Dr. Oldasdirt is an internist across the street. He takes every managed care insurance known to man.
Occasionally one of his patients needs a neurologist and is referred to me. That's fine, it's my job.
The managed care patients he sees generally need a referral to see a specialist. This is pretty common in American medicine, and has been since at least the late 80's. A form shows up on the fax machine saying something like "AUTHORIZED: patient Kris Kringle, DOB: 8-17-29. National Illness Insurance HMO plan. 4 visits. To see Ibee Grumpy, neurology, for Rangifer's disease."
So Mary files it. A few days later, when Mr. Kringle calls to see if we got the referral she looks it up, says "yes" and schedules him. When we send in a bill for his visit we have to include the referral to make sure we get paid.
About 3 months ago one of his referrals showed up before Mary got in, so I pulled it off the fax. I was about to put it in her filing book when I noticed something different about it.
At the bottom it said: "Only valid for CPT level 2."
To explain this, medical office visits are billed by CPT codes, ranges 1-5, with 1 paying the least and 5 paying the most. The difference is based on how complex the case is, how much time you spend with the patient, what percentage of that time is spent talking vs. doing an exam, whether you're seeing them on a day that does or doesn't end in a "Y," if Mercury is in retrograde, etc. For the record, there are more than 10,000 CPT codes for different stuff, but I'm just talking about office visits.
I began digging through Mary's file. No referral from any other doctor with that insurance had such a qualifier. It looks like the ones from Dr. Oldasdirt had started including the line about a week previously - fortunately I hadn't seen any of those patients yet.
Basically, what Dr. OldasDirt (or his office staff) were doing was putting a cap on how much I could get paid for the visit, no matter how much time I spent or how complicated the patient was. A level 2 new patient CPT code applies to visits between 15-29 minutes, and (as of 2024) pays a whopping $71. So that's what I get whether they take up 15 minutes or 90 minutes.
This isn't, at least to me, acceptable. Basically I'm agreeing to a set fee, without even knowing why the patient is coming in. Yeah, they could be simple, like carpal tunnel syndrome, but not likely in my field. You think you can take a history, examine, and explain to grandpa and his 7 person entourage what Alzheimer's means in 29 minutes? Good luck. The alternative is to have an alarm go off at 29 minutes, and say "Times up!" & leave the room.
Try calling Target and saying "can I buy any item in the store for $5, in advance, without you knowing what I'm getting until I check out?" I'm pretty sure they're not going to play.
So Mary called Dr. Oldasdirt's office and asked for a new referral without that line. She was told no, that was their new procedure, and if we didn't like it they'd stop sending me patients. With my approval she said okay, and shredded the referrals from them.
If they can find a neurologist desperate enough to work under that condition, more power to them.
Some out there are going to say I'm just here for the money, and don't give a damn about those patients. Whatever. The truth is that I'm here for the patients. This job is what I love. But I also have to pay both of my awesome staff their salaries, and my rent, and all the other overhead items. Not to mention my own mortgage, utility bills, kids college tuition, and so on. I can't help any patient if I can't keep my office open.
Why is Dr. Oldasdirt doing this? I have no idea. Other doctors haven't sent patients from the same insurance to me with that limitation, so I doubt it's the plan. Maybe he was hoping I'd start refusing to see his patients for whatever reason. Maybe the insurance is secretly letting him pocket the difference as a kickback.
I don't know, probably never will.