Veteran

My clinic has gotten three calls in the last week to take more rural Veteran’s Choice patients. One was too far away on Whidby Island. Apparently few providers will work with Veteran’s Choice: but I understand that too, because it took me a full year to get the contractor for the insurance, Triwest, to start paying me. And it took me hours, hours that I could spend doing medicine, instead of fighting with a corrupt for profit corporation.

And I am glad that I won that round.

I took the photograph at our Rhody Parade, in 2006.

Dear Mr. Donald Trump

Two weeks ago I sent this letter to Mr. Trump and all of the presidential candidates. To date I have gotten a form letter from Mrs. Hilary Clinton.

Dear Mr. Donald Trump and all Presidential candidates:

Mr. Trump, I am a rural family practice physician, a woman, who owns and runs my own medical clinic. I take care of patients from age zero to 104. Currently my oldest is 98. I take medicare and most insurances, but not medicaid.

I am running into legal immorality across the board from health insurance corporations that are maximizing profits at the expense of my health care dollar, our taxes and my patients. I would like your advice.

For example, the Veterans Hospital contacted me in May of 2015 and asked me to accept Veterans Choice patients, veterans who live more than 40 miles from the nearest VA Hospital. I accepted. I have 6 veteran patients, who are very complicated. To date I have not been paid for one visit. Now, before you say this is the fault of our government, it isn’t. It is the private for profit government contractor Triwest who is not paying me. They have my notes and we have followed their instructions on how to submit bills. Would you advise me to drop these patients?

For example, my father died in 2014. I called the oxygen company to pick up 6 tanks of oxygen. Then I found 8 more. I gently inquired why he had 14 tanks. The company said that his medical orders said that he should wear it continuously, so they delivered it. “Medicare paid for it.” they said. Ah. Well, I kept the other 8 tanks, because it is my and my father’s oxygen in those tanks: the company can have the tanks back when they are empty.

For example, the head of the sleep apnea supply company came to see me. He said, “You are getting in the way of your patients getting needed equipment.” I said, “Really? How?” “You only allowed a refill of one of the 8 necessary pieces of CPAP tubing instead of signing off on the whole group so we can fill as needed.” “Ah.” I said, “Actually my patients are tired of you mailing them 8 pieces of plastic that are filling up their closets and they don’t want extra plastic crap.” He mails it at the interval allowed by medicare, never mind whether the patient wants or needs it.

For example, I called a patient’s insurance to get a prior authorization last week for a limited sinus CT. They no longer do prior authorizations. They will decide whether to cover the CT scan once they read my notes. I asked if there was ANY way to see if it would be approved. They offered to let me send a letter to a PO Box in Wisconsin. My patient was sick, Mr. Trump. What do you suggest the patient and I do?

This is all legal. But it is not moral. So, Mr. Trump, where do you stand? Is our country’s highest value free enterprise and profit at any cost, no matter how many of our seniors are legally ripped off? Or do we have morals that health care and our elderly are important and need to be protected from legal but predatory businesses.

Please let me know, Mr. Trump. I would rather stick with my small clinic in the United States. At this point I would be financially and emotionally better off working as a temporary doctor internationally. I am sure that there is immorality internationally, but I will be less ashamed when it is not MY country.

Thank you.

 

Paying as I am paid

Perhaps I will feel better about the state of medicine and corporate fraud preying on the poor and elderly and disabled in the United States, if I pay my bills as I am paid: let’s think about that.

I go to the grocery store and ask for a print out of the receipt before I pay. I look at it carefully. “I think that one sku number is incorrect. I am returning the bill for you to correct. Meanwhile I am taking the groceries. Please mail the corrected bill to me and I will check it and respond within 6 weeks. Thank you.” I smile and leave.

I look at my electric bill. My name is misspelled. I write a note. “Your bill is incorrect. Please correct it so that I can pay you promptly.” I mail it.

I look at my garbage and water bill. My ex-husband’s name is still on it. “Mr. Lizard is not at this address. Here is his forwarding address. Thank you.”

I carefully examine my gasoline bill at the pump. I step inside and explain: “I think that your pump dispensed 3 oz less then the measured amount. I have an exacto fuel measuring device, and your pump is wrong. Please mail me a corrected bill so that I can pay you promptly.”

There. I have no more bills to pay. I eat lunch, happy that I will be earning interest on the pittance that I am paid.

Thank you, United States corporations: you have taught me so much.

I took the photograph in 2011 on Halloween.

 

 

Fraud in medicine: Veterans Choice

Yesterday I tried another tack to get paid for seeing Veterans Choice patients.

We are more than 40 miles from the nearest Veterans Hospital. Starting May of 2015, I was called by the Veterans administration to ask if I would accept a veteran as a patient. I said yes. I have seven by now, but we are currently refusing to take more.

That is, I can see them, but so far I have not been paid a penny.

The VA sends me an authorization from Triwest, the (for profit) contractor in the Northwest region, I see the patient, I fax my note and everything to Triwest, I fill out forms for referrals…. my biller follows Triwest’s instructions…. and they do not pay us. Over 25 visits now, over $5000.00

I have called Triwest, I have written to my senator and representative, I have called and called….

Yesterday I looked at this site: http://www.va.gov/

From there to the US map: http://www.va.gov/directory/guide/division.asp?dnum=1&isFlash=0.

We are district 20: http://www.va.gov/directory/guide/region.asp?map=1&ID=20

VA Puget Sound Seattle: http://www.pugetsound.va.gov/

Under “about us” a dropdown menu to the leadership team: http://www.pugetsound.va.gov/about/leadership.asp

And I called the office of William H. Campbell, MD, FACHE | 206-277-1330, chief of staff, third one down.

The administrative assistant who answered asked if he was expecting my call.

No, I said and explained. I said that I very much like my veterans and would like to continue to work with them but as the owner, CEO and sole physician in a small business, I do need to get paid. Please help.

She put me on hold. And then I spoke to Dr. Campbell and explained again. I said that I am not getting paid, we have contacted Triwest multiple times and followed their instructions, when I call Veterans Choice the response I get is “I don’t know.” and that my patients can’t get their mail order refills because even though the VA called me to see the patient, I am not “entered” in to their pharmacy system.

Later I got a call from a person who promised to speak to Triwest and expedite payment.

I got a call from the head of pharmacy at the Seattle VA.

Who knows? I might, someday, get a check from Triwest.

The issue is really that this is not an isolated problem. All of the insurances are getting worse. I get postcards from 50 different insurance programs a month telling me how they have changed their benefits for the different plans and inviting me to go on line and read their detailed instructions. Noridian, the northwest for profit contractor for medicare, held my payments for 5 months last year because they were getting audited and suddenly realized that my application and everyone else’s had been wrong for years. Doctors are quitting all over the Olympic Peninsula and I suspect all over the United States. At this point I do not think anyone could DESIGN a more unintelligent, arcane, frustrating system. And if you see a US doctor, half of their staff is there to go on line or on the phone to get prior authorization to get a CT scan, get an MRI, see a specialist. And the paperwork for every lab, every insurance company, every xray, every physical therapy office is DIFFERENT: tell me, is this efficient? No, but someone is making a huge amount of money and it is certainly not me. I want my health care dollar to go to health, not to stupidity and not to corporate profit.

And I am wondering if it is worth it……

I took the photo of the trees and bunkers at Fort Worden in 2005.

 

 

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.