Leaning to the Left

Chicago skyline from a boat in Lake Michigan

“They denied it again.”

“WHAT?”

I had, no joke, completed various permutations of that paperwork half a dozen times and I was done. DONE, I tell you. The faxed rejection notice included two pages of suggested changes to be completed before resubmission, all things I had already taken care of.

Four months of this back and forth. I was trying to get diapers, pads, wipes, and barrier skin cream for a patient with cerebral palsy via Medicaid.

Initially, I had completed the form just as I had for years. However, I found through subsequent denials that I could not use just cerebral palsy as the diagnosis code. Nor could I just use the code for incontenance or neurogenic bladder. I had to use ALL of them together. But that was still denied.

Then I wrote a letter of medical necessity, as Medicaid said the paperwork forms were not enough. The letter I wrote said, “This patient has cerebral palsy and incontenance and needs diapers, pads, wipes, and skin cream.” Seriously, it was exactly the same thing the forms themselves conveyed, only I wrote it in sentence format on a letterhead.

After the letter, they said they would cover everything except the skin cream. 

Take a guess why.

Because I had to say the skin cream was to be used as a barrier.

I rewrote the letter, adding the phrase “for barrier to prevent skin breakdown” after the skin cream mention.

Finally, it was approved. 

Two months later everything had expired. So I meticulously rewrote the forms and the letter with the exact same codes and phraseology. I even placed the periods and signature flourishes in exactly the same places.

It was denied.

You know what? I will play whatever damn game they want me to play but I need to know the rules. Changing the rules randomly without warning and without explanation is absurd. Sure, it wastes my time, but the real issue here is the patient needs the covered supplies and the state is doing its darndest to make sure that doesn’t happen. Not on their dime, at least.

These are the games we play.

Meanwhile, skin breakdown and ulcerations….

Kerfe at Method Two Madness asked, “Do you have a solution for remaking the way medicine is practiced in the United States? I know our politicians don’t consult either doctors or patients when they write their laws. But let’s pretend they will listen and do the right thing…what would you suggest?”

My list of biggest desires is this:

1. A simple EHR and an end to the litany of stupid ways that I have to prove to the government that I am using it *wisely* or demonstrating that I am providing a “patient centered medical home” or any other inane acronym/phrase they come up with.

2. No more silly game changes like the paperwork situation above. There would be a simple rule book that does not change on someone’s whim without notice.

3. Controls on the costs of medications.

4. Universal healthcare coverage that is shared by all politicians. This scares me because I have seen the government muck up almost everything it gets its hands on and healthcare is too important to screw up any more than it already is, but I don’t know how else to do it. I have watched as even people with insurance cannot afford needed care with the high deductible plans now provided by employers. It is a sad state of affairs.

5. A salary cap for healthcare, insurance, and pharmaceutical company CEOs.

6. Better security for the IT part of healthcare. I have read that stealing healthcare data is much more valuable than stealing a credit card number. I don’t doubt it. We have rushed into the technology without adequate safeguards. 

To be honest, though, I am probably the last person who should be fixing things. I have very little knowledge in the areas of politics, policy, and government finance. If you relied on me to take care of things, we would probably have a collapse of our economy… 

Advertisements

82 thoughts on “Leaning to the Left

    • That’s because there is too much room for interpretation in the system and you get a different person interpreting your input every time you submit. If you could resubmit to the same person, your chances of approval would increase. Unfortunately, that doesn’t allow for load balancing, so it won’t happen.

      Maybe, you might say, the answer is to tighten to rules so there is less room for interpretation. But, it is probably the ability for a human to interpret the rules that allows the system to operate at all. Make the rules too tight and the system comes to a standstill.

      Well, then, maybe the rules are already too tight and they should be loosened. That makes fraud easier, and fraud comes directly off the bottom line jeopardizing the CEO’s bonuses.

      We are stuck with a system that has not scaled well to its present size and will only get worse as it gets bigger. I’d be optimistic that the problems could be fixed except that use of the legislative process is required.

      Sigh.

      Liked by 4 people

      • Everything is open to interpretation—English is not a precise language. But even without the issue of English, when the form has been filled out correctly is an interpretation. Whether you need to specifically say “barrier cream” is an interpretation. Whether you need the redundant letter of medical necessity is an interpretation.

        Liked by 1 person

  1. I want to interview about a zillion doctors so I can understand the healthcare situation. I don’t want to hear political rhetoric but the truth from the front lines. I know our family pays an exorbitant amount to BCBS only to be denied the new miracle drug for cholesterol growers. That’s me. I’ve tried everything but nothing works. I’m the patient who cannot take statins due to gruesome side effects and is a perfect candidate for Repatha. The wonder drug in question. My cardiac lipidologist keeps trying to convince them pay now or pay later if heaven forbid I have a stroke or some other issue. So frustrating from doctor and patient’s ends. You have a right to be pulling your hair out dealing with this every day. I’m sorry.

    Liked by 4 people

  2. Thank you for being so diligent and caring so much about the details. Our system is broken and it makes me furious. Those who really suffer are those who can least afford. I’m sorry these crazy rules and game changes have to be part of your workload.

