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.
Why would he care what you get paid? Maybe he's aiming to become their next medical necessity reviewer!
ReplyDeleteROFL over Kris Kringle having Rangifer's disease.
ReplyDeleteThe best part of having your own business is that you get to decide which 80 hours a week you want to work. Most people can’t even conceive of this type of thing I regularly get people who called me up and asked me to perform some legal desk and ask how much will it cost and a pod being told they tell me that Joe Smith esquire will do it for $150 less. Have at it, I say.
ReplyDeleteI did a collection thing for a guy I’ve known for 40 years he was supposed to pay me 20% contingency he complained so I told him forget about it. He calls me up and he wants to me to do a closing and then wants to negotiate my fee I told him no and he says but we’ve known each other for 40 years and I said George remember the collection thing I did for you and for gave you the fee didn’t charge you don’t bother me anymore we no longer know each other after 40 years. Knowing value and knowing worth or two different things
I'm assuming the patient's co-pay would be the same no matter what the billed amount, so why would it matter to the referring doctor what you billed the insurance? That is the strangest "policy" for his office to adopt
ReplyDeleteThis is ridiculous. What is the solution?
ReplyDeleteI'm going to guess it's a primary care provider who has been questioned on how much is spent, or perhaps a capitated plan so spending more on you actually hurts him.
ReplyDeleteNeurology is hard enough. Financial cheeseparing like that makes it a lot harder.
ReplyDeleteHuh. I assumed the insurance company itself was putting the cap on the referral. The doc submits the request for a referral, and the company says “ok, but keep it to level 2 or else!” I can’t say that I have ever seen such a thing, but I work for Giant Hospital Enterprise specifically so that I don’t have to deal with stuff like this…
ReplyDeleteAnyway, the doc then got defensive when Mary pushed back bc he somehow took it as a personal attack. Maybe he doesn’t even know about the cap bc his busy and well-meaning staff didn’t bother to inform him of this new development, choosing to shield his elderly person from niggly details like this. They themselves not being clinical ppl, just clerical, perhaps don’t realize the weightiness of this limitation. After all, Dr internist guy sees patients in 15 minutes and moves on, so why can’t the neurologist? It’s only even one organ system while GP doc deals with ALL of them! (/s if it wasn’t obvious)
I know that’s a lot of maybes and perhapses, but it’s otherwise super weird.
Dr G: totally correct and ethical decision. No other choice.
ReplyDeleteMaybe Dr. oldasdirt needs a dementia consult
ReplyDeleteEternal fun and games in the insurance coverage business. Most of the independent pharmacies went out of business in the 80s and 90s when the prescription dispensing fee was less than the actual cost of the drug; pharmacies have to have working refrigerators and sinks --it's the law. It helps business when they have security systems that work, too.
ReplyDelete