I am sharing a recent experience regarding Blue Cross of California denial of care. I hope this is useful to fellow CANS colleagues who may have also struggled with this problem in their own practices. The process has been somewhat tedious and drawn out but ultimately with a satisfactory resolution. I have included a brief synopsis of the clinical aspects of the case followed by the letter which summarizes my interactions with the grievance and appeals department at Blue Cross and their medical benefits subsidiary Carelon.
The patient DS is a 64yr-old, right handed, female with no previous history of cervical spinal problems and was seen in urgent consultation in my office on 11/00/23. Her symptoms and signs were consistent with a subacute, progressive myeloradiculopathy. The MRI scan revealed congenital spinal stenosis with severe focal compression of the spinal cord at C5-6. There was a large central HNP with underlying myelomalacia. My recommendation was to proceed with an urgent ACDF. The sequence of events both pre and post operatively are reviewed in the letter below. She did well following this uncomplicated procedure and has returned to near normal neurological function.
Anthem Blue Cross
Attn: Grievance and Appeals
21215 Burbank Blvd, Woodland Hills, CA 91367
Re: Patient DS
Date of Service: 12/07/2023
ID: XDP000A00000
Date of Birth: 8/00/1959
Claim No. 0000000BP0000
Case No. REQ-COMM-0000000
Dear Reviewer:
I am a practicing neurosurgeon in San Luis Obispo, California and have been a member of Anthem Blue Cross dating from 1989. Since that time, I have been privileged to assist in the management of many Blue Cross neurosurgical patients. Generally, my relationship with the organization has been professional and supportive. Most recently, I have encountered difficulties with reimbursement on procedures pre-approved and then secondarily denied after the surgery had been performed.
Specifically, I am writing about a patient named DS, who underwent a cervical spine surgery on December 00, 2023. Prior to this operation my office manager was told by both your organization as well as the Carelon review subsidiary that no authorization was required for this surgery. The procedure was performed and has undergone extensive review and repetitive denials from your organization. Specifically, we have spoken on numerous occasions to Blue Cross as well as Carelon and have documentation of these extensive interactions. Repetitively, we have been ping-ponged from one organization to the other without resolution of the reimbursement issue.
I am alerting you to my level of concern in this regard and would ask that you resolve this situation such that I do not have to utilize the Municipal Court of San Luis Obispo for a small claims lawsuit to recoup the fee for my services. I will also be including the extensive amount of labor, time and expense concurred with the lawsuit.
It is my hope that this situation can be resolved however I am committed to recoup the monies that are owed for my neurosurgical care of your patient DS. Please feel free to contact me via my cell phone listed below for further information regarding this dispute.
Very sincerely yours, Phillip Kissel, MD
There was no response from the company to my letter so I proceeded to file a lawsuit with the San Luis Obispo Municipal small claims court.
This process is fairly straight forward. It can be completed online via the county website by submitting the appropriate forms. I choose to seek assistance from a proprietary online support service called Squabble. For a fee, they will check over the information prior to filing the court documents. Their website is concise and answers the questions regarding the process and procedures. squabbleapp.com
I submitted the data to Squabble on 2/17/25 and the court filing was accepted the following day. The date for the court hearing was set for 4/25/25. This could either take place in person at the court house or via Zoom. The next step was to obtain “proof of service” which again was handled by Squabble. This documented that Blue Cross was on notice to appear in court as a defendant in the lawsuit.
The next interaction with Blue Cross was a phone call to my office from Anthem legal department with a settlement proposal. This offer included reimbursement for my contract rate for the procedure, interest and court filling fees. I choose to accept the offer, probably should have negotiated harder, and signed the Settlement Agreement and Release.
Lastly, I had to formally notify the court that the case had been settled on 4/11/25. I have no qualms about revisiting this process and would encourage CANS members to utilize this public service in similar insurance denial problems.
“Show Me the Doctor, and I’ll Show You the Infraction”
Anarcho-Tyranny in Medicine
Anthony DiGiorgio, DO, MHA
I’m on suspension again.
Not for harming a patient. Not for failing to respond to a page. Not for being late to a case.
No, I’m suspended because my history and physical note was “incomplete.” The note is thorough. It covers the clinical situation in full. The patient had an acute subdural hematoma and was herniating. I documented everything relevant to the case.
But I didn’t include a full review of systems.
A full ROS is no longer required by CPT, but the hospital still mandates it under its own internal guidelines. So despite treating a patient in extremis and documenting accordingly, I’m technically “noncompliant.” And for that, I’m suspended.
Lavrentiy Beria, Stalin’s infamous chief of secret police, once said:
“Show me the man, and I’ll show you the crime.”
