Referrals

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.

Resistance is futile

Dr. Grumpy: "So let's work on that MRI... What dates, or days of the week, work best for you to have the study?

Ms. Dixon: I'm not sure yet, I need to make a call."

Dr. Grumpy: "That's fine, just call back after you know what days work with your job to get this done."

Ms. Dixon: "Actually, I need to call my astrologer."

Dr. Grumpy: "Your astrologer..."

Ms. Dixon: "I don't want to have it done at a time when the planets are in the wrong position to affect the results, you know what I mean?"

Dr. Grumpy: "Uh..."

Ms. Dixon: "I mean, if Mercury is in retrograde that can screw up the machine's magnetic field, right?"

Dr. Grumpy: "Actually..."

Ms. Dixon: "She knows a lot about this stuff, she went to a special school or something like that."

Annie's desk

Phone person #1: "Thank you for calling Low-Cost Radiology, where our prices reflect our quality every day! Can I help you?"

Annie: "Hi, this is Annie, at Dr. Grumpy's office. I'm trying to get insurance approval for a patient to have an MRI there, and to submit the form I need your facility's tax ID number."

Phone person #1: "What's a tax ID number? Is it how much we paid in taxes? Last year I paid..."

Annie: "No, it's the number your facility is assigned for tax and business purposes. The insurance companies need it so they can pay you for the MRI."

Phone person #1: "Is that the same as my social security number? I can give you that. It's 738..."

Annie: "No. It's the assigned..."

Phone person #1: "Let me transfer you."

 

On hold with a subdued piano & cello version of "Smells Like Teen Spirit."

 

Phone person #2: "Thank you for holding. Can I help you?"

Annie: "Hi, this is Annie, at Dr. Grumpy's office. I'm trying to get insurance approval for a patient to have an MRI there, and to submit the form I need your facility's tax ID number."

Phone person #2: "Hmmm... Is that the number you just called to reach us?"

Annie: "No, that's your phone number. It's..."

Phone person #2: "Oh, is that like a special number the IRS calls us on?"

Annie: "No it's..."

Phone person #2: "Let me transfer you."

 

On hold with a subdued piano & cello version of "Safety Dance."

 

Phone person #3: "Thank you for holding. Can I help you?"

Annie: "Hi, this is Annie, at Dr. Grumpy's office. I'm trying to get insurance approval for a patient to have an MRI there, and to submit the form I need your facility's tax ID number."

Phone person #3: "I don't think we have one."

Annie: "No, you do, every business has one, it's assigned to you before you open by the..."

Phone person #3: "Let me transfer you." 

On hold with a subdued piano & cello version of "Paint It Black."

 

Phone person #4: "Thank you for holding. Can I help you?"

Annie: "Hi, this is Annie, at Dr. Grumpy's office. I'm trying to get insurance approval for a patient to have an MRI there, and to submit the form I need your facility's tax ID number."

Phone person #4: "Oh, hang on. Let me look that up for you. Hmmm. I thought I had it on a Post-It note somewhere... maybe it's behind the take-out menu for Blumenthal's Chinese... no, maybe it got stuck to the menu for the place we ordered lunch from on Monday, I can't remember the name though... that may be over by the fax machine with the Chipotle forms, hang on... you know, I may have accidentally thrown it out because a bunch of stuff got marinara sauce on it when I was eating yesterday... let me transfer you."

 

On hold with a subdued piano & cello version of "Girls Just Wanna Have Fun."

 

Phone person #5: "Thank you for holding. Can I help you?"

Annie: "Hi, this is Annie, at Dr. Grumpy's office. I'm trying to get insurance approval for a patient to have an MRI there, and to submit the form I need your facility's tax ID number."

Phone person #5: "I hate you phishing scams. Fuck off."

click

Current status

Sir, if you don't stop tapping "Rock Lobster" out on my desk with your horribly untrimmed fingernails I am going to have to kill you with a Trömner.

Fore

Mr. Lewy was brought in by his son.

 

Dr. Grumpy: "So, what happened? I mean, I spoke to the police earlier, but want to..."

Son: "A neighbor called the police, Dad was chasing invisible people down the street, screaming at them and waving a golf club."

Mr. Lewy: "There were people all over the house! And in my yard! And they were having a party, and I told them to leave, and they wouldn't! So I told them to get out or I was going to clobber them, and when they didn't I chased them outside and down the street!"

Son: "The police calmed him down and searched the house and yard, there were no signs of anyone besides Dad. They also took away the golf club."

Mr. Lewy: "It wasn't just a golf club. It was a 3-wood. And I need it back before the tournament next week."

Son: "Dad, you aren't in a tournament next week."

Dr. Grumpy: "Okay, so..."

Son: "And it was a 9-iron, not a 3-wood."

Mr. Lewy: "I'm not that far gone. It was a 3-wood. Know your damn Callaways."

