by Marie Cooper
Consider two patients with the same managed care plan.
One has multiple sclerosis and receives an infusion of Tysabri every month. It needs pre-certification. The requirements are black and white. The patient qualifies if they have relapsing/remitting MS and have failed other therapies. The drug costs $2,000, the infusion center is another $1,000. The infusion center is a contracted provider that has two of their staff people dedicated to keeping track of needs for referrals and pre-authorization’s for their patients.
To the patient, this is a seamless process. She shows up every month and receives her treatment. She has no co-pay. Patient A loves her insurance plan.
The second patient had a fall and broke her right humeral head a year ago. Following an open reduction internal fixation, she has physical therapy three times a week. PT has been effective, but recovery is slow. Things are fine until the tenth week, when PT is denied, as the patient has a PT benefit of 30 visits per injury per year. The patient and the physician are incensed. This is medically necessary. The doctor has ordered it. The patient needs it. But the contract says only 30 visits will be covered. Two levels of grievances uphold the decision, it is a contractual exclusion. The patient is welcome to continue attending physical therapy. But the insurance company will not pay for it. Patient B hates her insurance plan.
Patient A and Patient B are the same person.
I use these examples to show the best of managed care and what makes people unhappiest about managed care. Managed care is designed to save money and increase profits while paying for needed care. Americans, in a culture that traditionally wants to have its cake and eat it too, has a love/hate relationship with their insurance carriers because they don’t necessarily get everything they want when they want it.
Insurance is a business and, for now, it is here. It what we have. The old days are gone and are not coming back. So I suggest the best way to cope is to deal with it.
I don’t mean that to be obnoxious. I mean deal with it in a way that is productive and emotionally healthy for doctors and patients until something better comes along.
Doctors
* Have one person (or more) in your office dedicated to dealing with managed care. Or, for practitioners with small offices, hire a part time consultant. It will pay for itself in better organized claims and increased revenue.
* Know the rules; understand that these are contracts and if something is contractually excluded, that is it, it is just not covered. It is not a malicious plot, it is a business model intended to save money, employer money and employee money. Almost all of the time, it is the employer who chooses limits in a plan, not the insurance company. And the limits are chosen to save money.
* Document everything the patient says about their condition, even if it seems innocuous or offhand. That way down the road, if something needed 6 months of conservative treatment, you have it documented. Too many progress notes simply say “no complaints” or “better”, which practically begs a denial.
* Know the criteria for your most common procedures so you can have the documentation to back up your request.
Patients
* Read your Evidence of Coverage – the book you get when you enroll. Know your benefits and their limits.
* If you don’t understand something in the EOC, go talk to your benefits rep in the Human Resources deptartment.
Remember that insurance is a business. It is not personal. If something is denied, look at your part in the process. Did you follow the guidelines? Is it a contractual exclusion?
It is not a perfect system. There is greed, carelessness and errors. It can seem complicated and capricious and unfair. But it can work.
However, if providers and insurance companies don’t work together, everyone suffers. Doctors do not receive their well-earned compensation. The insurance companies cannot sustain themselves financially because they will lose members. But most of all, it is the patient who loses the most if providers and insurers continue their hate fest.
Marie Cooper is a freelance writer and management consultant at Achievement Strategies.
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“She might be unable to judge what is “worth it” and what isn’t.”
My ear has been ringing for 4 weeks. An internet search says it might be ear wax. Nurse recommends I come in and have it looked at. Pay $150 to get ear wax removed? It could be more serious. $150 to get a referral to a specialist? An expensive workup for something that can’t be cured or treated effectively. Too bad my HSA won’t pay for the bottle of hydrogen peroxide.
Marie, I don’t think any of the comments were intended as personal hate mail!
I think it was the phrase “deal with it” that made so many of us see red. That’s exactly what every doc has heard thousands of times over the last twenty years, while we have seen the insurance companies become more and more an obstacle preventing us from delivering quality health care. Reading Lynn’s truly Kafkaesque nightmare reports, it’s clear that “deal with it” is a completely inadequate response.
Thanks for participating in what has turned into a very emotional discussion.