In the Soviet Union, the rule of law was so convoluted that anyone could be arrested at any time if the regime decided they were inconvenient. That’s the point of complexity. It’s not to ensure order. It’s to ensure control. Stay quiet, and they’ll ignore the rule you’ve broken. Speak up, and they’ll pull the file.
Modern medicine now operates under this same logic. Ask any physician what’s clinically required to document in an initial hospital encounter, and you’ll get one answer. Ask the hospital, and you’ll get another. Ask CMS, and you’ll get a third. And that’s just one note.
Take Stark Law, which governs physician self-referral. Dr. John Asghar recently pointed out that multiple legal teams have given him diametrically opposed interpretations of the same regulation. As he put it: “Physicians are told to sit tight, follow shifting safe harbors, and be grateful we’re allowed to own anything at all. It’s not about protecting patients. It’s about keeping doctors in check.”
This is the design of the system. With enough volume and complexity, everyone is out of compliance. That creates the perfect weapon. If you’re seen as difficult, nonconforming, or just happen to make someone uncomfortable, they don’t need a real reason to punish you. They’ll find a late chart, a missing module, a misfiled H&P.
We’ve all seen it. Talented, respected colleagues labeled “troublesome,” who suddenly find themselves under scrutiny for documentation delays or audit discrepancies. It’s rarely about patient care. It’s about power.
Marc Andreessen popularized the term “anarcho-tyranny,” where there is simultaneous tolerance of criminal behavior with oppression of law-abiding citizens. Hospitals claim they can’t possibly improve OR turnover times below three hours. They tolerate broken processes, inefficient workflows, and abysmal IT systems. But if a doctor points out the areas of inefficiency or low quality, they are instead scolded about not answering CDI queries.
This is a major driver of burnout. As if life-and-death decisions, medicolegal liability, declining reimbursement, and endless prior authorizations weren’t enough, we now live under constant administrative threat. One misstep, and your privileges can be suspended. Worse yet, a Medicare billing violation could bring federal prosecution.
Just ask the three top-tier cardiac surgeons prosecuted by Medicare for overlapping surgery, despite the fact that the practice is safe and widespread, and the three of them were renowned worldwide.
This has to change.
Locally, physicians should push their medical executive committees to reduce documentation burden and streamline policies. Nationally, our specialty societies must prioritize federal and state reform, especially around laws like Stark, which are now weaponized more often than they are protective. We need major reform, or even elimination of the National Practitioner Data Bank, a major weapon used against physicains. Until then, don’t be surprised as more doctors leave medicine. Some will burn out. Others will simply be documenting using the wrong template.
Are We Still the Shining City on the Hill?
Is it Wrong to Show Empathy?
On June 30, 2025, The Lancet published “Evaluating the impact of two decades of USAID interventions and projecting the effects of defunding on mortality up to 2030: a retrospective impact evaluation and forecasting analysis.”
This is a uniquely interesting study — the only one — that not only contains a retrospective analysis of the positive impact of USAID but also forecasts the detrimental effects of its defunding on the many recipient countries over the next five years.
The US Agency for International Development (USAID) was created in 1961 with two objectives:
1 – To provide humanitarian assistance
2 – To assist and support economic growth and self-reliance of developing countries, particularly those deemed strategic for the US economic and geopolitical impact.
Please see https://foreignassistance.gov/
Over the years, USAID has become the largest funding agency for humanitarian and development aid in the world, with $55 billion in 2023, or approximately 30% of the total development assistance of all countries.
The authors of The Lancet study estimated that “over the past two decades, USAID-funded programs helped prevent more than 91 million deaths globally, including 30 million deaths among children.” Indeed, this is impressive and laudable; it makes me proud.
The authors also predict that dismantling USAID “could result in more than 14 million deaths by 2030, including 4.5 million deaths among children younger than 5 years.” What an awful and unthinkable prospect!
Notably, although the US is the largest donor in absolute terms, it ranks 25th among all other countries relative to their national income. We give 0.24%, compared to Norway’s 1.09% and Luxembourg’s 1%. The UN had targeted 0.7% as the desirable goal.
Regardless, the US was always looked up to as an example to emulate. To confirm this, several countries, unfortunately, followed the current administration’s lead in defunding USAID. The UK announced plans to reduce its aid budget by 40%, France by 37%, the Netherlands by 30%, and Belgium by 25%, thereby magnifying the detrimental effect of this decision. So our actions have consequences on more than one level.
Historically, the USAID was not the only aid program our country provided. We have been generous even toward our previous enemies. The Marshall Plan – The European Recovery Program – was to aid Western Europe after World War II; the Government and Relief in Occupied Areas (GARIOA) provided food aid and other assistance to occupied countries like Japan, Germany, and Austria; after the end of the Vietnam War and the normalization of relations in the 1990s, we helped Vietnam generously on several fronts. These are only a few examples.
