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?

I fumed. 

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?”

“No, never.”

“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….


171 thoughts on “Grave

  1. this is why I am glad I don’t live in America and have to deal with stupid insurance companies. Medicare sucks! At least you sorted it though, that part is good for the patient so she doesn’t have to pay. XXX

    Liked by 1 person

  2. You did right on all counts. Particularly calling the insurance. Finally it went ok. Problem is, in insurance compamie decisions are taken by actuarians not doctors. Here for instance it is better with some companies to go trough ER (and add to their backlog) do a bunch of useless tests, than skip it and just do specific targeted tests. Happened to me once. A shame.
    But again, you did right.
    Now, can you fight all the bureaucracies? You can’t.

    Liked by 1 person

  3. I just started reading a book I wouldn’t recommend at all, but I am glad to have read the first few chapters on how the pharmaceutical industry came to be what it is today. Those readings made me feel even more certain that capitalism and healing don’t belong together; only one wins, due to no fault of doctors. They also made me recall some of what you’ve written about patients coming in and requesting specific medicines, and want to bang my head against a table. How do we step away from a sorry, terrible situation so long in the making, when so many–not doctors, but those with cadres of lobbyists–make so much money off others’ unhealth?

    Argh to all of it. Argh, argh, argh.

    Liked by 1 person

  4. Do you suppose it’s all about money? Is it as simple and ugly as that or is the machine more complicated and have more moving parts?

    I saw your mention about blogging to preserve your sanity. I write some terrible things that rattle around in my head but I never hit post. I can’t. But having the words pass from my head, down my arms and through my fingertips is a Zen exercise in letting go. It’s also loads cheaper than therapy. Who can afford that?!

    Liked by 1 person

  5. This post makes me sadder than you can imagine.

    I suspect the analysts at the insurance company have *quotas* of claims that they have to reject. Perhaps your’s just got caught in a quota that needed to be met.

    It’s not about patient care at all … but Big Business. Plain and simple.

    Liked by 1 person

  6. I don’t know how you do it….. When Trump gets elected (I am secretly hoping for a 3rd choice to fall from the sky) it’s because there are a lot of old people that have had it. They are p**sed off royally. I see it all day everyday and they are not afraid to tell you about it. It’s a mess out there!

    Liked by 1 person

  7. I went in for my annual visit with my doctor, as I do every year. This time I saw someone else, perhaps a nurse/practicioner or assistant, who took me through the usual questions, discussed my general health and prescriptions and spent about an hour with me. I bragged to my friends – prematurely it turned out – about what caring folks I had overseeing my health. Then I got the bill.

    Medicare had paid for the usual visit, but they disallowed a $545 charge for the extra time. I called the doctor’s office and spoke with someone at length. It was a matter of coding, I was told, and I got a note back, telling me that they would recode and resubmit the claim. As a result, everything was covered and paid.

    I have always been outspoken about NOT having tests, procedures, anything that insurance wouldn’t cover. I also spoke up about my outrageous bill, and they backed down. Patients have to be proactive about their health, which includes their economic health. If you don’t understand or feel you are being overcharged, speak up! The squeaky wheel . . .

    Liked by 1 person

  8. I am afraid of that too. I work for a hospital in the city I live in, but I am not a medical professional. I sit at a desk and check in patients for their appointments, schedule new ones, and verify information in our system. I may not be wearing a lab coat or scrubs, but I get asked a lot of questions- most of which I have no idea how to answer. It feels like a performance when I speak confidently in whatever half-assembled answer I choke out. Billing – I reassure you- are the worst of all questions or concerns I’ve ever gotten. I have even been privy to inspecting a man’s gaping, bloody, hand wound in the E.R. Nothing is worse than having no idea how or where or when a bill will come. “How much does this visit cost me?” a patient asks. You know what I say? “I’m not sure, that depends on a lot of things; insurance coverage, date and location of your appointment, and what sort of things the physician does/recommends for you during your visit.”
    Its sad (but true) that I have gone above and beyond my job expectations in seeking the answer to a few of those bill related questions. It wasn’t easy, and I still don’t know how much their visit to see a physician here will cost. I sympathize and apologize profusely if they tell me their complicated story. I do my best not to become deaf to their constant complaining. I want to see them as sick people and not just the things bothering me at work. In all this, I’ve learned that the scariest thing is that no one person or department is to blame, it’s not that simple. Not surprisingly, the woman in Grave may not have ever figured out why she’d been denied for the scan. She would could have been stuck with a bill and thought to herself, “That’s healthcare here in America.” And who could argue?

