Mad as Hell Doctors in California: October 6

Mad as Hell Doctors in California ( October 6, 2010

Up at 6:30, quiet tea in SoCal, with steady soaking rain outside. Not the image I really have of SoCal.

Our hostess fed us french toast with yohgurt and applesauce and we discussed single payer, medicare for all and the current insane insurance, billing and coding systems. My host asked, “Why does my bill say one amount and the insurance company pay another, much lower amount? What is that “adjustment”?”

The amount a doctor is paid has little to nothing to do with the amount that we bill: that is, if we are “preferred providers” and “take insurance.” Did you think that “preferred provider” or “in network” had to do with the quality of the medical care? Don’t be silly. It has to do with money and insurance profits. Here is the back story:

In starting up my own clinic, I’ve interviewed billing companies. Every billing company tells me not to worry about coding, they’ll go over each chart, they will let me know about mistakes. They will take care of it.

The thing is, I know that every place that I’ve been employed and in residency and in medical school, not one place had good coders. What is a coder? Every medical visit in the United States must have ICD-9 codes for every diagnosis. High blood pressure is 401.1. Diabetes, type II “not stated as uncontrolled” is 250.00, but there must be at least 30 different codes for diabetes. Diabetes, type I, uncontrolled, with kidney problems, has a specific ICD-9 code. Words are not ok, I have to provide a number for every diagnosis and if the number is not specific enough, the insurance may say that it is “not a covered diagnosis” and they will reject the bill. So I can’t use 250, that is not specific enough. It doesn’t matter that that code means diabetes, I have to specify it out two more digits. Does the patient feel better or get better care if I say 250.00? No. Do I give better care? No. The system benefits the insurance company because every bill they reject add to their profits.

Now, that is just the first number I have to provide. I also need to put a CPT code on every bill. That is the procedure code. A visit to the doctor for a code is billed as a procedure: for a level of visit. Doctor notes have gotten longer and longer to try to satisfy all of the requirements for documentation so that an insurance company can’t “downcode” to a lower level and pay less. Surgeries all have procedure codes and lab tests and strep tests and immunizations, but as a family doctor, most of my “procedures” are talking visits. Talking, explaining, asking questions, teaching, and gentle nagging: studies have shown that if doctors remind people to quit smoking, they are more likely to quit. The most common CPT codes for me are 99213 – a straightforward office visit, and 99214 – a more complicated office visit.

The CPT codes each have assigned RVUs- Relative Value Units. These attempt to put a value on each procedure. This involves a three part formula: and then each state pays a different amount for medicare for that CPT code. It doesn’t matter what the doctor bills: if they are contracted with medicare, medicare pays whatever is assigned for that state.

Insurance companies have followed suit, so to be a “preferred” or “in-network” provider, the doctor has to contract with each separate insurance company. Each contract is different and they all frequently change, so to try to track what is billed, verses what multiple insurance companies, medicare, federal medicaid and state medicaid have agreed to pay, is a nightmare. At this time, the administrative cost to be a “preferred provider” is $65,000 per primary care doctor per year. This is the cost of contracting, keeping track of the contracts, filling out all of the applications to be a preferred provider, and having employees to submit bills, keep track of bills, to resubmit bills that have been rejected and argue with insurance companies when they refuse to pay a bill. Quite a privilege, right? And maybe YOU thought that “preferred provider” meant really good doctors that your insurance company carefully screened. Don’t be so silly, this is about corporate profits!

I asked one billing company how they keep track of all of the rules. For example, now medicare will pay .03% more on a bill if I e-prescribe and put a special CPT code on the bill. Try remembering that. “Well,” said the biller, “That code is to your advantage this year, but next year it would net you more to use the special code for having an electronic medical record. You can’t use both. That would be illegal.” Ok, my head hurts. I’m supposed to keep track of this AND see patients? Biller, “Honestly, we try to keep track of the big insurers, Blue Cross, medicare, medicaid, but we just give up on the rules for the little ones. And we track whether each big company is paying you what they agreed to pay on the contract. Often they don’t. When we contact them, they say, oh, that was a computer upgrade, we misfiled Dr. X. We see these “misfilings” all the time, but honestly, we’ve never once seen one in the doctor or patient’s favor.” Huh. 100% of errors pay less to the contracted physician. That is some really creative corporate planning, don’t you think?

I have met one set of good coders. My previous employer hired coding auditors, who would check 10 charts per doctor per year. Last year I asked them to review one of my high risk obstetrics charts. Remember, I got nearly no education on coding and billing and frankly m career has been about taking care of sick people, not billing and coding. They said I was doing one part wrong. That means that my employer’s internal coders have not caught the error nor given me feedback for the last 10 years. How much lost revenue is that?

So I called the coding audit company and asked them to recommend a billing company. I have the name and now a very good set of questions that I have to answer before they will consider working with me. Usually they work with cancer doctors, not primary care. But they will consider it.

