INSURANCE FRAUD


October 20, 2011


In the world of medicine, ICD-9 and CPT codes reign supreme.  Insurance companies and Medicare do not understand English.  Insurance companies and Medicare communicate in codes.   One code tells the insurer what the diagnosis is, the other tells them what the doc/lab/radiology department did.  In order to get reimbursed (we don’t get paid), the insurer must agree that the procedure code matches the diagnosis code and that it meets the insurer’s definition of necessary (which is often not the doc’s or patient’s definition of necessary) or covered benefits.


As your doc, I need to be paid for my services.  I also recognize that I spend your money and I am as cautious as possible to assure that I do not abuse that privilege.  When I order a test or procedure, I match my diagnosis code to the proper procedure code, justifying the services render.  Insurance companies often deny care and, if I anticipate a problem, I discuss it with my patients prior to ordering the test/procedure/x-ray.  I try to estimate what the cost to my patient is going to be.  If my patient is a Medicare patient, they will need to sign a ABN (Advanced Beneficiary Notice) telling them why I anticipate the government will not pay for a procedure or lab and how much it will cost. 


Unfortunately, I do not have a crystal ball and often cannot anticipate what the insurer or Medicare is actually going to deem necessary.  There is also no way to know exactly what any individual’s covered benefits are.  My patients also have no idea what their policies cover.  When my staff schedules an individual for a wellness physical, they mail the patient instructions, one of which is for the patient to contact his/her insurer and verify what is covered and what is not.  One hundred percent of my patients sign that document, verifying that they received it and were instructed to check on their insurance coverage.  Only 20% actually check on their coverage.


Making matters worse, some policies have coverage limits.  If you simply ask, “Is XYZ covered?” the answer is “Yes.”  XYZ is, in fact, covered; but XYZ cost $600 and the policy has a limit of $200, leaving the patient on the hook for a whopping $400 surprise.  Here’s where the issue of fraud comes up.


Patient P calls his insurance company.  He complains bitterly about being stuck with a bill he didn’t expect.  The insurance clerk, wanting to deflect P’s anger, informs Patient P that the doc used the wrong code and “all” he has to do is get his doc to change the code to a well-care code or some other diagnostic code and all $600 will be covered.  Now Patient P is angry with his doc who, he now thinks, obviously did not do his job right the first time.


The insurance clerk has done two things.  The clerk has re-directed his/her client’s anger and invited the doc involved to commit insurance fraud by changing a valid code to a less valid or inaccurate code.  Patient P calls his doc’s billing staff insistent that the code be changed.  Patient P is not only angry, he feels cheated!


On rare occasions, I can find a legitimate, alternative code or use a code I missed.  On most occasions, there is nothing I can do.  Changing a sick- care code to a well-care is fraud.  Patient P came in for a follow-up visit after surgery.  The tests ordered were not well-care tests, they were specifically designed to measure the outcome of the surgery and safeguard the patient.  


The fact that an insurance clerk would advise a patient to have the coding of his/her visit changed from sick-care to well-care is outrageous.  The fact that such blatantly fraudulent suggestions are made every day (this is a common problem) is beyond absurd!  The cost of this outrageous practice is enormous.


The financial cost of this common practice is borne by both the patient and the doc.  My staff can spend hours on the phone, working with both an angry patient and his insurer.  The emotional cost is even higher.  The doctor-patient relationship can be seriously damaged or even severed.


“Doc, I can’t afford $400!  I’m out of work, supporting my children and parents.  All I have left is my credit and this will ruin it!”  The insurance company insists you can just change the code and this will all go away.  Can’t you just make a note that I was seen for a physical?  You examined me, isn’t that a physical?”


“I’m sorry, Mr. P.  Changing my notes and the code would be insurance fraud.  Your insurer is wrong.  I can’t change the codes.  There are no other legitimate codes.”


“Doc, we’ve been your patients for 20 years.  I can’t believe you won’t help me.”


