Prior authorization: call for comments

The Washington State Medical Association has called for comments on prior authorization rule making for insurance companies. https://wafp.net/prior-authorization-rulemaking-oic-call-for-comment/

Here is my reply:

I have a small solo family practice clinic. My business plan was arranged to spend more time with patients. I have an office manager and no nurse, no back office.

Thus all prior authorizations are done by me, with the patient in the room. Often patients have talked to their insurance company the day before and have been told “your doctor’s office needs to call us”. More than half the time, when I call, we are told that the patient’s insurance company does not cover that service. The patient says, “But I talked to your company yesterday.” The insurance representative responds: “I only talk to physician’s offices, that is another part of the company that speaks to patients.”

This is triangulation, where in the “standard” office, the patient has called their insurance. They call the doctor’s office as instructed by the insurance. The doctor’s office requests prior authorization. The insurance says it is not covered. The doctor’s office notifies the patient, who then assumes that the doctor’s office did something wrong, not that it’s not covered.

This is unacceptable.

I have stopped telling insurance companies that I am face to face with the patient, because some representatives say “I am not allowed to talk to patients, take me off speaker phone.” I document the name of the insurance person in the chart, the length of time for the phone call and I bill for time: counseling and coordination of care. Review by coders say that this is legal.

I suggest that every WSMA physician pick one day to call a prior authorization themselves with the patient present. This would reduce the insurance company triangulation.

I think that insurance companies should be required to tell a patient if a service is not covered, and not be allowed to say, “have your doctor’s office call us” for a service that is not covered.


Feel free to send YOUR comments to the WSMA! https://www.insurance.wa.gov/secure-forms/rules-coordinator/

I like slugs better than health insurance companies.

W is for wrath

W is for wrath, the seventh sin.

From Webster 1913:

Wrath

1. Violent anger; vehement exasperation; indignation; rage; fury; ire.
Wrath is a fire, and jealousy a weed. Spenser.
When the wrath of king Ahasuerus was appeased. Esther ii. 1.
Now smoking and frothing Its tumult and wrath in. Southey.

2. The effects of anger or indignation; the just punishment of an offense or a crime.
“A revenger to execute wrath upon him that doeth evil.” Rom. xiii. 4.
Syn. — Anger; fury; rage; ire; vengeance; indignation; resentment; passion. See Anger.

 

Wrath is a sin, yet is it ever justified?

I am wrathful about this: http://www.npr.org/sections/health-shots/2016/03/23/471595323/drug-company-jacks-up-cost-of-aid-in-dying-medication

In my state a terminally ill patient may choose Death with Dignity: http://www.doh.wa.gov/YouandYourFamily/IllnessandDisease/DeathwithDignityAct

The person must be terminally ill, must not be suicidal and must go through a process. But one of the tablets prescribed, which only the person may administer to themselves, has had a price increase from $200.00 to over $3000.00.

I heard this from another physician, who has a patient who is going through the process.

I feel wrath and anger and hurt and rage that a corporation is choosing to make an enormous profit from terminally ill patients.

And so wrath may be a sin, but it is also an appropriate feeling at times.

In a sermon about forgiveness, hate is also discussed:

“Let me also say a word here about hatred, since I am speaking of forgiveness as being the release of hatred. Many  of us,  I suppose, like myself, have been taught not to hate.  We have been taught that hatred is always a bad thing and there is no place for it.  Thus, we feel uncomfortable in the face of this intense emotion and attitude.  Many times I have stumbled on the line from the biblical book of Ecclesiastes which reads, “There’s a time to love and a time to hate.”

Can there be  a time to hate?  Ironically, when  reflecting on the subject of forgiveness, I see that there is a place for hatred.
 
First,  your  hatred  lets  you  know  that  you  are  feeling  diminished  and  perhaps  being stepped on and treated as no human being ought to be treated.

Secondly,  your  hatred  lets  you  know  that  you’re  fighting  back  and  that  you  have something  to  fight  back  with.    It  lets  you  know  that  the  situation  is  intolerable  and  you will not put up with it.

And  so  hatred  can  be  a  natural  and  even  necessary  response  to  situations  that  threaten human dignity.  Says one author, “Not to feel resentment when resentment is called for is a sign of servility,… a lack of self-respect.”  (Forgiveness, Haber)”

From: November 15, 2009, here: http://www.quuf.org/index.php?page=2009—2010-sermons

p7
http://www.quuf.org/uploads/Sermons/Is%20Forgiveness%20Always%20Called%20For%20Part%20II%20Nov%2015%2009%20print.pdf

I took the picture in 2007. No wrath here, but three different expressions, and all complex….

fraud in medicine: cow thymus guinea pig

We are making a change in clinic. We ask all new patients to bring ALL the pills they take. Prescription, vitamin, supplement. Most of them don’t. So now we are telling patients that they need to bring all pills or they will be rescheduled.

