Wednesday, March 10, 2010

Things that make me grumpy

Gad (short for gadolinium) is an element. In my field it's used in certain MRI studies as a contrast agent. Not all MRI's need to be done with gad, but for some things it's very helpful.

Gad is also expensive, roughly $200-$500 a dose, on top of the already pricey MRI. So I only order it when I need it.

A few MRI places (not most, just a few) try to push giving gad, even in cases where it's not needed, just to pad the bill. Annie and I know which ones do that, and generally don't use them. But yesterday, for various reasons, we ended up scheduling a patient at one to have a study there.

So I faxed over an order that said "Brain MRI". That's all.

Annie had to run an errand, so I was covering her calls while she was gone. At one point Mary grabbed me between patients, and said I needed to talk to the staff at the MRI place, who had questions. So I picked up the phone.

Dr. Grumpy: "This is Dr. Grumpy."

Ms. Gouge: "Hi, I'm looking at your order here, and it doesn't specify if you want gad on the study."

Dr. Grumpy: "I didn't write "gad", so therefore, no gad."

Ms. Gouge: "But shouldn't we do it with gad?"

Dr. Grumpy: "Do you have my patient info form in front of you?"

Ms. Gouge: "Of course."

Dr. Grumpy: "What indication for gad do you see on there? She doesn't have any."

Ms. Gouge: "Yeah, but it's still helpful. So just give me an order for gad, and I'll take care of it."

Dr. Grumpy: "You and I both know that she has no indication for gad, and so her insurance won't pay for it."

Ms. Gouge: "Yeah, but we can bill the patient for it."


I hung up on her. I immediately called the patient myself, and moved the study to another MRI place.

46 comments:

Matt M said...

Thank you for protecting your patient. Does this place know why you don't refer people to them? Do they care?

Whenever I took my car to Firestone for service they would find two or three other things that needed to be fixed. Finally, I read a story that showed that the training manual for Firestone (and other shops) required the repairman to suggest two other fixes per visit. Screw them! It is just an upsell, but short sighted. Sure, you make more money on each visit, but if you have fewer clients you are not going to make as much money.

Magdalene said...

Thank you for that. Not every physician is as scrupulous as you. I sincerely hope that if I would ever have need of a neurologist, mine would be as wonderful as you. You may be grumpy but you have a very sweet, chocolate chip cookie interior.

Sandra said...

Good for you, Dr Grumpy, for looking out for your patients!

Celandine said...

If all docs (and other folks in medical-related fields) were as honest as you, the system wouldn't be in nearly as much trouble as it is with regard to soaring costs.

JP said...

Dr G-

A daily reader for well over a year now- you restore my faith in physicians! Im a PharmD just trying to stay sane in the crazy retail world. Glad to hear of a MD who is grumpy for similar reasons. Thanks for your blog.

Wanted to write to tell you that your link to "the long road to medical school" pops up as a malicious website on my antivirus each time. Just wanted you to know.

Happy blogging.

Celeste said...

WOW, that is just sick.

Your patients are really lucky that you've got their back.

Anonymous said...

It's refreshing to hear of someone being ethical.
After a recent hospitalization I am still being billed by hordes of physicians of whom I never heard or remember seeing.
Their bills are hideously bloated reflecting the partial payback they hoped to receive from insurers and sent in anonymity by a billing agency.
I believe you had a post about these vultures a while back.

Li'l Azathoth said...

Isn't she at least supposed to offer you a cut?

dan said...

"bill the patient for it." I think people who protest pharmaceutical and health care companies are missing out on another key component of the root cause in rising healthcare costs - and that is in the doctor/care offices themselves. It is businesses like this MRI place that are pushing hard on providing extra and unnecessary procedures on patients only so they could reap the monetary benefits from billing multiple procedures. It's so aggravating. So many of us have no idea we are filled with so much greed it's exhausting to think about.

stewbert said...

oh my hell ... how dishonest. good for you for standing up for your patient and what's right.

Old MD Girl said...

That really annoys me.

I had a brain MRI once (indication = mom with multiple AVMs + aneurysms, possibly genetic). I think it was with GAD, but I don't remember.

What I DO remember is that despite the fact that my insurance company paid for everything (I had truly stellar insurance at the time), the MRI place happily re-billed me for the full amount. And then they got all snotty on the phone with me when I pulled out my records that proved it.

Gah! Did they really think I was going to cough up 3 grand that they'd already been paid?? I concluded (maybe I was being paranoid) that they probably had a policy of rebilling their customers because every once in a while, they'd get someone to pay twice. Or they were really badly run.

Either way, your story reminded me of that, so I thought I would share.

Nectarine said...

Once again: glad I live in Canada. While this system is far from perfect, at least I don't get bills sent to me. This story truly shocked me.

Anonymous said...