The insurer wins!  They save $400 dollars.  They continue to safeguard their record profits.  My patient loses.  He loses $400 and his faith in me.  I lose.  I have cared for Patient P for 20 years.  P is a great guy and in a bind.  I want to help him.  I can’t!


It’s time this deep dark secret becomes public knowledge! 


What can you do to protect yourself?  While it is extremely hard to do, you need to find out just what your policy covers.  Once you find out what is covered, find out if there is a coverage limit.  Prepare for frustration.


Patient – “I’m calling to get prior authorization for my surgery.”


Insurer – “Mr. P, your surgery is authorized.  Authorization does not guarantee payment.”


Patient – “Then why waste my time calling?  What do you mean payment is not guaranteed.”


Insurer – “You have our authorization.  We need to inform you that prior authorization does not guarantee payment.”

Catch 22, anyone?

SLEEP APNEA AND WEIGHT


October 19, 2011


My sleep apnea (http://livewellthy.org/2011/08/12/sleep-apnea-revisited.aspx) is much better.  I have spent years fighting with my CPAP machine.  Unlike most patients, I just couldn’t get used to wearing a mask.  Knowing that sleep apnea has the potential to cause serious medical problems, I struggled to make peace with my sleep mask and the mechanical wonder it was attached to. 


One consequence of writing this blog is that I have lost 30 pounds and am healthier than I have been in years.  It’s amazing what happens to you when you follow the doc’s advice!  Of all the benefits I have experienced since losing my weight, getting rid of my CPAP machine is the greatest.  I no longer snore.  I no longer wear a mask to bed.  The only rhythmic noise in my room at night is my dog’s snoring!


According to MedPageToday, patients with sleep apnea who were enrolled in a study on the intensive treatment of diabetes had a significant decrease in their sleep apnea scores (improvement in sleep apnea). 


The article stated, “The findings came from Sleep AHEAD, an ancillary study of the Look AHEAD trial, which compared an intensive lifestyle intervention with diabetes support and education for weight loss in obese patients with type 2 diabetes.”  It went on to say that,  After one year, patients undergoing the intensive lifestyle intervention lost an average of 24 pounds, whereas those in the control group had no weight loss (P<0.0001).


While the effects of lifestyle change and weight loss were not as pronounced as mine, they were significant.  The author stated, “I don’t want to give you the impression that this is an alternative treatment to [continuous positive airway pressure],” he said. “It’s probably a complementary treatment.”


So, what have you got to lose?  Ten, twenty or thirty pounds?  A four pound CPAP machine?  Even if you have to continue using your CPAP, you’ll be healthier. 


How do you lose ten to thirty pounds when diets have failed you in the past?  Stayed tuned to this blog.  “Diets and Other Unnatural Acts” should be available by early December.  I’ll give you a hint.  Define who you are and then work at refining who you are.


As always, remember:  the life you save may be your own.

“I’M BETTER”


October 17, 2011


Yesterday, I wrote about the word “enough” and how it applies to the field of medicine.  While writing that article, I realized that “better” is another one of the difficult words I have to deal with on a daily basis.


“Doc, I’m better” can mean a lot of things and can lead to both misdiagnosis and poor treatment.  Does “I’m better” mean you are well?  If not, are you really better or is it just wishful thinking?  How much better are you? 


On a busy, stressful day, even the most skilled physician can fall for, “Doc, I’m better.”  “I’m glad you are better, Mrs. J.  Please stay on the same medications and see me in a month.”  This typical exchange sounds perfectly fine, doesn’t it?


Mrs. J was very depressed when she was seen 2 weeks ago.  While she was not suicidal, she had started to disengage from her family and friends.  She was feeling somewhat hopeless and could not envision ever being happy again.  I often ask patients to assign a numeric value to their problem, 10 being the best day they ever had and 1 being the worst.  Mrs. J would have been a 2 of 10 when first seen.


