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.

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.

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.

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

Chronic pain and antidepressants

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