    Liked by 1 person

    • “I do my best not to become deaf to their constant complaining. I want to see them as sick people and not just the things bothering me at work.” I love those two sentences. Bless you for all that you do. May you never become jaded. 🙂

      Liked by 1 person

  9. Pingback: Meet A Blogger: Victo Dolore | That's What Anxious Mom Said

  10. I don’t blame you! I would be angry too! Have you seen Michael Moore’s Sicko? If you haven’t, you really should. The ONLY first world country IN THE WORLD without socialized medicine. So insurance companies profit, big pharma profits, everyone else gets screwed! (one way or another, and not the good kind!)

    Liked by 1 person

  11. If you take the profit away from pharmaceutical research and development, then breakthroughs and possible cures go out the window.. Sadly this is why innovation progresses in almost any venue.. Insurance companies are for profit companies, with 2 extremes in thier history.. First, almost completely unregulated now completely under regulation by government standards and still remaining for profit with the government’s nod of approval.. It all started spiraling when people chose to flock to have the new HMOs when they hit the scene.. Not even questioning the quality of care or who was going to determine the treatment plan.. Insurance companies brought HMOs into existence so they could see more profit by having more control..
    I liked it much better when there wasn’t HMOs or the successors of them.. And the government should only have one duty when it comes to healthcare and any other for profit business that impacts a citizen’s quality of life ( like utilities).. To make sure reasonable and fair rates/premiums for services are enforced.. And that services are rendered that comply with quality of life..
    Then and only then, will insurance companys go back to vying for your business with lower rates and more liberal covered services over and above just meeting quality of life standards.. Right now with the government’s intervention we have less than quality of life minimum standards..
    Had my generation balked at the idea of HMOs in the beginning, we might now have a better healthcare system that would cover the people who can’t afford private healthcare.. It’s already in place but a shambles, its called Medicaid..
    That and Medicare both needed overhauls but instead we get this mess..


    • @ Pan,

      I think you are giving Big Pharma too much credit for creating breakthroughs and cures. Most research is done by the government, free to the drug companies. Their principal contribution is in trials and dosage development, but they typically only choose the products likely to be used long-term and therefore be most profitable. They contribute little to the likes of vaccines and new antibiotics.


  12. Thank you! Docs like you give me hope.
    I’m in Nursing Admin. and I’m a big patient advocate. You can just imagine how many doctors have told me that I can’t save them all (the patients) coz I won’t give up til I feel that I have actually done everything in my power to help. The state of our healthcare in the US is getting worse and people were so happy that ObamaCare was the answer until they started feeling the pinch. I guess it’s too late now.

    Liked by 1 person

    • It is getting where Medicare patients in particular are too challenging. I ordered an MRI on a patient this week with terrible back pain for five months who failed PT, failed a run of steroids and NSAIDS. All of that was documented. The MRI was denied because they did not have enough info. WTF? Someone in my office had to spend 45 minutes of their day calling and resubmitting everything. I don’t have the staffing for that. It gets worse every year, especially with Medicare. New “rules” no one knows about until things get rejected. There are no physicians in my area accepting Medicare except for a few quacks off dubious character because it is too burdensome on practices. It makes me angry. All of this does not affect fraud one bit. Instead, it takes advantage of a vulnerable population…. Whew! I could go on and on and on about this. Sorry!

      Liked by 1 person

      • I understand. Props to you for going beyond your calling. I know a lot of Docs who can’t be bothered so the patients have to suffer the consequences.

        I feel frustrated myself because my nurses (and some doctors I work with) feel that with MediCare’s strict requirements, we have to make sure their documentations are “perfect” to MC specifications or else we won’t get reimbursed. Pressure much! The time they spend on charting is taken away from the quality care that the patient’s deserve. I think everyone in the healthcare field who has a conscience feels the same way.

        Liked by 1 person

  13. We need more people like you in the field and less bureaucracy in our lives. I took special note of how you made mention of the sad fact that things like this can turn people into conspiracy freaks, and thought I would share another instance of that nature with you. All sections of oil pipelines must be replaced with new pipe once every couple years. To do so, the company has two options: 1) Shut down the pipeline and replace the pipe at a cost of around $1 million per day to the company in lost revenues, or 2) wait for a pipe to burst (an oil spill) and replace the pipe while getting PAID by their insurance company to do so. Thus, you have a lot of people convinced the oil companies cause their own spills just to save money.

    Liked by 1 person

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s