I had something rather upsetting happen last week:
A patient, old enough to be on Medicare, came to the office with acute onset of left lower quadrant abdominal pain a few days earlier. It was getting worse. The pain was constant and bad enough that she had a difficult time standing up straight. She denied constipation or diarrhea. No black, tarry stools. Her temp had been 100.0, not quite a fever. Her urine test was negative for bladder/kidney infection.
It was a Friday afternoon. These sorts of things always happen on Friday afternoons. I checked the time. Fortunately, it was early enough we could get a CT scan done STAT and hopefully save her a trip to the ER. My staff arranged it and she went over to start drinking the contrast.
About two hours later, I got the call. It was diverticulitis. No abscess. No perforation. No cancer.
I called the patient, got her started on the antibiotics, and told her that if things got worse she needed to go the emergency room. I saw her back on Monday.
She was doing great, the pain was gone.
Score one for the win column!
On Thursday, though, I got a fax from a company contracted by that patient’s Medicare replacement insurance who had reviewed my documentation and decided that her CT scan would not be covered until she had failed a course of antibiotics for seven days first. They also wanted me to know that they had sent a letter to the patient notifying her that the scan would not be covered because it was not ordered appropriately.
Your doctor sucks so now you have to pay…
My first feeling was confusion. Did I do something wrong? Had there been a change in the management of a first case of suspected diverticulitis? Some new paper that I was not privy to? I scoured all of my references. I asked my partners. I even Googled it, folks.
My second emotion was anger. Here’s a vulnerable population, the elderly. Now the patient, who is on a fixed income, was going to get stiffed for a couple thousand dollars because I did the right thing. If I had just sent her to the ER, they sure as hell would be paying a lot more for that CT scan, as well as paying through the nose for a crap load of expensive blood tests, IV fluids, meds, urine tests, and the ER physician’s bill. They would not be sending denial letters to the hospital for that CT scan. Oh, no.
How DARE they make me second guess myself! I thought we were all trying to keep patients out of the hospital?
My head hurt with the rage.
When I got a chance, I called them and spoke to a “medical director”. I have no idea what his qualifications actually were. He did not identify himself as a physician.
“Has the patient had a prior case of diverticulitis?”
“Do you have anything else to add before we make a decision?”
“What? Aside from her severe abdominal pain? No.”
“Let me go ahead and give you the approval number for that scan.”
Thanks so very much.
Why was the scan denied days after it was ordered, after we already had results? Why was it even necessary for me to waste my time fighting their decision when I only had to answer two stupid questions? All of the necessary info was in my office note, a copy of which they had been provided with prior to the scan. Why was it necessary to tell the patient their study was denied without first giving me the opportunity to fight it?
They crossed a line.
In a month, I may order 1-2 CT scans, maybe 5-6 ultrasounds. MRI’s? Maybe 5-6 in a whole year. It is not like I over use expensive studies when they are not going to potentially change what I do with the patient.
They keep databases on me.
I think they were secretly hoping I would not call, that I would tuck tail and run. I wonder how many physicians do, whether it is out of embrassment or ignorance, thinking it really is some new Medicare guideline they didn’t know about, or simply just from lack of time. Then, the patient would bear all of the cost, despite the fact it was a completely appropriate test. Saves the company tons of money, I bet.
This is what medicine has been reduced to, now.
I had a patient tell me recently that she felt doctors were in cahoots with insurance companies and the pharmaceutical industry because her endocrinologist told her that her new insurance company would not cover her medication, the one she had been taking for almost a year, the one that had finally gotten her diabetes under control, until she tried and failed their preferred drug. The new med made her feel awful. She was angry and no amount of explaining was going to change her mind. Since her endo had to deliver the bad news, she felt it was the physician’s fault for not getting the med covered. There must be money involved for that doctor. That, or the endocrinologist was lazy because they just didn’t try hard enough.
She isn’t the only one and you know what? I don’t really blame her. Making sense of all of this is hard for patients.
Why can’t we all work together to take the best care of patients? Why does there even have to be a bad guy?
Meanwhile, perpetuating the public’s mistrust of physicians, undermining care plans, is in the insurance industry’s best interest. I am afraid this is only going to get worse….