Tag Archives: fraud

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Perspective

This is taken at night from the beach, camera at full zoom. The mountain is Mount Tahoma, also known as Mount Rainier. The object that looks like a gibbet for hanging people is at the end of a dock. It is a small crane.  The perspective makes them look like they are the same size, doesn’t it? But one is very close and the mountain is very much further away.

We have to be careful not to misinterpret what we see when we don’t have enough information or when we are given misinformation. Truth is complicated and there are people who will lie for power and advantage and their own agenda. Consider the source, use more than one source, consider if what you are seeing has been edited, exaggerated, placed out of context or if it’s really just a lie.

For the Daily Post challenge: Conventional Wisdom.

Music: I can’t keep quiet.

 

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Coming soon: The Unaffordable Health Care Act!

Coming soon in the United States!

Aren’t you sick of the Affordable Care Act? aka Obamacare? Time for a new administration and time to get rid of Affordable Care. We don’t want that! Competition, Corporations and Profit First!

Call Mr. Future President Trump, call you congress persons, call your senator, call your representative, call your state ones. Stand up and be heard, US Citizens! Tell them you are all for the Unaffordable Health Care Act! We can kill more small businesses faster! We can make doctors and nurses quit by age 50! We can have more people turn to addictive drugs for numbing and comfort!

Come on, US Citizens! You voted! Now call! The Unaffordable Health Care Act! brought to you by an all conservative all corporate all discriminatory group of unbelievably rich congresspeople and your stinking rich and suing everyone future president.

Or you could say you want Medicare For All! Hey, one system, one set of rules, all US citizens have care, we could start small businesses, business might return to the US since they don’t have to pay more and MORE and MORE for health insurance, wages would go up instead of yearly decreases in health care coverage….nah, US Citizens, you wouldn’t want that, would you?

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Your health care dollar

I have been writing posts about fraud in medicine: but I think I am using the wrong title. Instead it should be your health care dollar: how the US medical corporate system wastes your health care dollar.

Think about it. What do you want to spend that dollar on?

Do you want it to go to 1300 different insurance companies and their web sites, their advertising, their competition and their profit? Do you want your healthcare dollar to go to complex coverage rules and contracts, to forms for prior authorization, for the weekly postcards and emails that they send me telling me that they have changed your coverage? Is it any surprise that I have no idea if your insurance company covers a test? They may have last week and not this week. The overhead for medicare is 2-3% administrative costs. Now why would we privatize that when the overhead for the health insurance companies is 20-30%?

How much of your health care dollar do you want to go to corporate competition?

I don’t want ANY of my health care dollar going to corporate competition and profit. I want my health care dollar going to my HEALTH. We spend the most per person in the world, almost twice as much per person per year as the next most expensive: and we don’t guarantee care. Hello, the next most expensive and all of the other nearly 40 countries, first and second world, have universal care for all their citizens. So is our care twice as good?

No, no, no, and no.

Hello, new administration. Let’s put the health care dollar where it is paying for health…. in medicare for all and in a single payer system. We have guideline after guideline on how we should treat illnesses, here:

US Preventative Task Force

The guidelines are regularly updated. If we have medicare for ALL then I will KNOW whether a test is covered or not. I have memorized the entire list of medicare covered screening tests and all the details: screen for abdominal aortic aneurysm is covered in male patients age 65-75 who have smoked more than 100 cigarettes in their life and any patient who has a family history. I have the whole list in my brain.

You CAN make a difference. Write to your congresspeople, state and national. Call them. Email them. They all have websites. Tell them YOUR health care story or the story of a friend or family member.

Join Health Care Now and Physicians for a National Health Program.

I want my health care dollar to go to HEALTH CARE.

For the Daily Post Prompts: gone and interior. Interior because I am so angry at the poor spotty costly health care for my fellow people in the US. And gone: your health care dollars is GONE: let’s use the next one wisely.

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Pick a plan right for you…..

We are in open enrollment for health insurance in the US. Meaning that they all are going up in cost and they are cancelling plans and offering new ones. And advertising: pick a plan right for you!

What the hell does that mean?

