Monthly Archives: March 2016

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Fraud in medicine: prior authorization III

I see a patient who has had prolonged sinus symptoms AND her right upper molar has been irritated for weeks, but then Saturday it started hurting. She saw her dentist. The dentist did x-rays and said it’s her sinus. “But my tooth hurts too.”

On exam, her gum is bright red above the tooth, but not swollen as it can be with an abscess. No fever. No bright red spot over the maxillary sinus.

I call our independent radiology service and ask for a limited sinus CAT scan. She is off on Mondays only, it is Monday, she is out of town next Monday. Can they do it today? Yes, but she needs a prior authorization.

I call her insurance, after looking up the CPT code for sinus CT on google. As usual I have to enter numbers before I talk to a human:
patient insurance id number
my tax id number
my national provider index number
and others until I get a human.
Then I have to give the numbers AGAIN because the insurance company deliberately makes it inefficient, even though I have entered them into the phone it doesn’t transfer to the representative and you know that it COULD.
I give my name
patient’s name
patient’s date of birth
clinic address
clinic phone
clinic fax number
tax id
national provider index number
and finally explain: we need a prior authorization for a limited sinus CT and she has five ICD 10 symptom codes.
“She doesn’t need a prior authorization.” says the rep.
“What?” I say, “So it’s covered.”
“We don’t guarantee coverage, but we don’t give prior authorization.”
“What do you mean, you don’t guarantee coverage. I am calling to check.”
“We review the chart afterwards and THEN decide if it’s covered.”
“No. That isn’t good enough. I want to speak to someone who will check the codes and tell us if it will be covered.”
“I will have to transfer you to the (patient something).”
“Fine. Transfer our information please too.”
We go on hold. Time passes.
We are back to a recording:

TALKING TO A REPRESENTATIVE DOES NOT GUARANTEE COVERAGE OF A TEST. PRESS ONE IF YOU ACCEPT THIS.

No two. No other options are offered. I press one.
I talk to the new representative. “I have five diagnosis codes and want to know if the sinus CT will be covered. She is off and they can do it today. She is only off on Mondays.”
“We don’t do prior authorizations.”
“Isn’t there ANY WAY we can find out?”
“You can mail a letter to a PO box and we will review it and let you know.”
I am ….. hard to describe…. my head hurts.
“Would you like the PO box address?”
“How long does that take? Yes we want it. Don’t they have a fax?”
We get the fax number too. I hang up and look helplessly at my patient. “I think it will be covered. I would recommend we do it.”
“Ok.” She says. Her face and tooth hurt.

I call the independent radiology center and set it up for 2 pm.

They call back in the afternoon. She has a sinus infection and the tooth is bad too, they don’t quite look connected. I call the Ear Nose and Throat specialist who wants her on three weeks of augmentin if she tolerates it and then to see her. I thank him and get it rolling.

But….. ok, so the insurance companies contract with me and the patient say that they can change the benefits any time they want. They “notify” me with postcards with online links. Like I have time to read and remember the changes for …. 50 different plans? There are over 500 in the US.

When are we going to stop letting insurance companies take our money and refuse care and refuse to pay the physician and the radiologist? Medicare for all, one set of rules, I COULD LEARN THEM. I can memorize huge amounts of data: I am already busily memorizing the ICD10 diagnosis codes. There are only 48,000.

And I don’t know yet if her insurance will pay for the sinus CT…..

The picture is from Lake Matinenda in Ontario: no computers at our cabin, no outlets, phones mostly don’t work…. heaven.

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Fraud in medicine: prior authorization II

The insurance corporations and the culture of business fraud is destroying the United States economy and allopathic medicine.

I am a US physician who calls for prior authorizations myself, with the patient in the room, and bills the insurance company for the time “counseling and coordination of care” by the minute.

I called with patient X, to get authorization for a medicine, last week. We had already tried by me filling out on line forms, twice, and faxing paperwork to the insurance company. Now I was calling them. His insurance card has a separate number for “Rx”, that is, prescriptions. I call the number.

Call 1 takes me through a phone tree, puts me on hold and then hangs up on me.
Call 2 takes me through the same phone tree: enter my national provider identification number, my tax id number, the patient id number, etc. I reach a human. She asks for my number in case we are cut off. I give it to her. I also confirm my clinic address, national provider number, tax id, fax number, patient id number, date of birth, patient name. She will call back if we are cut off. We are cut off. No call back.
Call 3 takes me through the same phone tree. It hangs up on me before we reach a human.
Call 4 takes me…….we reach a human. He takes my number. He promises to call back if we are cut off. Repeat previous information. We are cut off.