Why did we do this? The simple answer is that it was the right thing to do.
Yes, the right, the moral, and empathetic thing to do.
Empathy is, unfortunately, becoming a dirty word in this administration. Elon Musk, while he was in charge of DOGE and during his honeymoon period with Donald Trump, suggested that “Empathy was the fundamental Weakness of Western Civilization.” He is so wrong! (editor’s note: Musk’s exact quote was “Modern Western civilization has extraordinary empathy compared to its power. This is also arguably its greatest weakness.”)
Can we afford to lose our empathy toward the suffering and the underprivileged people of the world? Absolutely not!
In an essay published in the New York Times on July 7, 2025, Craig Spencer, an emergency room physician, assistant professor at Brown University, and a member of the advisory board for Doctors Without Borders USA, indicated that “ if we allow the Trump administration’s assault on empathy to define our global health agenda, or ourselves, we won’t just be turning away from the world – we’ll be turning away from who we are.” He is correct!
Much like Ronald Reagan, and particularly since I am an immigrant who grew up in a totalitarian society, I believe in American exceptionalism. And we should always endeavor to deserve the appellation of the “Shining City on the Hill.”
No, we don’t want to divorce ourselves from empathy, as Americans, but particularly as physicians. And let us remain “true to who we are,” good and caring people.
Graphic of the Month:
In 1990 manufacturing or retail dominated every state’s payroll. By 2024, health care is the largest employment sector in 38 states, thanks to massive subsidies that now top $2.5 trillion a year. Yet the head-count growth isn’t at the bedside. Administrative, billing and compliance roles are expanding nearly five times faster than clinician jobs, and the Bureau of Labor Statistics projects another 29 % jump in medical-and-health-services managers this decade.
When the fastest-growing slice of America’s biggest industry is paperwork, not patient care, something is out of balance and taxpayers and premium-payers are footing the bill. Without productivity gains or structural reform, this trend will strain budgets far more than it heals patients.
CANS MISSION STATEMENT
To Advocate for the Practice of California Neurosurgery
Benefitting our Patients and Profession
HealthcareCORP
Hunter Yamada, MD candidate UCSF 2027
Article: Defining Health Care Corporatization, New England Journal of Medicine
Health care corporatization has been an expanding element in the modern era of medicine. In Paul Starr’s 1982 work, The Social Transformation of American Medicine, he described the evolution of medicine in the United States and predicted the rise of “an industry dominated by huge health care conglomerates.” Brown et al. defines health care corporatization as “the general trend throughout the health care industry toward higher levels of integrated control by consolidated profit-seeking enterprises.”
Despite being four decades out from Starr’s prediction, it is difficult to overstate the changes health care corporatization has produced. This has been an era of medicine marked by consolidation and a decline in physician autonomy. Since 1983, the percentage of hospitals owned by companies that control three or more hospitals has expanded from 11.6% to 56.1% today. Over time, being a “Kaiser patient” or “Sutter patient” has become an informal identity marker, shaping how individuals talk about their healthcare and align themselves with the medical system. It has also changed the opportunities that newly minted physicians have access to. Whereas roughly three-quarters of U.S. physicians owned their practice in the early 1980s, in 2023, a similar proportion were employed through hospital or corporate groups.
Central to any discussion involving healthcare is the mutual understanding that patients come first. This is the fundamental basis of medicine. The providers, payers, and policymakers exist in this ecosystem to support patients and meet their needs. The system fails when any one group is not properly regulated. In this modern era of medicine, providers are under multiple layers of scrutiny that are too numerous to mention. In contrast, payers and corporations have been relatively unhampered in their spread and methods of practice. While most would agree that cost-efficiency is a worthwhile goal in medicine, it is problematic when it is at odds with patient care. When payers create an obstacle course of barriers, such as their complex referral systems and preauthorization requirements, patients suffer. Profit-seeking at the cost of patient well-being cannot be tolerated, and providers cannot rectify it alone. I believe it requires policymakers to evaluate healthcare from a unique criterion. Seeing healthcare as a business sector risks prioritizing efficiency over the health of citizens. We must think about the policymakers’ ins and outs of information and the part physicians can play in that. Joining and supporting physician advocacy groups, educating through popular media, and speaking to politicians at all levels are concrete ways to go about this. The unchecked corporatization of medicine is not a transient development, but rather a structural issue that requires careful and deliberate intervention.
What the NEJM Misses on Corporatization
Anthony DiGiorgio, DO, MHA
Hunter does a great job on his overview of the structural and financial consolidation in US healthcare. We all feel the effects on physician autonomy, and he is right to highlight it. However, I want to focus on a few points that the NEJM article gets wrong, and why it’s important to get this right.