"Gee, Ms. Gouge, I'd be happy to have you give gad if you'd be happy to send over a signed statement indicating that you will be responsible if the patient develops nephrogenic systemic sclerosis."
CardioNP

Silena said...

Kudos. It's comforting to know there are still ethical people in practice.

I just switched my 15 year old's doctor because of crap like that.

Who orders a bone scan and endocrinology study on a perfectly healthy girl who's 5ft tall and 95lbs?! Oh and an EKG. Just because, "he likes to have them done on all his patients". Eh?

student dr. blaze said...

Old MD Girl is right, but the practice is more prevalent than anyone could possibly imagine. I always tell people NEVER to pay a medical bill unless they've received & reviewed their EOB first. All sorts of medical providers will send out bills--sometimes of the sort that look threatening--before the insurance company renders payment, just hoping that the patient will be paranoid enough to pay the bill without question. Even if they're one of the more honest groups that will send a refund if there's been a mistake in billing (e.g. the bill is paid by the insurance company so the patient deserves a refund), it still means they've gotten to hold on to the patient's money for months and earn interest on it. There is so much about medical billing that borders on fraudulent that it's not even funny. It's as bad as the practices of credit card companies and banks. No joke. Dr. Grumpy, I think we should get you to do a PSA on the subject. :-)

Stephany said...

Thank you for being a patient advocate!

I've been enjoying reading old and new posts here, Dr.G, great blog!

Anonymous said...

I'm an academic radiologist and share your concern. Glad you handled the situation in that manner. My other concern is why are non-MDs protocoling these studies? We (residents, fellows, or attendings) protocol all of our MRIs and review the indications prior to the patient's imaging date. It's time consuming, but at least the right studies gets done for the right reason

rlbates said...

This behavior makes me grumpy, too.

Sandra said...

Student Dr Blaze: I had this happen to me when I had surgery last year. The pathology doctor's group (I had a potentially cancerous mass removed) billed me and the insurance company for the full amount. When I called them on it, they insisted that what they sent me was just for my information and not a bill. Hmmmm, if that's true, then why did it have a section with the amount due, a due date, and a return envelope? I wondered how many people paid those "bills" without asking questions?

Anonymous said...

This is why there can't be any significant, meaningful reform on Health care - too many people are making too much money the way things are.

Anonymous said...

There is a very interesting article about rising health care costs over here: http://www.theatlantic.com/magazine/archive/2009/09/how-american-health-care-killed-my-father/7617/3/

Despite the title, it talks about how the health came to be in its current form and some reasons why it is skyrocketing the way it is, along with some ideas on how to start improving things.

minimedic said...

...and this, ladies and gentlemen, is why this man has a fan club!

Grumpy, M.D. said...

(blush)

ndenunz said...

Their indication for Gad?

Positive wallet sign.

Moose said...

A year ago I was supposed to get an MRI of my unhappy spine. The first place I went to had a table that could handle someone of my weight, no problem. The tech tried for nearly an hour to get an image, but couldn't. Kept saying that my weight was too high for things to be clear. Tried various things, some kind of reflector, moving me around the table (oh that was fun), etc. Still couldn't get a clear image.

Then when I went to get off the table the tech handed me my cane. My metal cane. Which promptly flew out my hand and zoomed into the machine, just missing my head. He had to get the receptionist to help him pry the thing out. (It had a nice bend to it after that, too.)

As I was finishing up some paperwork before leaving the guy who was scheduled after me came out after about 5 minutes, telling the receptionist, "I gotta reschedule, the machine is broken, he can't get a clear image." No, REALLY?

IF the machine wasn't broken before I got it in -- assuming that it really was my weight and not the machine already broken before I got there -- it surely was broken after having a 3' metal tube fly in it.

I went to another place which got images of me just fine. Some of these "imaging" places are so shady it scares me.


My captcha word is: CHESSE. When you're getting an MRI, don't forget to say CHESSE!

LilMsHppyPillz said...

My son is autistic and I held off on any sort of ADD/ADHD meds as long as I could. But there came a point last year he needed the help. So we went to a neurologist and he ordered the usually EKG, blood work, etc. When he was ordering the blood work he told us about a new test for a genetic marker for autism and asked if we would like it. We thought it might be interesting to find out, so said yes. Turns out the test is $3000+. Luckily insurance covered most of it, but we still had a $700 bill. The next visit, we were talking about my son, our practices, the latest meds on the market. I told him about the cost of the test and his jaw dropped. He doesn't recommend the test anymore until after he calls the insurance company first. Oh, and the test was negative.

Flavius said...

Thank you, Dr. Grumpy. In a way it helps all of us out.

-Flavius

Celeste said...

That whole exchange sounds like something your state's Attorney General should know about. I'm certain you were not the first doctor they tried to persuade to order something that wasn't needed.

Dan said...

