Category Archives: medical billing

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I will fight no more

I am tired of fighting
I am tired of fighting for justice
I am tired of fighting discrimination
I am tired of fighting for health care for all

I am tired of fighting insurance companies
I am tired of fighting medicare’s contractee
I am tired of fighting for prior authorization
I am tired

I will fight no more forever

I heal
I am a healer
I am trying to heal patients
I am trying to help patients heal

I am a healer
I help heal cancer
I help heal heart disease
I help heal PTSD
I help

heal cancer
heal heart disease
heal PTSD
heal addiction

I am a healer

heal the insurance company
heal the medicare contractor
heal the pharmaceutical company
heal

heal anxiety
heal depression
heal addiction

I will fight no more forever

I heal

The legs in the photograph don’t look delicate, do they? They are strong and beautiful and powerful. I took this at the National Junior Synchronized Swimming Competition in 2009. Those girls on the edge of being women are strong, they are a team, they work and play together. They have the skills and the strength to lift their bodies out of the water that far using their arms… think about the practice and strength needed to do that. We all want to heal and create fun and play and beauty. Let’s work as a team.

also on everything2.com

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fraud in medicine: prior authorization I

Prior authorization is where, in the insane United States medical system, the doctor orders a test or medicine. The insurance requires “prior authorization”, that is, the doctor or their office have to call or go on line to fill out forms to get the prior authorization. Otherwise the test or therapy or medicine or even surgery will not be covered by the insurance and the patient eats the bill. Over 60% of bankruptcies in the US are now over medical bills*.

In most doctors’ offices, the prior authorization is done in the back rooms. Employees are on the computer or on the phone trying to obtain the permission, the code number, the magic words that will help the patient. This is a HUGE business and a scam as well. Physicians for a National Health Care Program estimated in 2011 that it costs at least $82,975 PER PHYSICIAN PER YEAR to have a person calling.* Now, there is a person on the other end receiving that call or going over the forms. That person is paid with your insurance premium. Is that health care? It seems more like a barrier to health care. Let’s look at an example.

I do my prior authorizations in the room with the patient. I only have a front desk person, no back room people, and anyhow, if I do it face to face with the patient, I can charge the insurance company for the call. It is face to face counseling and coordination of care. I don’t get paid well for this, but it’s worth it for the patient education.

Yesterday I called for a patient. The insurance company first has a recording that tells me it is recording this conversation. I am too, in the chart note. Then it reminds me I could do all this on line. Well, that is sort of true. I could, but every insurance company has a different website, they all require logins and passwords and it would take me hours to learn them all. Nope, not doing that. After the message it says: “Please enter the physicians NPI number.” I do. Then it leads me through choices: confirm the patient is insured, check the status of a prior authorization, appeal a prior authorization, initiate a prior authorization. That one.
At 3 minutes 50 seconds, I get a human. We are on speaker phone.
“This is Rex. You are calling for prior authorization?”
“Yes. This is Dr. Lizard. Mr. X is in the room.”
“Please spell the doctor’s name.” They are not used to doctors calling.
“Please give the NPI number.” (ok, we typed that in. But every time you are transferred, you have to give all of the information again. I am not kidding.)
“Please give your clinic address. Please give your clinic phone number. Please give your clinic tax ID number. Please give your clinic fax number.”
I do.
“Please give the patient id number. Please give the patient name. Please give the patient date of birth.”
Ok.
My patient is looking amazed. This is how insurance companies treat the doctors who call them? Yep.
“What medicine are you authorizing?”
“A compounded testosterone.”
“Please list the ingredients.”
Crap. didn’t think of that. “Ok, we want to authorize an fda approved one.”
That is entered. “What are the instructions for the patient?”
“What is the dose or strength?”
“What is the diagnosis?”
“He has a condition from birth with no testosterone.”
I have to spell the condition for Rex.
“What is the ICD 10 code?”
I give that.
“Have you measured a testosterone level?”
“Yes. It’s zero. His body doesn’t make testosterone. Since birth.”
My patient is rolling his eyes.
“The form will be sent for review and you should get a fax within 24-72 hours regarding the authorization. Here is a number for tracking.”
“Thank you, we are recording this phone call as face to face counseling and coordination of care in the chart.”
Phone call is 13 minutes and 50 seconds. That is a fast one, actually. Most are 25-30 minutes and I fought for an hour once when a patient’s prescription coverage was cancelled.

I wish that every doctor in the country would do one prior authorization on the phone once a week with the patient in the room. The doctors’ heads would blow off. They might finally see what the current system is doing and how the insurance companies throw more and more and more barriers up to refuse people care.

And how is it a scam? One way is that the patient calls the insurance. The insurance has people who only talk to patients. That person says, “Have your doctors office call for a prior authorization.” The patient calls the doctor’s office. The doctors office calls the insurance, but they are talking to a different branch of the insurance company. That branch tells the doctors office “We don’t cover that.” The doctors office calls the patient, who then thinks that the doctor’s office has screwed up the prior authorization.

How do I know that? With the person in the room, the insurance tells me “No.” I have had patients say, “Your company told me yesterday that all I needed was for the doctor to call!” The insurance person replied, “I only talk to doctors. It is another part of the company that talks to patients.” I have also had an insurance person say “Take me off speaker phone, I am only allowed to talk to physician’s offices, not to patients.” Riiiiiight. I took him off but put him right back on. My patients are outraged and furious: at the insurance, not me. The insurance companies are doing brilliant business plan triangulation and I hope whoever thought it up and whoever allows it as a business plan roasts in hell. No, instead I hope that they wake up and realize how many people they are hurting and I hope that they turn and work to heal a broken sick system.
*http://www.pnhp.org/new_bankruptcy_study/Bankruptcy-2009.pdf
http://www.pnhp.org/sites/default/files/docs/Bankruptcy_Fact_Sheet.pdf
**http://www.pnhp.org/news/2011/august/us-doctors-administrative-costs-4-times-higher-than-in-canada
http://www.pnhp.org/news/2014/august/adventures-in-prior-authorization

I took the photograph at Lake Matinenda in August 2015. It is of a storm. A storm is here in medicine: people versus the corporations who prey on us. We need to heal the system and heal the fear and greed.