Dialing for dollars

Doing some marketing surveys for $ over the long holiday weekend.

They often include questions to see if you're paying attention, like this one:

Then there's this, asking me how many patients with a given condition I've seen in the last month:

The first choice (which I had to look up) is from a Roald Dahl book. It's a disease contracted by eating shoelaces that turns you into a rat. Although personally I think it would be much cooler if it turned you into a cassowary.

Then you get stuff that makes no sense whatsoever:

 

 

 

Or this one, which didn't give me any options in case this wasn't the case:

 

And lastly, in the middle of a survey on treatments for Alzheimer's disease, I encountered this question. I can only assume the survey writer had a personal interest in the topic.

Reality check

Yesterday I was on my way home from work when there was a loud noise and the Grumpymobile immediately veered right. I pulled into a side street to assess the damage:

 

Sigh.

So I dug out the spare and its gear and got started, jacking up the car, unbolting the shredded tire, tossing it in the trunk...

I'd just started rolling the spare around to the front when a crew from the Grumpyville fire department drove by. They pulled over and 4 guys piled out. One of them took the wrench out of my hand, another handed me a bottle of water. They bolted the spare on, lowered the car, and put all the stuff back in the trunk in what seemed like 15 seconds (maybe they were secretly an Indy pit crew).

As they piled back in their truck one of them said, "sir, it's pretty hot out, and a guy your age should know better than to do stuff like this."

Random pics

Okay, time to hit the mailbag for stuff you guys have sent in.

First, we have this, from a patient medication form:

 

I never thought of this product coming in different grades, and I really don't want to know what the difference is between "professional" and "amateur."

 

Next, in the way only Amazon can, we have this juxtaposition from their "you might also like" algorithm:

 

One reader is currently on an Alaskan cruise, and one night at dinner they were serving uh...

 

 

 

And lastly, the same reader saw this in a brochure on board. While I'm sure the award is well-deserved, I really don't want the details. I'm sure it involved being called at 2:00 a.m., was really disgusting, and had something to do with the all-you-can-eat buffet.

 

"Helluva diuresis, eh?"

One of my patients landed in the hospital overnight for mild pneumonia, and his wife asked me to look at the records to make sure there weren't any changes in his Parkinson's medications.

In the discharge summary I noticed this:

 

June 6, 1944

"There have only been a handful of days since the beginning of time on which the direction the world was taking has been changed in one 24-hour period by an act of man. June 6, 1944, was one of them.

"No one can tell the whole story of D-Day. Each of the 60,000 men who waded ashore that day knew a little part of the story too well. To them the landing looked like a catastrophe. Each knew a friend shot through the throat, shot through the knee. Each knew the first names of five hanging dead on the barbed wire offshore, three who lay unattended on the beach as the blood drained from the holes in their bodies. They knew whole tank crews who drowned when their tanks were unloaded in 20 feet of water.

"There were heroes here no one will ever know because they're dead. The heroism of others is known only to themselves.

"What the Americans and the British and the Canadians were trying to do was get back a whole continent that had been taken from its rightful owners. It was one of the most monumentally unselfish things one group of people ever did for another.

"It's hard for anyone who's been in a war to describe the terror of it to anyone who hasn't. How would anyone know that John Lacey died in that clump of weeds by the wagon path as he looked to his left towards Simpson and caught a bullet behind the ear? And if there had been a picture of it - and there weren't any - it would've shown that Lacey was the only one who carried apples for the guys in his raincoat pocket.

"If you think the world is rotten, go to the cemetery at Saint-Laurent-sur-Mer on the hill overlooking the beach. See what one group of men did for another, D-Day, June 6, 1944."

- Andrew Rooney (1919-2011)

I'm not following this

 Seen in a chart:

 

 

Quiz time

Okay, as required to maintain my hospital privileges (in addition to sending in a check) every 2 years I have to take mandatory online testing to make sure I can deal with situations at the hospital.

So, without further comment (that's your job, isn't it?) here are some of the questions I was asked, along with the answer options:

 

Here

LOOK, PEOPLE! JUST BECAUSE LADY GAGA IS ADVERTISING FOR A MEDICATION DOESN'T MEAN SHE'S GOING TO PAY FOR YOURS IF YOUR INSURANCE WON'T!

Waiting list

Mary: "Dr. Grumpy's office, this is Mary."

Ms. Frantic: "Hi! I really need to see a neurologist! All the ones at Massive Clinic are booked out to July, so I was hoping your office might have something sooner."

Mary: "Actually, you're in luck. We just had a cancellation for tomorrow, so Dr. Grumpy can see you at 10:00 in the morning if that works."

Ms. Frantic: "Dr. Grumpy has an opening for tomorrow?"

Mary: "Yes, would you like it?"

Ms. Frantic:" Um... no. Honestly, if your doctor isn't booked out, than he probably isn't very good. I'll just wait for July."