To paraphrase Claude Raines, I am shocked, SHOCKED, to find that there are unethical medical businesses that are out to extract the maximum cash possible from patients by hook or by crook. Lucky for your patient there was an ethical practitioner around.

Is there no ethics board for these places to whom the Ms. Gouges of the world can be reported? No Better Medical Business Bureau to issue warnings? Referring patients elsewhere helps those patients -- which is of course a good thing -- but does not address the real problem, and if ethical doctors don't speak out, I fear nothing ever will address it.

Anonymous said...

Dr. Grumpy, you are the best. You bet I'm a member of your fan club.

Jacqueline said...

And this is why Dr. Grumpy kicks ass!!!

Texas Pharmacy Chica said...

Thanks for showing concerns for your patients on many levels. I admire that greatly. You can continue blushing.

And yes, always, ALWAYS, check your EOBs and don't ever pay a single dime until you have your EOB. The provider's billing cycle may not be the same as the third party's payment cycle, leaving you to think it is not going to be paid. I'm obviously in health care so I have a clue of how it works and have demanded three-way calls between insurance companies, providers and myself to clarify payments. I hate being a pain in the butt, but I am not going to back down.

Anonymous said...

C'mon Dr. G. I thought this was just the American way of 'seizing the opportunity' and do unto others before they do unto you.

Celeste said...

Hopefully this place will go on your permanent Do Not Call list. No matter how convenient they might be, it doesn't sound worth it to have to deal with their tactics. I like the idea of doctors voting with their feet not to send business to places like this.

The Evil Receptionist said...

Ergh! This is exactly the way I'm currently feeling about Those Skooter Places. Those guys are nearly as bad as Ms. Gouge.

Don said...

There are hospitals in my area that are sending out bills to Medicare patients for the difference between what Medicare and the secondary insurance didn't pay.

For example, Pretend someone spent a night in the hospital. Hospital bills $2,000. Medicare pays their max allowable, 2nd insurance has a contract that says the maximum you can charge is $1800 and pays the difference. After receiving payment the hospital sends another bill to the patient for $200.

My parents are savvy and noticed this happening to them and refused to pay. Talked to their insurance company was their insurance company has started a fraud investigation with the State Attorney General's office.

My Dad's brother, 500 miles away, completely different medical system had the same thing happen and paid because he was afraid to challenge them.

I am starting to believe the medical misbillings are intentional and endemic.

Anonymous said...

I wish my Mom had you for her neurologist. You rock!

pharmacy chick said...

And THIS dear Grumpy is exactly why Obama is tearing providers apart. Thanks for taking a stand on this one!
you are awesome!

Anonymous said...

"We (residents, fellows, or attendings) protocol all of our MRIs"

Anon 9:22; Ok, i'm a little in love with you right now! We've been trying to get our Radiologists to protocol all our PET/CT orders beforehand but so far no go. They're all "too busy" so when the pt shows and we (techs) have a question we have to waste tons of time finding a radiologist and calling ordering docs and tons of other bull...

and Dr. G, thank you for being such a wonderful pt advocate and saving the pt unnecessary medication and bills.

Aaron said...

I think you're just looking for trouble writing your order thay way...

"MRI brain w/o contrast" would be much clearer, and could avoid situations like this.

All of my MRI and CT orders specify whether contrast should be administered. That seems to be fairly standard around here.

If you omit that instruction, you're really inviting problems from these centers, whether they stem from greed or lack of understanding.

Good job looking out for your patients. But save yourself the hassle and just give a clear order from the start...

The Hatchling said...

IDK Aaron.

The difference between your two orders is minimal and easy to mistake.
"MRI Brain w/ contrast"
and
"MRI Brain w/o contrast"

My preference when writing scripts has been to only what is necessary. My training center has now moved to form ordering for Imaging and contrast is a check box with a type. Probably a little safer.

ausduck said...

Dr G, I wish we could clone you :)
(in a nice, non-mad-scientist way, of course!)

Anonymous said...

GAD-dam, how unethical can you get????


May I join in the Greek chorus thankful to you for your honesty and advocacy? You can never quit blogging, as you and a strong cup of coffee are my biggest reasons for hauling my substantial gluteus out of bed in the morning!

Pattie, RN

ERP said...

Did you consider reporting that to the BBB?

Anonymous said...

You rock!! I have to tell Ultrasound techs every 6 months, that my GYN oncologist only ordered a VAG US -- Not an abdominal one and a VAG one. they will bill be for both and when you pay 30% it sure adds up.

The techs always insist they must do both, but the Oncologist has told me she doesn't need the abdomnial one.

Now I just refuse the abdominal one and tell them they better not bill me for it.

Thanks for looking out for your patients and their wallets!

Anonymous said...

Instant Fan!
Dr G, you are writing the script for a fantastically funny comedy show.....anyone *listening* out there?

 
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