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Fraud in medicine: medicare application

Medicare quit paying my clinic at the end of July, on the 31st.

I was still half time in clinic, we were interviewing a new receptionist as my receptionist of five years wanted to retire by August first. We got some sort of notification from medicare, but their letters are very cryptic.

My new receptionist was needing orientation and help and I was really tired after July. I redid the medicare application and sent it in. We continued to see medicare patients and turn in the bills.

Our medicare contractor is noridian. They sent us a cryptic letter saying that something was wrong with the application. This was, mind you, a renewal. I had been seeing medicare patients for five years in my clinic.

I call them. I am given a name and a number to identify the call. I have two Ptan numbers, one for me as a physician and a second for the clinic. The first call said that my personal Ptan application was correct but the clinic one wasn’t.

I did it again and mailed it. Second day air. He said that our payments should be released in 10-14 days.

Ten days. Nothing. Fourteen. Nothing. I am pulling from savings to run the clinic. I call a second time. Again I am given a name and a number. She said I had to CALL to get paid once the application was received. I said the first guy didn’t say that. She said another 10-14 days.

We wait. After ten days I call. A third number and person. Once again I have a cryptic email. I ask about the PTan number on the email, which is not my clinic’s Ptan number. Oh, says the man, that is what is wrong with your application. He says to do form (numbernumbernumber B) not form (numbernumbernumber A). And it will be 10-14 days after they receive it.

I do it AGAIN. I do notice that all of the old copies of the form in our file have the PTan numbers wrong. Weird. They have been paying me for five years.

Ten days. I call a fourth time. She says that it will be 30 days not 10 to 14 until medicare lets me know if my application is correct. Or they might pay me after 10-14 days. They aren’t, so I argue that something must still be wrong. What is it? She can’t tell me. I want a supervisor. She says that I can talk to a supervisor in 10-14 days. We figure out that the Ptan number on the application is correct. I say, “I am writing my congresswoman.” and hang up.

So I do. I find my Senator’s email and I write to her. I have been a rural family practice doctor for 25 years and I saw a 98 year old yesterday and a 91 year old today and I LIKE my elderly patients, but I have HAD it with medicare, at least with the contractor noridian that is running medicare for my state. I list the phone call dates and names and identifying numbers and I say FIX IT because otherwise I am for the first time in 25 years seriously considering quitting medicare.

Two days later noridian sends an email saying they are releasing my payments.

The next day we get a direct deposit for $9000.00. That is a START.

One week later we get a call from noridian explaining what is wrong with our application. Not just one thing. Noridian doesn’t seem to have a copy of our business license from five years ago. We have to put the personal Ptan on page xgyb-14. They want details about the nursing home. Do I do home visits?

The noridian person explains that our application has actually been wrong for five years, but now they are getting audited so they have to get everything cleaned up.

So THEY have KNOWN it was wrong for five years, but held my payments since July, while they try to get their act together and tell me what the hell is wrong with it?

I want to be paid INTEREST for all the time I have spent on the phone and redoing the cryptic application.

And many thanks to my congresswoman, for keeping my clinic open.

I took the picture at the Kinetic Sculpture Festival here in September. The outfits make more sense than dealing with noridian, that’s for sure….

first posted on everything2.com on 11/30/15

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Fraud in medicine: mail order pharmacies

My clinic refuses to fax to mail order pharmacies. Instead, I give the prescription to the patient and tell them to mail it.

I started this policy over a year ago, when five different patients called in the same week, about two mail order pharmacies.

Patient: “I called my mail order. They say that they don’t have the prescription and the doctor just needs to cal.”

I check. Each of the prescriptions had been faxed. I called the two companies a total of five times that week. Each time they would ask for my identifying information, the patient’s identifying information, transfer me and then say, “Oh, yes, we have the prescription.”

Ah. This is a nice example of triangulation. The patient calls for their refill. The mail order company faxes me a request. I check the chart, see if the person is due for labs or a visit, and fax the prescription. Then the company sits on it. The patient calls them and the company says they don’t have it. They delay. Finally the patient calls me to call the company and then the company admits, oh, yes, actually we do have it.

So we refuse to fax to these companies.

Last week I saw a patient who had mailed her prescriptions. She did not get her medicine.

“I called the company five times. They told me they didn’t have it. They said to call you to send a “hard copy”. I said, “I mailed it to you myself on this date.” Then they said, “Oh, yes, we have it.” However she was out of her medicine for three weeks.

I said, “They saved the cost of three weeks of medicine. That is fraud.” I explained the scam.

Comprehension dawned on her face. “They do it on purpose?”

I shrug. “Five in one week seems like a business operation to me. I recommend that you write to the state insurance commissioner.

She said, “Next time I will mail it certified. And yes, I will call the insurance commissioner if they do it again.

The patient main insurance sends information that getting the prescriptions mail order will be cheaper, and so people want to use the mail order: but the mail order pharmacies in our area are saving costs by ripping people off and delaying prescribed medicine. I do hope they end up in jail: if we can’t jail the corporation, let’s at least jail the CEO and the top 4 officers.

I took the picture yesterday at sunrise.