The medical bill for any insured person is “adjusted” down to the contracted amount. So who gets the full bill? You can guess, can’t you: the uninsured people and the underinsured people, the sickest and those who can least afford it. And maybe if they take all their tax and employment information to a clinic or hospital, they too can get their bill “adjusted”, though that may not be enough. The people who go in to bankruptcy from medical bills are most often the insured: one million US citizens per year now.

Mad as Hell Doctors in California: October 5, 2010

October 5, 2010

Today I rejoined the Mad as Hell Doctors ( on the road trip, this time in California. This day was a mix of planes, trains, cars, single payer health care, social justice and neoprene.

The Mad as Hell Doctors have been two weeks on the road in California, doing town halls for single payer. Some doctors are there for the entire trip, some have come for a week at a time, many local chapters of Physicians for a National Health Program (PNHP have local speakers and local providers join us at the events. Each event is different, with a mix of our team and the local team. One more week to go, ending in Chico, California on October 12th. I am leaving my practice and my children for one week, the last week of the trip.

The previous trip was from Portland, OR to Washington DC, 26 cities and more than 30 town halls, a road trip across the United States. I joined the Mad as Hell Doctors in Seattle and participated for a week. I flew home from Colorado and then rejoined them for the last 5 days, ending in a rally across the street from the White House.

Up at 3 am and quick finishing my packing, left at 3:40 after kissing the kids. Drove from home to Sea Tac, about two hours, down through Bremerton and across the Tacoma Narrows Bridge as the sky is starting to lighten and then north on I5. I5 luckily not busy and not backed up. Left the car with some company on International Boulevard and rode the van to the airport. At the scanner after I checked one bag, security found a jackknife in my carry on. Rats. I did not have time to go back around and mail it home. I wonder what really happens to all the confiscated knives. On to the gate and the flight was boarding. Nice flight down to San Diego. We left at 6:50 am and arrived at around 9 am. I felt disoriented as soon as I stepped outside: the sun was too high in the sky and those palm trees are just wrong. The air is so dry after the Pacific Northwest.

I checked on a van to go meet my Mad as Hell Doctor compatriots, but it would cost $170. “No? How about $150? How much can you afford?” The 3 pm train was $17.00 so I waited for that. I checked my bag at the train station and wandered around San Diego for a while, had breakfast.

At 3:00, the train moved out. San Clemente Pier was the third stop. The disembodied train speaker said “You should be going down the stairs and be ready at the doors: this is a very short stop.” I was ready and the only one to get off. I rolled my bag along as the train pulled away. No one was there. Then I heard my name and from the ocean side a man was running, sort of, in a black shortie wetsuit with one yellow flipper in his hand and the other on his right foot. I must be insane, I thought, and got a very wet oceany neoprene hug from Dr. Mike Huntington.

I changed into my swimsuit and joined Drs. Huntington and Sapir ( in the ocean, my suitcase tucked up on the lifeguard tower. No lifeguard. The water was at a crisp 68, which is better than the usual Pacific Northwest 56 degrees. I bodysurfed for half an hour until I couldn’t feel my toes and my hands were turning bloodless and white. Changed back into clothes and we played frisbee on the beach, me with enthusiasm but little skill. Mark Sapir said, “First chance to exercise in two weeks. I went running today and now everything hurts, so now we’re letting waves pound us in to the sand.”

We trooped back to the houses where they were staying and I met our hosts. Dinner with 14 people, kind and gracious hosts. Much discussion of medicine and politics. This was a day off for most of the [What I learned from my first Mad as Hell Doctors week|Mad as Hell Doctors], though Dr. Paul Hochfeld was at a talk given by a Physicians for A National Health Program California Chapter Fellow to medical students. He was back for dinner, reporting on the event.

This trip is streamlined. Currently there are eight of us. The trip is still 3 weeks, but with a little recovery time built in. Instead of staying in motels, we have stays arranged with PNHP members along the way. Phillip Kauffman is with us, saying that this trip is both easier and harder than the one last year. We have less paid support crew so more duties have fallen on him, but it is also a smaller group of people to coordinate. Dr. Hochfeld called him a “butterfly herder” in his blog yesterday, but I still think we’re more like cats. I don’t think of butterflies as having the same sort of egos or defense weapons as cats. And I am delighted to return to the group. They are incredibly dedicated and stubborn and willing to go on fighting for single payer. They, or we, are ignoring the people that say, “Why work on this? The health care bill passed. You won’t get another for years and years.” They might be right: but social change and social justice is not attained by sitting back, being apathetic or giving up. It takes dedicated people continuing stubborn work. I feel closer to these people after less than two weeks last year then some physicians that I have worked with for ten years: to be back on the road with the Mad as Hell Doctors is like coming home.