Friday, October 23, 2009

Your Insurance Premiums Hard At Work

One of my normally stable Multiple Sclerosis patients (Mike) went south on me today, so I saw him emergently over my lunch hour.

When this happens, the standard treatment is to give high doses of steroids through an IV line for 3 consecutive days. Generally it's done either with home health going to the patient's house to do the infusions, or the patient goes to an outpatient infusion center each day for 3 days to have it done there.

So I got Annie on it fast. Miracle worker that she is, she found both a nursing service and an outpatient infusion center that could do this over the weekend, giving me both options. Then she called the patient's insurance to get approval for one or the other.

Guess what? Mike's insurance company didn't have a supervisor available to authorize either one of these on a Friday afternoon. And the underling Annie spoke to (and then I got on the phone to argue with them) told me she wasn't allowed to give approval for this, and there was no one else around who could. So what did she suggest? She told me to admit Mike to the hospital over the weekend to do this, since that didn't require pre-authorization!

So let's think about this:

Home health OR an outpatient infusion suite would cost roughly $200-$400 per day (including nurse time, supplies, and drug) for 3 days.

BUT since Bozo Insurance, Inc. didn't have some magical person around on a Friday (which is a workday last time I checked) or anyone else who could approve this, they told me to admit Mike to the hospital.

I called a friend in hospital accounting. The rate for the basic room Mike is now in is roughly $1800/day. This does NOT include the costs of drug, supplies, or physician fees for docs having to round on him (since we're required to). All together, the hospital stay will cost the insurance $2500-$3000 per day for 3 days.

And Mike is pissed, too. Because he'd rather be at home.

And this is where your insurance premium dollars are going, and how your insurance company is working hard to cut back on costs and save you money.

29 comments:

Frantic Pharmacist said...

Absolutely freakin' unbelievable.

Anonymous said...

I totally Know how that is.. I had to be admitted to the Hospital for the Same Reason.. and trust me lying there thinking of all the things I needed to be doing and could be doing but instead I was the hospital becuase my insurance Company are Idoits..

Christine said...

And when the insurance company starts to look at ways to cut costs, they will look at you (because it's your fault you ordered stuff that cost money) or they will try to find a way to drop Mike. The last place they will look is their own policies and procedures.

Vegan Epicurean said...

And then the insurance company will deny the claim when the hospital submits the bill since that level of care wasn't medically necessary. Been there and saw that way too many times in my life.

hannah said...

As a nursing student...

can I ask WHAT exactly your nurse does? I guess I just have no idea what an OP nurse does. Apparently she deals with insurance companies?!

Grumpy, M.D. said...

Annie doesn't really do much "real" nursing, and nursing school isn't really needed to do her job.

She fields patient calls, takes care of refills, and schedules tests. Her main job is communicating between me and my patients when they call in with questions or problems.

Most importantly, she acts as my conscience and keeps me honest and in line.

Anonymous said...

Hey, as a hospital pharmacist, we see this REGULARLY. Patient has to go through an emergency room visit to be admitted because no one at the insurance company can pre-authorize out-patient antibiotic therapy because a patient's insurance only covers a particular infusion company, or pharmacy, even if the doc himself placed the PICC in his office on a Friday, but can't pick up the drug and give it himself, or has to undergo unavailable drug reconstitution training, or the drug is too expensive to obtain without insurance, etc. It's not just a simple issue of inconveniencing patients because they want to be home (especially if there are family obligations). It's the principle of the thing as these jokers with their devised contrivances explain increasing premiums and everything else that is increasing; drug costs (because therapy is delayed), facility costs, etc. Where are all the studies that show effects of delayed care and inconvenience to healthcare providers from such helpful insurance company intervention?

Anonymous said...

I really, really love your blog. Thank you for writing this.

Anonymous said...

Poor Mike! I hope he restabilizes. MS is a b*#ch.

Samsmama said...

A friend of mine was suffering from kidney stones. Alas, she had no insurance. The cost of surgery was evidently greater than keeping her drugged and letting them pass. So she laid in a hospital bed for 3 days until it happened. Insurance, such a mess.

And as the daughter of someone suffering horribly from MS, I thank you. It's quite evident you put your patients first.

Maha said...

That's simply disgusting. Sometimes I wonder what's the point of conducting any cost-benefit research when Ijit Insurance Company Inc will just ignore it (along with common sense) and inflate costs all around. What a waste.

MomNurseWife said...

....and this is part of why my career as nurse for a large insurance company lasted exactly 2 days....

Anonymous said...

Only one word to describe this: DUMB!!

Sue

Anonymous said...

I have to fuss about other things they will not pay for...like birth control pills. Would't it be cheaper for them to pay $55 a month vs $20,000 to have a baby? They also won't pay for Chantix. Wouldn't it be cheaper for them to pay the $120 a month vs lung cancer treatment? I owned a pharmacy once and shook my head at the craziness. Too bad we couldn't bill them for all the item we spent calling and waiting on the line for an authorization!

The Good Cook said...

Great post. Although I am looking at the cost for outpatient IV treatment and can't believe it is that cheap. My husband had 2 outpatient Ritaxin treatments and the bill was $56K. Yup... 2k for the drug.. the rest was hospital (outpatient chemo) and dr. fees.. ) now we are worried that our insurance co is going to drop us.. husband says if he had known cost before hand would never have had the treatment... what kind of choice is that?

Anonymous said...

