What is the name of your state (only U.S. law)? WI/NE
Doctor's office is in NE, we're in WI. Not sure which would have jurisdiction.
I'm an investigator for an insurance company; we had a file reviewed twice for medical necessity and needless to say, it came back both times by two peer independent reviewers as not medically necessary (per the plan definition). Everything was done by the book on the reviews.
A broker for the group didn't understand any of it, so she asked for a more detailed "laymen" explanation as to why the reviewers stated to deny the charges. Normally in those situations we provide more "behind the scenes" and insider information as to why we're targeting these services for review, which is usually due to abusive and/or fraudulent situations. It's something that would never be sent to a client and certainly not a patient or a physician's office. It's treated essentially like an internal e-mail since brokers are our business partners.
The e-mail spoke of that in general; i.e., not naming any specific physician or entity and a good chunk of it constituted of my own personal views/opinions of trends that I've seen/experienced over the years with this particular form of treatment. Editorializing, I guess one could call it. And then I broke down what this particular reviewer was saying in laymen's terms.
The only specific comment I made about this physician was just a general one that said there was no guarantee that he (call him Dr. Smith) could know ahead of time that the procedure would be successful (as the discussion was about how some of the physicians in this field tend to use the ends to justify the means--but conversely when the procedures don't work, they still want to be paid. It can't go both ways), and that I've had his files reviewed before (true) and that not all of his patients experienced sustained relief 100% of the time (what procedure does?). But there was never any accusation made that he was engaged in any abusive or fraudulent behavior on this or any previous files. If anything, it was an inference that no doctor is correct 100% of the time (that's why the call it 'practicing' medicine, as the saying goes) and beyond that, we had two physicians Board certified in the same specialty backing us up on the denials on the file in question.
Well, needless to say since I'm on here, the idiot broker--instead of treating it like an internal e-mail--just forwarded the whole thing onto the group contact, who in turn forwarded it onto the patient's wife, who in turn sent it to the physician's office.
An overly long and somewhat ridiculous cease and desist letter followed accusing me/us of slander (although written in an e-mail, which is libel) and defamation of character, and also claiming that by merely discussing the file or explaining in laymen's terms the content of the peer independent review, that I was essentially guilty of practicing medicine in the state of Nebraska without a license. I mean, don't get me wrong--I've been doing this for a while so it's not my first time to the rodeo dealing with attorneys and I don't quake in my boots when I get a letter from one (no offense to you all!), I've just never seen anything quite like this. It should be noted that at no point in the letter does he even specifically say which parts of the e-mail were slanderous or defamatory, or alleges aren't true. More of a "how dare you question the expertise of Dr. Smith, you insurance jockey you" type of letter.
My employer took the reins on it and sent a letter of retraction back and even spoke with this physician,, who admitted that he understood where I was coming from but he didn't appreciate being "lumped in" with all of these other dastardly physicians (understandable).
So we thought that was the end of it, until we get another letter from the attorney once again calling it slander and saying that my employer's apology wasn't "worth the paper it was printed on" since it didn't come from me and that it wasn't disseminated to the parties the original e-mail went to...except beyond the aforementioned parties, we have no idea who it all really went to and they don't spell it out.
So now if we don't do that, they're threatening any and all legal recourse (yada yada) in 10 days. Well, actually my employer is late to the party on it and it's past that already (19th would have been their self-imposed deadline). He asked me to write a brief retraction, which I did, but even as of today we have no idea who to send it to.
My questions are:
--Does this seem like a lot of needless posturing given the circumstances;
--Does what I described seem to you to fit any legal definition of "slanderous" or "defamatory" (and it kills me the lawyer doesn't know the difference between slander and libel to begin with)
--And even if it would be, my understanding is that he has to show proof of damages, i.e., damage to his reputation, livelihood, etc. As far as I know, exactly 4 people besides him and his attorney have seen this outside of our company. If anyone else has seen it, it's by their doing. The patient himself hadn't been back to see this physician in over six months by the time this all went down. If no one else has seen the e-mails, it hasn't stopped new or repeat patients from coming back to his practice. What's your opinion that he could reasonably prove damages anywhere near worth the money and time it would even take to bring it to court?
Just curious on your take. Gnawing at me obviously since I'm on here. Or if we should even bother with the additional retraction at this point and let the attorneys we use for certain things take a look at it before we dig ourselves a larger hole. That was my first instinct but needless to say, it wasn't my call.