No. Call. Back.

Ok. I call the insurance company main number and explain. Meanwhile I am documenting each call in my patient’s chart. The insurance company explains that the patient is in a Union and the Union has it’s own prescription program which has NOTHING TO DO WITH THE INSURANCE COMPANY. I insist that as the patient’s insurance company, they must help. They give me the number of the Union headquarters and put me on hold to transfer me. We wait five minutes. Then we hang up.

I call the Union. I reach a person. I explain that my patient needs prior authorization and we can’t reach the Rx company and we called the insurance company. The Union person kicks it upstairs and swears someone will call me. Tomorrow.

I apologize to my patient for the continued delay. I document in the chart: billing by time one hour face to face counseling and coordination of care making SIX PHONE CALLS TO TRY TO GET PRIOR AUTHORIZATION AND UNABLE TO. I express frustration in my note. I hope the company reviews the clinic note regarding the high bill, because I would be very happy to think that the insurance company might get upset at the Rx company for costing them money.

This is fraud. This costs United States citizens $82,000.00 per provider per year to have people sitting on the phone, on the computer, trying to get prior authorization approval from the insurance companies. The contract that I sign with an insurance corporation to be a “preferred provider” basically says that the insurance company can change their policy whenever they want. There are 500 plus insurance policies. Do you think you could keep up with every policy’s changing rules? I can’t. Nor can my patients. It is in the interest of the insurance corporation to make it difficult and incomprehensible.

I am told that Donald Trump knows how to run a business. I think he does, by US corporate standards, which means that the business is dishonest. I am not in the land of the free and the brave and the independent. I am in the land of corporate dishonesty and lies and I am angry.

I like my patients and I like medicine. But I hate United States business practice: rob from the poor and the sick to enrich the rich.

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Sink

Sink

I tried for a long time but now I am back in the water. My tail is back. I am so happy with it that for 20 minutes I just swim and dive and play with my own tail, chasing it. I am ready, strong again. I call my people and the waves.

I tried awfully hard on land. I hid the knife that my sisters bought. He married the other one and kept me in the little building in the garden. Everyone knew including her, it was normal for them. She didn’t enjoy his tidal pull, his pounding, the waves. It gave me so much joy. I sang without my tongue. My tongue was not cut out, that is a myth, one of those stories. It’s just that that is how they like the women: voiceless. Silent. Obedient. Admiring. Wounded: oh, he would kiss the poor feet, mangled jangled feet that I am forced to wear on land.

All for love. But: she had children. Three. And I watched as he treated the males as princes and ignored the girl. Mere princess, valueless, to be trained for a strategic wedding. Added value for the land, a pawn in training. She found me. And I pitied her and raised her and told her tales of my home, where people are people, not a gender. Not raised as a separate species.

She disobeyed and her father had her beaten, only where it would not show, and locked up. Bread and water. Cold and cruelty. And suddenly my love was slain. It was as if I was awakened and looked about and saw his cruelty to women and to his wife and his daughter and to me. I was a toy, an amusement, loved only if I kept silent and was crippled by my feet.

I rose and called the waves. The land flooded and the castle was broken and I reached the little princess in time to change her, to give her a tail too.

She is so surprised: in the water. She keeps trying to go up and breathe air and it chokes her. She swims in wild panicky circles, choking on the air, as I drag her out from the castle.

Now we are in the sea and the waters recede, full of broken bodies. Male bodies. I changed every woman I could find and the children if they were young enough and the girls. I called my family, my people. They came and each grabbed one, to drag towards the sea. The ex-humans fight and cough and wail and cry, but we drag them.

And now we sink, each holding one. We sink into the depths. They hold their breath, fighting, but we are so used to our tails and are stronger. And one by one they let the air go and breathe: and breathe the ocean. Breathe. We are entering the dark and the phosphorescent fishes come to see.

Soon we will be home. Just a little further into the ink black: sink.

 

I took the photograph in 2012 at the Pacific Northwest Synchronized Swimming Regionals. This is a young team routine with eight swimmers. These two are each lifted by three teammates, using only swimming, never touching bottom……

 

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Light and dark

This is for Photrablogger’s Mundane Monday #48, playing with light.

Boa Black in our back yard, just at the edge of the high grass, relaxing and enjoying the sun…..March came in like a lion here yesterday and even the Hood Canal Bridge had to close for a while because of high winds! A friend said that her cat kept asking to go out at different doors and then complaining. Her cat was looking for the door into summer, she said, and was mad that she couldn’t find it…..