It means that all of the plans exclude things. Oh, well, aromatherapy…. that’s what you are thinking if you are not a US citizen. Of course the plan doesn’t cover aromatherapy or crystal healing or fringe treatments….

Well, no. I had to choose between two plans when my daughter was 17, that is, two years ago. I could choose the one that covered cancer OR the one that covered pregnancy. Uh, yes, that is correct. One EXCLUDED pregnancy healthcare and the other EXCLUDED cancer healthcare. For me and my children.

Which would you choose?

My mother died of cancer at 61 and my sister at 49. My daughter was not dating yet. Observing.

So we picked cancer.

I photographed the crows out on a walk the other day… how many does it take to make a murder?

 

 

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Update on marijuana 2016

I attended the Swedish Hospital Update on Chronic Pain in Seattle two weeks ago on the stormy Friday. The power went out and we were without slides from about noon on.

The first two hours and three lectures were about marijuana. Including medical marijuana and one speaker for and one against. So here are some of my notes.

In 1960 and 1970, the marijuana had about 4% THC. Now some strains have 30% THC, so long term there is no data about what 30% THC will do to a person rather than 4%. THC in strains ranges from 0% to 30% and CBD from 0 to 3.5%. However, those two are not the only active ingredients, so to speak. 537 constituents have been identified that work at the cannabinoid receptor…. that is impressive. I think it might take a while to sort out what they do.

At any rate, we don’t know what smoking 30% THC will do, because it’s new. 4% had pretty minimal psychotropic effects. 30% has a lot more. The average now is 12%. Hashish is closer to 66% and hash oil 81% THC. A patient recently told me that she fainted within the last year. She got butter from the fridge at a friend’s and buttered her toast. Turned out it was THC infused butter and she was taken by surprise on a walk 30-60 minutes later. Luckily someone was with her and she was not hurt.

Recent data is showing that there is not much tolerance smoking 12% THC regularly. However, higher doses show tolerance in about 2 weeks in a study of HIV patients with dronabinol, which is 40% THC. Another study of multiple sclerosis patients with 15/15% CBD:THC reduced pain, reduced spasticity and did not show tolerance.

There is anecdotal evidence about seizures, but no study yet. There is some evidence that CBD reduces THC induced paranoia and/or hallucinations. THC side effects from dronabinol include drowsiness, unsteady gait, delusions, hallucinations, mood change and confusion.

The growers are being very creative in names and marketing. This is re recreational pot.
There are hundreds of names and hundreds of varieties and they make interesting claims as to effects. For example:

AK47 with 36.6% THC and 0.3% CBD ….. creative, euphoric and hungry
sage with 27.5% THC and 0.7% CBD ….. attentive
flow with 23.2 % THC and 0.6% CBD ….. happy, relaxed, alert
Super Sour Diesel 22.7 % THC and 0.8% CBD ….. attentive, giggly, hungry
707 Headband with 22.1% THC and 0.7% CBD ….. euphoric, lazy, inspired

How amazing the difference less than a percent of THC makes… oh, wait. There aren’t clinical trials on this, hon, this is MARKETING.

Onset for oral is 30-90 minutes
peak in 2-4 hours
half life 8-12 hours but sometimes 20 hours

sublingual tincture
onset 30-45 minutes
peak 60 minutes
half life 3-5 hours

Smoked onset quicker and I did not get those numbers.

The emergency rooms in Colorado saw lots of people who were “trying it” but if they had only tried smoking marijuana in the 1970s, a strain with a much higher percentage made many people sick or hallucinate or frightened. The gummi bears look just like the ones for kids, so kids got sick. More sick people with edibles, as some eat too much.

People using THC before age 25 who have risk factors for schizophrenia are more likely to develop it. Family history, other hallucinatory drugs, mental health problems. The age 21 limit should be taken very seriously.

In Arizona re medical marijuana, 90% of the prescriptions were from only 24 physicians. In Colorado, 94% of the patients applying for medical marijuana did so for “severe pain”. Two of my friends in their early 20s  got medical marijuana permits in California for “back pain”, um, ok, hooey. Some people DO have severe chronic pain….