The author, Erin Fuse Brown, defines corporatization as “the general trend throughout the health care industry toward higher levels of integrated control by consolidated profit-seeking enterprises.” Yet it falls short of naming the most insidious actors, which are not technically profit seeking: large consolidated nonprofit health systems.
Despite acknowledging that “powerful nonprofit health systems may come to prioritize revenue over patient and community welfare” and engage in aggressive financial behavior, such as inflated pricing, network exclusions, and suing patients, the NEJM still frames for-profit conversion as the central engine of corporatization. This is an ideological blind spot.
In practice, nonprofit systems behave no differently from their for-profit counterparts, and often worse, because they are shielded from taxation, qualify for favorable bond rates, and benefit from programs like 340B. These levers, granted under the guise of community benefit, are routinely used to accumulate capital, build empires, and extract revenue, not to subsidize care for the poor or the indigent.
In fact, many so-called “for-profit” actors often serve Medicaid and uninsured populations more readily, without suing patients or closing unprofitable clinics. The reflexive assumption that “profit” equals predation while “nonprofit” signals benevolence is dangerous. It excuses the behavior of the most powerful and unaccountable institutions in American healthcare and calls for policy solutions that increase regulation, not for those that increase competition.
When looking to correct the disease, it’s important to get the diagnosis right. Large nonprofit health systems have been consolidating because of regulations that increase their revenue and systematically disadvantage smaller, independent actors. The cure lies in rectifying those policies instead of implementing MORE regulation, which will only help large established entities further.
The California Association of Neurological Surgeons would like to thank all of exhibitors in helping making our annual meeting a success!
We value your presence and hope to have you all next year in Southern California!
Medtronic -Gold Sponsor
Aesculap – Silver Sponsor
Cooperative of American Physicians -Silver Sponsor
Integra LifeSciences-Silver Sponsor
Orthofix -Silver Sponsor
Rosman Search -Silver Sponsor
Surgeons Capitol Management -Silver Sponsor
Ruthless Spine -Board Meeting Presentation
Astura Medical
ATEC Spine
Brainlab, Inc
Carbofix Spine
Cerspedics
Day Surgical Products, Inc
GE Healthcare
Globus
GT Medtech
Johnson & Johnson Medtech
KLS Martin
Leica Microsystems
META Dynamic, Inc
Mitaka USA, Inc
NX Development Corp
Q Surgical
Spineart
Stryker Spine
Surgical Theater
Zap Surgical
CANS, Annual Meeting
January 16-18, 2026 Oxnard, CA
CSNS Meeting April 24-25 Boston, MA
Any CANS member who is looking for a new associate/partner/PA/NP or who is looking for a position (all California neurosurgery residents are CANS members and get this newsletter) is free to submit a 150 word summary of a position available or of one’s qualifications for a two month posting in this newsletter. Submit your text to the CANS editorial office by emailing Anthony.digiorgio@ucsf.edu
Newsletter Editor
Anthony DiGiorgio, D.O.
Contributing Editors
Deborah C. Henry, M.D.
Brian Gantwerker, M.D.
Ian Ross, M.D.
This newsletter is published monthly from the Executive Office:
California Association of
Neurological Surgeons
5380 Elvas Avenue
Suite 215
Sacramento, CA 95819
Tel 916 457-2267
Fax 916 457-8202
www.cans1.org
CANS Board of Directors
| President | Samer Ghostine, MD | Los Angeles |
| President-Elect | Brian Gantwerker, MD | Santa Monica |
| Vice-Pres | Anthony DiGiorgio, DO | San Francisco |
| Secretary | Odette Harris, MD | Stanford |
| Treasurer | Sanjay Dhall, MD | Los Angeles |
| Imd Past Pres | Ciara Harraher, MD | Santa Cruz |
| Past President | Joseph Chen, MD | Bakersfield |
Directors — Northern CA
| Marco Lee, MD | Stanford |
| Eze Goldschmidt, MD | San Francisco |
| Leslie Robinson, MD | Chico |
| Sherry Taylor, MD | Fairfield |
Directors — Southern CA
| Garni Barkhoudarian, MD | Santa Monica |
| Linda Liau, MD | Los Angeles |
| Ian Ross, MD | Pasadena |
| N. Nicole Moayeri, MD | Santa Barbara |
Resident Board Consultants
| James Brazdzionis, DO | RUHS |
| Jessica Campos, MD | UCI |
| Jose Castillo, MD | UCD |
| Alex Lopez, MD | UCI |
Executive Secretary
| Emily Schile | Sacramento | emily@cans1.org |