On her return visit, Mrs. J was “better.”  Had the doc asked her to define better, she would have been a 3-4 of 10.  While better, she was far from well and still in jeopardy.  Hopelessness is a very bad thing and Mrs. J still felt hopeless.  “Mrs. J, please stay on the same medication and see me in a month,” sends the wrong message!  The message Mrs. J hears is that she is going to feel like this for another month or this is the best the doc can do.  These are not messages that inspire hope!


Accepting “better” leads to a mediocre outcome at best.  Had Mrs. J said, “Doc, I feel a little better,” or had the doc asked, “How much better do you feel?” the scenario would have played out differently.  “Mrs. J, I’m glad you are feeling a little better.  That’s a good sign that we are on the right track.  Let’s increase your dose of medication and see me in 2 weeks.  Hopefully, you will feel a lot better.”  In this scenario, Mrs. J has can have hopes of feeling better and one day being well.


If “better” means well, say so.  If better means a little better, acknowledge that, as well.  Set your sights on being well and work towards that goal.  While a 10 of 10 may be an unrealistic goal, 8 of 10 should be obtainable.  Become a great communicator and help your doc do the same.


I hope reading this and the other articles on this blog help you find your 10 of 10!

WORRY


October 15, 2011


Do you worry?  Does worrying ever keep you awake at night?  Does your worry make you less effective at work and home?  Does your worrying about this and that accomplish anything positive?


Most people worry.  I worry about a lot of things!  Worrying about lots of things is usually unproductive and downright unhealthy.  Tonight, I saw a patient who was exhausted due to being sleep deprived.  He wanted a sleeping pill or something to take the edge off.  He stated that, when he went to bed (11 pm), he couldn’t turn his mind off.  He would toss and turn until he finally fell asleep at 2 a.m.  Three hours of misery and wasted time.


Mr. W has a lot to worry about.  The economy stinks.  He has bills to pay.  His health is failing.  His friends are in trouble.  He worries about what goes on in Washington and the Middle East.  The list goes on and on.  When I asked him what he has been able to accomplish by worrying, he realized that he always worries about the same things.  Nothing ever changes.


Years ago, one of my mentors taught me an excellent technique for helping worriers.  I told Mr. W that a sleeping pill or tranquilizer was like patching a leaky pipe with chewing gum.  Instead, I asked Mr. W to schedule an hour of “Worry Time” every night.


“Worry Time” is the solution to sleepless nights.  The first ½ hour of worry time is spent making a list of everything you are worried about.  Once you have the list, divide it into those things you can control and those you can’t.  The second ½ hour of “Worry Time” is spent designing solutions to the problems you are worrying about.  The solutions to those problems that are totally out of your control are to take them off your list or give them to someone else to worry about.  Once your list is complete, you can go to bed knowing that your concerns have been addressed.


“Worry Time” is only part of the solution.  Mr. W’s second task was to schedule ½ hour of “Resolution Time” during his morning breakfast.  During “Resolution Time,” Mr. W is to start acting on the solutions he designed the night before.


Mr. W’s first impulse was to insist he did not have 1 ½ hours to work on a worry list, solution list, and resolution action plan.  I pointed out that he had been wasting 3 precious hours every night in unresolved worries.  My plan would not only free up 1 ½ hours but, for the first time, effectively relieve some of his worries.  I think Mr. W is going to do great.


So, if you worry a lot, can’t sleep, and never resolve the issues that plague you, schedule yourself a little “Worry Time.”  Let me know how it goes.  On my list of worries today was writing tomorrow’s article.  I can go to sleep now. 

HOW MUCH IS ENOUGH?


October 14, 2011



Enough is one of the most confusing words in the English language.  “How much is enough?” not only depends on who you’re asking but also refers to what you’re asking about.  If you ask me, there is never enough summer, steamed crabs and Krispy Kreme Donuts.  “When is enough, enough?” is a difficult question to answer, as well.  Everyone seems to have a different cut off point.


The United States Preventative Services Task Force, in reviewing the controversy over the PSA test, decided that there were not enough lives saved by screening for prostate cancer using a PSA test to warrant the use of this test.  I’m glad I didn’t have to decide how many lives saved were enough to warrant the expense and risk of savings those lives.


