Thread by @PatrickMRucker

Ever been sick but your insurer refused to pay for the care your doctor said you need? Who gets to decide the treatment is “not medically necessary”? One Colorado surgeon tried to find out. 1/x

Dr. Braden Jones’ patient was hurt on a job site. The electrician slipped on some ice and tore his rotator cuff. He tried physical therapy but wasn’t better a year later. Jones looked at the MRI and knew what was needed. “It was a pretty clear-cut case for surgery,” Jones said.

Jones was ready to operate but he needed permission from Pinnacol Assurance, the workers comp company that covered the electrician. Pinnacol said no.

The patient only needed steroid injections and some physical therapy. That was the finding of Dr. Jon Erickson, who Pinnacol hired to review the case. The decision made no sense to Jones, so he went to investigate.

Jones checked to make sure Erickson was licensed. He was. In fact, he was an orthopedic surgeon just like Jones. But Jones found something troubling.

Erickson has a valid medical license but was banned from performing surgeries as part of a 2017 settlement he had reached with the Colorado medical board. Something had gone very wrong in the operating room, a disciplinary report from the board said.

Erickson had performed a “substandard” hip replacement in 2013 that he tried to fix with three more surgeries but he couldn’t, according to the settlement. The patient will always walk with a limp.

That wasn’t all. The settlement faulted Erickson for another botched hip replacement six months after the first. The surgery had taken place on a Friday, and by Monday the same patient was back on the operating table with a broken hip.

Erickson performed a second surgery but something was wrong. An X-ray showed the problem.
Erickson had put the hip in backwards.

Erickson agreed to stay out of the operating room for good. In other words, he was prohibited from performing the very surgery that Jones wanted for his patient.

“If you have ever seen a Lego, you know which way the hip goes,” Jones said.
Jones’s patient successfully underwent the surgery after appealing the initial denial of the procedure, and he is doing well.

Dr. Erickson defended his decision, calling it a “relatively clear-cut case” and said reviews like his “prevent a lot of inappropriate care” and save money for the insurer’s clients.

Pinnacol said Erickson was not an employee and was contracted as an independent reviewer. It said its mission is to serve workers and employers in Colorado and it does not “support denying necessary medical care”  to save clients money.

For most people, the inner workings of their health insurer are a black box: Requests to cover treatment or pay claims go in, and approvals or rejections are spit out. Our investigation looks inside the system that denies care. propublica.org/article/malpra…

If you’re an industry insider or have information that can help us with our reporting, please get in touch. propublica.org/getinvolved/in…