The history of medical marijuana is that Eli Lilly produced a medical version from 1850-1940 for pain. It was removed in 1942. In 1970 it became a schedule one, that is, illegal, drug. There are a few randomized clinical trials for pain, the best ones with high CBD/low THC treatments. Marijuana smoke alone has not been proven to cause lung cancer, but combined with tobacco or other smoke, the evidence is that it is synergistic and makes things worse faster. Dependence can occur, an increase in antisocial personality disorders and there is a withdrawal syndrome for dependent folks. For the small number of people I have had working hard to stop, sleep is the most difficult issue. Anxiety as well.

If people state that they use pot a small amount a couple of times a week, their urine sample should clear after a week. If it’s not clear they 1. couldn’t stop and/or 2. were using quite a bit more.

As far as Washington state law, it was described as a mess. Physicians can’t prescribe, they can only “attest” that the person has a problem treatable by medical marijuana. To attest, the physician has to sign a document saying that they are sure that not only has the patient READ the law chapter 69.51A RCW but also “understands the requirements of being a patient”. There are 24 sections. The physician doing this part of the talk said that he would only prescribe to non-driving MS patients in wheelchairs. Because he finds it hard to read the law himself, so the signing that the patient has read and understood it…. well, the driving legality issue is huge. And the provider, including NDs (naturopaths) and ODs (Doctor of Optometry) in Washington can attest. They are then immune in Washington but not at the federal level.

Every marijuana store is legally obliged to have a medical marijuana consultant present at all times that they are open. The medical marijuana consultant has 20 hours of training to get certified. Patients that are certified with an attestation can grow 6 to 15 plants but ONLY after they have been entered into a database which includes the person who signed the attestation and a photo of the patient. If they grow without being entered, they are breaking the law.

Use of THC long term, the risk of addiction is 25-50%. 17% of the addicted folks started during adolescence. Addiction is currently estimated at 9% of people who have tried it overall. About 30% of users have “problem use” and starting before age 18 increases the problem use 4-7 times. The DSM-V has diagnostic criteria for “marijuana overuse syndrome”, including not being able to stop even though the person wants to. Risk factors for addiction and problem use include early use, family history, PTSD (especially sexual abuse), bipolar diagnosis, ADHD, conduct disorder, oppositional defiant disorder. Mediating factors include parental disapproval, parental supervision, academic competence, higher perceived risk and availability.

And am I attesting? No. My MS patients get the attestation from the neurologist if they want it….

Medical marijuana consultant training: http://www.doh.wa.gov/YouandYourFamily/Marijuana/MedicalMarijuana/RulesinProgress/MedicalMarijuanaConsultantCertification
Washington State Medical Marijuana attestation form: http://www.doh.wa.gov/Portals/1/Documents/Pubs/630123.pdf
WA law: http://app.leg.wa.gov/RCW/default.aspx?cite=69.51A
And pain clinics getting closed down: http://www.seattletimes.com/seattle-news/health/pain-patients-scramble-for-care-after-clinic-crackdown/

The tree trunk is a bonsai from the Lan Su Chinese Garden in Portland. I like the thorns…..

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C is for Credulous

C is for credulous. Have you ever felt credulous?

“willing to believe or trust too readily, especially without proper or adequate evidence; gullible.”

My young guest in the picture is not quite sure how to interact with the old lady: she is the old lady who swallowed the fly. The fly, the bird, the cat, the dog and even the horse have just been neatly delivered back out of her. My guest is not sure what she will do next. The world is a magical place.

C

Adults get caught up too, but in a darker version of credulous. Something for nothing. A deal too good to be true. A young relative on the phone, caught in another country, asking for help. Email from people saying that we have money from a distant relative who has passed. Calls over and over to my clinic that say they are from my long distance company and that they want to “help” me lock in service before a change…. I asked for a number to call back and was given the number of a sex line. I called my long distance company and they said, “Yes, they just lie.”

I think that fraud is on the upswing in the United States, but perhaps I am just a credulous person who believes that most people would like to earn their living in honest work and doing good for other people and the world.

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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 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: 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.

 

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Chronic pain and antidepressants

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