuaded to act in the insurer’s best interests rather than the patient’s by rubber-stamping coverage denials – especially if the doctors are being paid well to do so.

In a written statement by one insurer, a spokesperson argued that medical malpractice claims against doctors are “common” – especially in specialties like surgery – and that “settlement of malpractice claims does not necessarily mean that malpractice occurred.”

As  West Palm Beach medical malpractice attorneys, we can assure you the burden of proof in Florida medical malpractice cases is high. Plaintiffs are required to jump through many hoops before they are even granted approval to file – including securing the favorable testimony of an expert physician who is similarly situated with the defendant in specialty, education and experience. These are not by any stretch of the imagination “easy” cases to win.

In fact, we think it’s the opposite: Far too many legitimate medical malpractice claims are lost not on merit, but procedural red tape and extraordinarily high proof burdens. Need more evidence? According to the New England Journal of Medicine, only 6% of doctors in the U.S. had paid any medical malpractice claims in a recent 10-year span. Only 1% paid two or more claims. Even among surgeons, only 5% paid medical malpractice claims during that same time frame.

Not Just a Case of “One Bad Apple”

There is no public database of health insurer medical directors. Nonetheless, ProPublica’s extensive investigation found that the Brevard doctor with a spotty malpractice history was far from an outlier in the insurance industry. In the 17 states in which they were able to gain at least some information on doctors in these roles, they found at least a dozen with a history of at least one of the following:

  • Multiple medical malpractice settlements.
  • One medical malpractice settlement of $1 million or more.
  • Prior disciplinary action from the state medical board.

One had 11 prior medical malpractice settlements. Another had been scolded by the state medical board for deceptive and dishonest medical practices. Another bungled a cancer diagnosis of a young mother of two until it was too late and she died. Another installed a hip replacement backwards – and failed to fix it despite four follow-up surgeries.

None of this history would have been difficult for insurers to find – in court records, front page news stories, etc.

The bottom line here: The medical directors in charge of approving/denying care may have a questionable history.

If you have been harmed by medical malpractice in South Florida, our dedicated Palm Beach medical malpractice lawyers offer free initial consultations to help you determine the viability and value of your case, and how best to proceed.

Contact the South Florida personal injury attorneys at Halberg & Fogg PLLC by calling toll-free at 1-877-425-2374. Serving West Palm Beach, Miami, Tampa, Orlando and Fort Myers/ Naples. There is no fee unless you win.

Additional Resources:

Doctors With Histories of Big Malpractice Settlements Work for Insurers, Deciding If They’ll Pay for Care, Dec. 15, 2023, ProPublica and The Capital Forum

More Blog Entries:

CDC: 1 in 5 Women Report Mistreatment During Maternity Care, Feb. 20, 2024, West Palm Beach Medical Malpractice Lawyer Blog

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