I have to fuss about other things they will not pay for...like birth control pills. Would't it be cheaper for them to pay $55 a month vs $20,000 to have a baby?

Short term, yeah, but then you have the baby and you'll probably want insurance for the kid, too. so more premium payments to the insurance company down the line....

Isabella said...

That is infuriating!!!! I don't understand how an insurance company is able to do this. There must be a watchdog group to report this to. How do they get away with this stuff?

Thanks for sharing.

mommanator said...

I surprised an infusion company or Home Health agency couldnt help ya! I know the insurance approval is the prob! but those agencies need money too and they find ways to get around the companies insurance. I feel for Mike- and think of it most insurances have a limit law and he may hit limit one day for this stupid admit!
Wish I had been around I'd have done it for him, we'd have gottten the stuff from a pharmacy!and we'd be good to go!

Anonymous said...

My Dad was on hemodialysis. There was a renal center in the local hospital. In order for Medicare to cover his transportation to the facility (my Mom didn't drive and he couldn't drive after the treatment) he had to be transported in an ambulance (not an ambulette or a taxi or any other mode of transport).
Their linear thinking cost them (and us) more money. Not to mention, the ambulance which contracted to do this particular service came about 50 miles to pick him up to take him to the hospital which was only 4 miles away.
This was back in the late '80s. I hope things have changed since then.

One question: Is there any place to lodge a complaint about this? People don't get sick only Monday-Friday from 9-5. There should always be people with the authority to OK things at the insurance company.

Susan said...

Do you think a public option plan would be more administratively efficient? I hope we get the chance to find out..Medicare spends less than half the amount on administration dollars than private plans.

MT in Indiana said...

The thing is not only is this costing more, but the bed Mike was taking up (when he should have been able to receive treatment at home) could have been needed by someone else who in turn had to be sent to another hospital. Of course, I don't know how busy the hospital is or how many beds they have, but there is always the possibility of filling up.

BTW, I love your blog.

Dr. Trout said...

That kinda thing really cheeses me off. I'd be sure to document in the H&P and the D/C that the admit wasentirely the result of the insurance company, and even go through the hassle to file a complaint. If your patient gets stuck with a huge bill from the inpatient stay, atleast he'll have the records to support his appeal/lawsuit.

Jeni said...

And, to think that so many people are so worried about Death Panels and the government running their health care while the insurance companies, provided they even are able to afford insurance or supplemental insurance for those already on medicare make costly decisions like this for them already! Frankly, I would call actions like you described here from the insurance company as an equivalent to a "death panel" wouldn't you? Crazy, absurd, insane and all quite expensive as well!

Anonymous said...

Thank God that the new legislation will do away with denial of care due to "pre-existing conditions" and the dropping of insurance because the patient gets sick. I hate insurance companies! Thank you for caring enough about your patients to see that they get the care they need...
Classof65

Anonymous said...

May I make a side note? So I went to get an H1N1 vaccine for myself and 6 month old. I was able to get one due to my chronic asthma, but I was really pissed that the nurse on a power trip told me that being a pharmacist does not qualify me as a "health professional." She said that only those health professionals who come in direct contact with patients are eligible. Does a patient sneezing, hacking and coughing all over me while waiting for his tamiflu not count as contact? I dispensed 10 boxes of tamiflu today. Do you think that nurse was in contact with 10 H1N1 cases? I think not....

The Happy Hospitalist said...

multiply that by the hundreds of times a year Happy's hospitalists are asked to admit little old ladies with weakness and no inpatient admission criteria. Too weak to go home. Not sick enough to meet Medicare inpatient criteria. But no ability to arrange for a nursing home at 7 pm at night and no family able to pay for it either or willing to take them to their place for the next few days.

So we bring them in for up to 48 hours of "observation", code word for allowing the social workers to set up needed services and to talk with family about options while the nursing staff function as overpaid baby sitters and I charge between $50 and $90 a visit for being the attending on record.

I personally probably dishcharged 40 or 50 people last year alone under this generally accepted hospitalist social work Medicare protocol.

And it's all paid for. Every single one of them.

Anonymous said...

6:08 PM That nurse was on crack. Pharmacists in general come into contact with more crud than a lot of folks on the sidelines. We're sort of in a gray area, when some people attempt to think the exposure thing through.

In the IV hood in an aseptic environment, we try to keep our compounded products clear of particulates (when nurses routinely mix injectables and start IVs in a rather unsterile patient's room), so when is the last time someone noticed the pharmacist goes around encased in a bubble?

Some folks in hospitals were attempting to save money on respiratory treatments by reusing inhalation canisters, just replacing the mouthpieces between patients (yuck) and who got to handle the returned stuff? When the surgeons returned used medication boxes spattered with blood, guess who had to clean it up, plus all the blood products that weren't visible.

Sometimes we have a joke in the pharmacy about how none of us will ever 'need' a flu shot, because of all that we're exposed.

By the way, is it true that a person with asthma shouldn't come into contact with the person administered live vaccine?

Anonymous said...

A friend from Joliet, IL linked me to this article, Dr. Grumpy, and I bookmarked your blog immediately thereafter. I'm a 2nd year medical student at the Indiana University School of Medicine, and I'll be sure to share this with all of my classmates and instructors. I look forward to reading your past and future blog updates! :)

Anonymous said...

That's odd. I have MS too and on Saturday, I woke up to numb legs all the way up to my butt. Are the MS gods acting up again? Damn them!!

 
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