    Liked by 2 people

  3. These are really good common sense suggestions (especially making the politicians have the same insurance and coverage as everyone else). I understand your frustration, and I really wonder what it will finally take to get universal affordable care for all. No one likes what we have now. Well, maybe the insurance and pharmaceutical companies…
    Speaking as someone who just spent 6 phone calls and 2 frustrating office visits trying to get a referral to a doctor I see every year and who is supposedly in the same medical group as my primary care physician! Do we really have all that time to waste? (K)

    Liked by 3 people

  4. You know what else would help? A phone call saying “you need to include … please fax it over and we will approve the request.”

    As someone with skin problems l like this patient, I feel his/her pain.

    Liked by 2 people

  5. I like your ideas for change, and agree with them. Of course that makes both of us socialists, communists, radical left-wing nutjobs, heathens, and conspirators to destroy the American Way. But still, I can’t think of any better ideas.

    Liked by 2 people

  6. It’s crazy. Your time probably costs more than the dam’ cream, treating skin breakdown and ulceration certainly does. We are so lucky to have the NHS, but even here it’s hard to fund preventative stuff. The thing that really really really annoys me is when we have set up support and interventions for families, which are often complex, involving several agencies, and they work, and then it’s decided that they aren’t necessary any more because everything’s OK – but they are only OK because of the b****** intervention that’s in place, but the intervention is stopped because everything’s OK, and, oh my gosh, things fall apart again. Garrhh!!!

    Liked by 2 people

  7. Coding is a ridiculous endeavor. How can someone who is not there doing the assessment possibly know more than the clinician when it comes to diagnosis??? The rest of the process is just crap. The OASIS is built to purposely being difficult and open to interpretation. Why are we scoring our medical practice like it is some baseball team. “We are a four Star Home Care…..who gives a rip… your not feeding me dinner! I could go on and on….but the thing I agree with you the most is we need to dethrone these CEO of pharmaceuticals, who play with people’s life. I think they should all be injected with something they are allergic to and make them get medical help and pay for it!

    Liked by 3 people

  8. All the higher ups of everything live in a different world…they don’t know and they don’t care. I mean really…skin cream??? Makes me sick to my stomach…

    Liked by 1 person

  9. I feel like someone in the action should always be consulted before making new laws governing any portion of society. Talk to teachers before writing education laws, doctors when writing healthcare laws, etc. The outside perspective is never good enough to truly understand what’s going on.

    Liked by 1 person

  10. My job deals with similar details which are equally unnerving. The ever-changing bureaucracy. What was good enough last week isn’t good enough this week. It’s so bad, I often question if the people on the other end are purposely avoiding work and laughing maniacally at my attempts. lol
    On the medical side, I have friends and family who have experienced similar issues. The last one was catheters. Like, send one part, but not the other. Useless. Odd. Kinda mean, and definitely thoughtless.
    In both situations, it doesn’t help that every place is different.

    Liked by 1 person

      • A chosen sibling of mine has. Moved from my country to NYC. Bit of both…he could never access the complex trauma mental and physical healthcare he needed, plus trans healthcare and LGB healthcare where we lived… USA has been much better. But then being poor in USA with your broken system means horrible hassles getting treatments and meds approved due to insurance shit

        Liked by 1 person

      • I’ve a chosen sibling who moved from my country to NYC. He could never access the complex trauma mental n physical healthcare he needed back home, plus transgender healthcare and LGB healthcare…there isn’t ANY.

        But in the USA, his options are better…though now it’s insurance companies making it awful, and still few viable options.

        Liked by 1 person

  11. Leave it to the gov’t to screw it up. Sounds like the same dilemma teachers face. Teach math this way, it’s best. No wait. Last year was wrong, do it this way. Don’t teach this, teach that. But do it without x,y,and z. Standards are constantly changing. Schools undersupplied. I feel your pain… You’re a doc. Got anything for that kind of pain? 🙂

    Liked by 1 person

  12. It’s crazy everywhere and sad that it is. I just spent 2 weeks fighting with my Ins. company about something that is covered always has been for me and I sent everything they requested and have always sent and they decided it wasn’t enough. Having said that it was their mistake and I finally get it covered. Having said that, it’s frustrating and exhausting when you’re not feeling well to have to so to speak prove your innocence. I even had to get a not from my Pharmacist which they almost decided still wasn’t enough..lol
    I think the Gov. and Ins. companies bank on sick people not having the fight in them and giving up. I’m not one to give up.

    Liked by 1 person

  13. Your six points seem pretty concise.
    Have you thought about presenting a paper at the AMA?
    It seems to me the only way you (docs) will defeat Big Med brother is by taking a collective stand.
    Otherwise, you are toast. (And patients are ashes)
    Just imagine a one-day massive, nation-wide physicians strike? (Barring emergencies of course)
    🙂

    Liked by 1 person

Leave a Reply

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

WordPress.com Logo

You are commenting using your WordPress.com 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