I want to know what my patients are taking. My town is a delightful spectrum mix from very conservative to very liberal and some libertarians thrown in. But I look at the ingredients of the bottles.

With prescription medicines, people will say “I am on metoprolol.”

“What strength?” I say, “And is it the short acting, middle or long acting?”

Some patients: “Uh…. it’s blue. It’s a small blue round pill.”

Eye rolling would be unprofessional. I pick the lowest dose and type in “unsure dose”. “Bring it next time.”

I examine vitamin bottles. Some contain multiple herbs as well as vitamins. Most people don’t seem aware of this. Sometimes people have four different vitamins with vitamin A in them. “The fat soluble vitamins A, D, E and K can build up in your tissues and people have managed to kill themselves. I would recommend you take less then you are taking.” And then there are the high dose vitamins: one with 3999% of the recommended daily allowance of vitamin A. Hello. Why is this being sold? I guess people have the right to take things that can kill them. But I wish they wouldn’t.

Supplements. I read the ingredients. One ingredient is cow thymus. “This has cow thymus in it.” I say. Medicine seems a bit vague on what the thymus does, though it is involved with myasthenia gravis: http://www.mayoclinic.org/diseases-conditions/myasthenia-gravis/multimedia/thymus-gland/img-20007802

“Oh.” says my patient.

“I am very unenthusiastic about taking cow thymus.” I say. “Unless you are working with a naturopath who has prescribed it for a compelling reason. Who prescribed it?”

“Uh, it’s not prescribed. It’s made by a good company.”

Right. Like I trust corporations. Scamming thieves and liars. Sell anything that isn’t nailed down in pill form. Including cow thymus.

My medical philosophy is as few pills as possible. Prescription, vitamin or supplement. Eat food, exercise, make friends, work well, be kind to yourself and others and avoid pills unless necessary. We don’t know how cow thymus and metoprolol interact. The FDA considers supplements to be natural, like a carrot. A pill is not a carrot. It doesn’t grow on a tree or in the ground. It has to be made by people. The supplement companies do not have to do any testing for medical safety and efficacy and I frankly hate the pills with multiple herbs in them. They have to use ingredients that are “generally recognized as safe” which is pretty lukewarm: http://www.fda.gov/Food/IngredientsPackagingLabeling/GRAS/. Also, kidney failure is on the rise from too many pills. Everything is metabolized by either the kidneys or the liver and kidney failure is in the top ten causes of death in the US.

And I don’t want to be a guinea pig. I don’t want to be the personal home chemistry trial of cow thymus plus metoprolol. No way. And I will bet that you don’t want to be a personal home guinea pig either.

I took the photograph with a zoom lens looking down from the dock in Port Townsend Bay in 2014.

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.

 

Dream: home surgery

Yesterday I ask a friend to drive me to pick up my son, on his way home from college for spring break, an hour to a nearby pick up point and back. I can’t walk without limping horribly: apparently the recent stress in clinic has made my muscles mad.

F. drives. He has just finished reading Reinventing Collapse: The Soviet Experience and American Prospects, by Dmitri Orlov. Mr. Orlov says that I, as a physician, should start moonlighting as a midwife for barter to have a back up plan for when the economy collapses.

I laugh. “Not very helpful where the median age is 55.”

“Not to mention people want to use their pathetic health insurance.”

Home and I go to sleep. Dream: I am at F.’s house. There are two other men, one of whom needs abdominal surgery. We argue for a long time but he has no money and finally I agree to do surgery with F. assisting. The other man is to help hold the young man down. We do not, of course have anesthesia. I go over what I am going to do, force them to pay attention, discuss sterile technique, boil everything. Not ideal….

We don’t have a cautery or suction either. But there is almost no bleeding and the two things that need to be removed come out easily, I am very very  gentle, so I don’t cause other things to bleed. Never mess with the spleen.

Now I need to close the abdomen and I don’t have absorbablesutures. I am going to do a figure 8 from the surface, in skin, out the abdominal fat, across into the fat, down through the fascia, crossing very delicately up into the fascia on the other side, out the fat, in the fat on the other side and out the skin. Then slowly pull it tight, tight, and tie it off. It’s thick nylon. Nonabsorbable. Usually you would take the nylon out in 7-10 days but I am wondering how long I would need it for the fascia….I thought that would take 6 weeks to heal. I am worrying.

But now F. and the other man are not holding my patient, they are backing off and congratulating each other. My patient gets up off the table. “Lie back down!” I say, “Your guts could fall out the opening! We haven’t closed! F!” Surprisingly his guts are not falling out, but it’s because I have done such a beautiful low abdominal incision, bikini style. “Get back on the table or I will make you go to the hospital to have it closed!”

He reluctantly gets back on the table. F. and the other guy are still being morons but are calming down….

….I wake up.

 

The photo is in my yard during sunrise last summer: spring forward today….

music: https://www.youtube.com/watch?v=aEi_4Cyx4Uw

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