We are all working in a seriously flawed system, which I personally believe needs to be ripped out root and branch, but I have chosen to try to save the world retail, one patient at a time.
Recall that in our current system the best course for a pregnant woman with pre-existing diabetes is often–quit your job, drop your insurance, get on the public plan. The reason :, the co-pays for several weekly visits, fetal ultrasounds and strips and pump supplies, and the very high amounts ofshort acting analog insulin (esp if there is also child care) is higher than her take home pay . Now we could use regular and with GDM we do, but then we won;t meet the goals with preexisting type 1 and type 2 , and there will be hypoglycemia. Who gets pregnant? YOUNG women, who don;t have 3 months salary in the bank and if they do they want that to cover their time off work. Some of whom are even married and employed , even some married to guys with decent jobs. The insurance companies would save a bundle in neonatal ICU care by covering medically complicated pregnancies better, but they save even more by NOT covering and shifting the cost to the taxpayers. I think a healthy baby is a good use of my tax money, but it isn’t a good system. Show me your company’s possibly unpopular patient HEALTH centered uses of money then I will just deal with your company and your DME minions.
I don’t think for a moment a physician organization setting formularies would be perfectly ethical. I think that when death is predictably imminent , the companies should be forced to cover till the company gets its act together. had to put 2 weeks worth of anti rejection drugs on my Visa card for a young fool with a heart transplant 10 years ago awaiting approval, which came, I was reimbursed the next month , but –ouch! I have a patient with a BMT who wasn’t being covered for her re-vaccinations because they are a pediatric benefit. Was the university center that did the transplant or the hematologist fighting that battle? Hell, no , that’s an unpaid primary care job. Was she going to die tomorrow with diphtheria or chicken pox? No , so I just did those letters on the weekend. .
Approval at tier 3 is equivalent to a rejection I have a few patients sending to Europe or Asia for drugs, because here in Oregon they are afraid to go to Mexico because of the perceived drug wars, and the swine flu . Too late for that second worry, but so typical of the health care debate . The adequate dose of Revatio for IPH looked like $900 monthly without insurance and $500 at tier 3 when my partners and I talked about the NEJM review at lunch yesterday. Kind of tough when you can’t work full time and need to hire a housekeeper because you are too SOB to cook.
Instead of quarreling about any theoretical panel to rein in the life threatening abuses of the companies who keep the employees on the phone to THEM instead of the patiients (love that stray) , wonder why Humalog is still $100 a bottle and people need insurance to pay for it, 15 years after release . Wonder why insurance pays better for a non-fatal case of fibromylagia than lupus nephritis.
I would suggest organized physician input in the case of “what are diseases in which a delay in pharmaceutical treatment for 48 hours or a week (or some other magic number) is likely to have severe or even fatal consequences?” . The list needs to be very short and if something new goes on, something old goes off. What is one adequate treatment? Our organizations vary in how closely they are aligned with insurance and pharma. At least docs , with patient experience, can join and have a vote as opposed to being completely shut out . That is the current situation, unless you give up patient care so you have adequate policy credentials to enter the inner courtyard.
. . Marie is a well intentioned experienced nurse , who works with high ticket players –infusion centers getting $1000 for an infusion. Shoot, I’d be hiring someone to keep the coin coming also . She just doesn’t get it– my primary care world has no hidden profits. Those of us seeing patients don;t have time , money or energy to fight them, and the companies know it .The wolf is at the door and both my patients and I might get eaten!
Organized medicine can’t do a thing to change this because we are not unionized. We can’t unionize because of antitrust laws that don’t apply to insurance companies.
Focus your staff’s efforts on getting the patient what they need. Don’t waste your time on PAs. Prescribe generics whenever you can. Any info from insurance companies that are helpfull “hints” on patient care tear up and throw away. It is not worth you time to interceed. Get the insurance company to send you written guidelines on their screening criteria so you will know what to document in the patients record.
Bottom line: we are at war the patient are the hostages being held by the Insurance Companies evil empire and we are the guerilla warriors trying to free the hostages. Take off your blindfolds and jump in the trenches.
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