In “The Impact of Unnecessary Testing and Treatments on Patients,” (http://www.kevinmd.com/blog/2011/10/impact-unnecessary-testing-treatment-patients.html), Dr. Goldman reviews the causes and risks of over testing in the US and Canada.  How much testing is enough when it comes to diagnosing what ails you?  In “You’re Damned If You Do and You’re Damned If You Don’t” (http://livewellthy.org/2011/06/22/youre-damned-if-you-do-and-damned-if-you-dont.aspx), I discuss the madness involved in doing just enough testing to make a patient happy and healthy.


How much is enough medication?  Exercise?  Food?  Vitamins?  The list goes on and on.  Experts disagree.  People become judgmental!   Reputations are made and broken! 


I think Dr. Goldman hit the nail on the head when he wrote, “Welcome to the world of medical uncertainty.  There is no one right answer to this dilemma.  Health care providers practice with uncertainty all the time.  As a partner in your own wellness, at times so will you.”


I am certain that you will agree with me on one thing.  This article is long enough.

ENTHUSIASM


October 14, 2011


Enthusiasm and optimism can be marvelous emotions.  Enthusiastic people are full of energy, often optimistic and almost always smile.  They are fun to be around and can energize any room they enter.


Enthusiasm and optimism can also blind a person to the harsh realities of life.  They are emotions that, when unbridled, can hurt you.  It’s hard to know when these emotions will take you to the next level or sink you.


Every few months one of my patients comes to me with a vibrant smile, enthusiastically wanting to share their newfound gift of health and financial wealth with me.  “Doc, you’ve got to meet with Dr. So and So!  He introduced me to a new healthcare enterprise that will help your patients gain access to some incredible new products that are just unbelievably potent at fixing all that ails you!!”


I listen, not wanting to burst their bubbles but knowing I have to.  I ask a few questions.  Yes, it’s all natural.  Yes, it’s manufactured from the highest quality herbs/vegetables/tree bark/fruit/whatever.  Yes, the company has done gobs of research proving its ability to perform miracles.


I should just say, “No thanks” but I can’t.  I hate bursting their bubbles, but I’d rather burst their bubbles than have them inadvertently harm a friend.  So, burst their bubbles I must.


Here’s the scenario I lay out.  Let’s assume that this company in Europe or China has found the magic elixir of health.  Let’s also assume that they have proven that it is harmless.  Do they know how it interacts with the eight medicines your client is taking?  Have they proven that taking it with Digoxin (a heart medicine), will not cause your client to become toxic and die?


Before you sold it to your neighbor, did you take the time to find out that he has renal failure and that this product will worsen his kidney function leading to dialysis?  And what happens if your perfectly healthy neighbor or friend starts taking your product and ends up with kidney failure?  Did your product cause it?  Are you liable?  Can you prove your product did not cause the demise of your neighbor’s kidneys?


Sure, you have the assurance of the healthcare enterprise marketing this wonder pill.  What manufacturer is going to admit that his product is not of the highest quality?  What healthcare enterprise is going to share the results of failed experiments or risks involved in taking their products?  The answer is that those healthcare enterprises functioning under the auspices of the FDA are required to share all of their information under penalty of law, and Big Pharma occasionally gets caught with their pants down anyway.


If I haven’t burst your bubble yet, here are some more questions you should be asking:



  • What is the base material and can I eat it in its natural form?


  • Where does it come from and what are the hygienic practices of the country of origin?


  • What are the quality control procedures employed by the manufacturer?


  • What is the bioavailability of the product?  In other words, how much of it is absorbed in me?


  • How is the product excreted?  Though the kidneys?  Liver?


  • Does the product cross into the brain?


  • What short and long term risks are involved in taking this product?


  • Who can’t take it?  What are the effects on a yet to be born fetus?  Nursing mom?