Doctor's office is in NE, we're in WI. Not sure which would have jurisdiction.
I'm an investigator for an insurance company; we had a file reviewed twice for medical necessity and needless to say, it came back both times by two peer independent reviewers as not medically necessary (per the plan definition). Everything was done by the book on the reviews.
A broker for the group didn't understand any of it, so she asked for a more detailed "laymen" explanation as to why the reviewers stated to deny the charges. Normally in those situations we provide more "behind the scenes" and insider information as to why we're targeting these services for review, which is usually due to abusive and/or fraudulent situations. It's something that would never be sent to a client and certainly not a patient or a physician's office. It's treated essentially like an internal e-mail since brokers are our business partners.
The e-mail spoke of that in general; i.e., not naming any specific physician or entity and a good chunk of it constituted of my own personal views/opinions of trends that I've seen/experienced over the years with this particular form of treatment. Editorializing, I guess one could call it. And then I broke down what this particular reviewer was saying in laymen's terms.
The only specific comment I made about this physician was just a general one that said there was no guarantee that he (call him Dr. Smith) could know ahead of time that the procedure would be successful (as the discussion was about how some of the physicians in this field tend to use the ends to justify the means--but conversely when the procedures don't work, they still want to be paid. It can't go both ways), and that I've had his files reviewed before (true) and that not all of his patients experienced sustained relief 100% of the time (what procedure does?). But there was never any accusation made that he was engaged in any abusive or fraudulent behavior on this or any previous files. If anything, it was an inference that no doctor is correct 100% of the time (that's why the call it 'practicing' medicine, as the saying goes) and beyond that, we had two physicians Board certified in the same specialty backing us up on the denials on the file in question.
Well, needless to say since I'm on here, the idiot broker--instead of treating it like an internal e-mail--just forwarded the whole thing onto the group contact, who in turn forwarded it onto the patient's wife, who in turn sent it to the physician's office.
An overly long and somewhat ridiculous cease and desist letter followed accusing me/us of slander (although written in an e-mail, which is libel) and defamation of character, and also claiming that by merely discussing the file or explaining in laymen's terms the content of the peer independent review, that I was essentially guilty of practicing medicine in the state of Nebraska without a license. I mean, don't get me wrong--I've been doing this for a while so it's not my first time to the rodeo dealing with attorneys and I don't quake in my boots when I get a letter from one (no offense to you all!), I've just never seen anything quite like this. It should be noted that at no point in the letter does he even specifically say which parts of the e-mail were slanderous or defamatory, or alleges aren't true. More of a "how dare you question the expertise of Dr. Smith, you insurance jockey you" type of letter.
My employer took the reins on it and sent a letter of retraction back and even spoke with this physician,, who admitted that he understood where I was coming from but he didn't appreciate being "lumped in" with all of these other dastardly physicians (understandable).
So we thought that was the end of it, until we get another letter from the attorney once again calling it slander and saying that my employer's apology wasn't "worth the paper it was printed on" since it didn't come from me and that it wasn't disseminated to the parties the original e-mail went to...except beyond the aforementioned parties, we have no idea who it all really went to and they don't spell it out.
So now if we don't do that, they're threatening any and all legal recourse (yada yada) in 10 days. Well, actually my employer is late to the party on it and it's past that already (19th would have been their self-imposed deadline). He asked me to write a brief retraction, which I did, but even as of today we have no idea who to send it to.
My questions are:
--Does this seem like a lot of needless posturing given the circumstances;
--Does what I described seem to you to fit any legal definition of "slanderous" or "defamatory" (and it kills me the lawyer doesn't know the difference between slander and libel to begin with)
--And even if it would be, my understanding is that he has to show proof of damages, i.e., damage to his reputation, livelihood, etc. As far as I know, exactly 4 people besides him and his attorney have seen this outside of our company. If anyone else has seen it, it's by their doing. The patient himself hadn't been back to see this physician in over six months by the time this all went down. If no one else has seen the e-mails, it hasn't stopped new or repeat patients from coming back to his practice. What's your opinion that he could reasonably prove damages anywhere near worth the money and time it would even take to bring it to court?
Just curious on your take. Gnawing at me obviously since I'm on here. Or if we should even bother with the additional retraction at this point and let the attorneys we use for certain things take a look at it before we dig ourselves a larger hole. That was my first instinct but needless to say, it wasn't my call.