If these questions are not enough to dampen your enthusiasm and make you think twice, I have more!  Please forgive me for ruining your day by bursting your bubble.  Better I open your eyes with my questions than have your enthusiasm accidentally harm a friend, neighbor, or client. 


A bit of skepticism goes a long way.  “Big Pharma” (the FDA regulated pharmaceutical industry) has been under attack for years.  It is my belief that much of the attack on “Big Pharma” has been instigated by “Big Neutra” (the unregulated neutraceutical industry) and that Big Neutra’s “no holds barred” approach to merchandising far exceeds any sins committed by the nation’s pharmaceutical industry.  Buyer beware!

VITAMINS AND SUPPLEMENTS – PART 2


October 12, 2011


Yesterday, I reported on the latest controversy dealing with vitamins.  In January of this year, I published “DOC, SHOULD I TAKE VITAMINS?” (http://livewellthy.org/2011/01/23/doc-should-i-take-vitamins.aspx)  Today, I want to discuss my own experience with Vitamin D deficiencies.


First, I want you to understand that my experience with Vitamin D deficiencies falls into the category of anecdotal evidence (http://en.wikipedia.org/wiki/Anecdotal_evidence).  In other words, while my experience over the last two years raises some significant questions, it proves nothing.  Despite its inability to answer the key question, “WHY?” my “anecdotal evidence” deserves reporting.


Two years ago the “in vogue” disease was Vitamin D deficiency.  My patients started requesting that I draw their vitamin D levels and I complied.  Over the last 2 years, interest in vitamin D levels have peaked and I have done a lot of tests.  I was surprised to find that a large number of my patients have low vitamin D levels despite having no specific complaints. 


As any good doc would, I started replacing vitamin D with over the counter vitamin D supplements.  Two things happened.  The first was that very few of my patients called to inform me how much better they felt.  In placebo studies (patients given fake pills), the placebo rate of improvement is often in the twenty percent range.  I would have expected that at least 20% of my patients would have felt better.


Secondly, patients were instructed to return in 1-3 months for repeat testing.  On repeat testing, on supposedly adequate levels of supposedly high quality over the counter vitamin D, most of my patient’s vitamin D levels barely moved and some actually decreased.  Patients with low vitamin D levels on supplemental “D” were instructed to double or triple their intake.  Again, they were retested and again their levels remained low.


My experience with vitamin D deficiency and replacement has been relatively dismal.  A few individuals managed to get their levels into the mid- normal range (50) and a few of them felt “better” although they had trouble defining “better.”


So what’s the answer?  Are our “normal” ranges wrong?  Are the supplements my patients taking lacking in true vitamin D?  Is the bioavailability of the over the counter products poor?  Are my patient’s digestive tracks the problem?  I have lots of questions and very few answers.  What I do know is a lot of money is being invested in inadequately treating a perceived deficiency.


Adding insult to injury is a recent article linking the consumption of excessive vitamin D to an increased incident in skin cancer.   I worked hard at increasing my vitamin D level this summer by basking in the sun.  Unfortunately, my doc, noting my tanned, sun damaged skin, read me the riot act:  “Keep this up and you’re going to get skin cancer!”


Sometimes, you just can’t win!

VITAMINS AND SUPPLEMENTS


October, 11, 2011

The following is taken directly from THE AMA NEWS but is also being featured on multiple medical news sites and on the internet (My take on subject on page 2.):



“Vitamins associated with increased risk of death in older women.”


“The CBS Evening News (10/10, story 8, 0:30, O’Donnell) reported, “More than half of American adults take dietary supplements.” And ABC World News (10/10, lead story, 2:40, Sawyer) added, “A major new study in an important medical journal finds in some cases the supplements either do no good or could increase the risk of dying from cancer or heart disease.”


        NBC Nightly News (10/10, lead story, 2:40, Williams) reported that the study published in the Archives of Internal medicine found that “women who take supplements, including multivitamins, appear to have slightly higher death rates.”


        On the front of its Personal Journal section, the Wall Street Journal (10/11, D1, Dooren, Subscription Publication) points out that investigators followed some 39,000 women for approximately 19 years.


        The New York Times (10/10, D6, Bakalar, Subscription Publication) reports in “Vital Signs” that “some supplements, like iron, were associated with a substantial increase in the risk of death, while others — vitamin A and vitamin D, for example — had no effect.”


        “As in the broader population, women in the study who took supplements tended to be healthier — with lower rates of diabetes and high blood pressure, and lower body mass index — than women who didn’t,” the Los Angeles Times (10/10, Brown) reports. Still, “with the exception of the women taking calcium, they died at slightly higher rates.” The Times points out, however, that researchers “did not explore whether supplements contributed to the causes of death among the women.”


        Still, USA Today (10/11, Lloyd) reports, “The study highlights concerns about the long-term use of supplements and vitamins in people who do not have severe nutritional deficiencies,” the investigators said. “An accompanying editorial notes that [the] findings ‘add to the growing evidence demonstrating that certain supplements can be harmful.'”


        Vitamin B12 may play role in cognition skills in seniors. The Washington Post (10/11, Searling) reports that vitamin B12 may “play a role in memory and cognition skills in older people,” according to research published in the Sept. 27 issue of Neurology. After analyzing “data on 112 men and women 65 and older (average age, 79) who were given a battery of 17 tests of their memory and other cognitive skills, had blood drawn and were tested for five markers that reflect the presence of Vitamin B12, and were given an MRI scan to assess their brain volume, or size,” researchers found that “those whose blood indicated a vitamin B12 deficiency, based on high levels of four of the five markers, also had lower scores on the memory and cognitive tests and smaller brain volumes.”


So, what should you do?  Who do you believe?


While I have discouraged the ingestion of “all natural” pills and vitamins, I highly recommend the daily ingestion of both vitamins and minerals to my patients for years.  I recommend that vitamins and minerals be bought and ingested in their original, all natural, containers.  Fresh fruits and vegetables contain nutrients, cofactors, and perhaps substances that we have yet to identify, substances that were designed to keep us healthy.  While manufacturers of neutraceuticals, including vitamins, recommend that you take handfuls of pills on a daily basis, nature limits your ingestion.  Do you really need to take mega doses of vitamins?  If you want your vitamin manufacturer and local retail vendor to make a profit this year, you do!


While “An apple a day keeps the doctor away,” five apples eaten today is probably going to make you sick.  A couple of succulent oranges will make your day.  Eat six and the citric acid is going to give you indigestion.  Nature seems to have a way of protecting you while keeping you from overdoing a good thing.  Nature also has its own built in quality control.  Biting into a piece of fruit will instantly allow you to assess its quality!


Eat lots of fresh fruits, vegetables, and grains on a regular basis.  Avoid buying vitamins in a pill and you won’t have to worry about the controversies brewing in the neutraceutical world.  Your body will thank you!  I think I’ll go eat some blueberries.

STATISTICS


October 11, 2011


Statistics (stats) are the tools the medical world uses to decide which treatments are useful and which are not.  In actuality, the world runs on statistics.  In the financial world, quarterly stats can make or break a company.  In the medical world, stats can save a life or end a life.


The problem with statistics is that they can be manipulated.  The same set of data can be interpreted in a myriad of ways.  In a recent article in the New York Times, (http://www.nytimes.com/2011/10/09/magazine/can-cancer-ever-be-ignored.html?pagewanted=1&_r=1) the authors review the controversy surrounding the PSA test and how the same statistics can be interpreted by each side in order to validate each sides viewpoint.


So what do we do with statistics when they can be manipulated, massaged and used to represent and support diametrically opposing viewpoints and conclusions?  As physicians, we must assess each view separately and as a whole.  We must recognize our own biases, our own experiences and try to give our patients the most balanced approach we can.  We must arm our patients with the knowledge they need to make a truly informed decision. Ultimately, it is the patient’s decision.


It all boils down to the individual patient’s needs and wants.  Statistics are for the masses. I have never met a statistically average patient.  As physicians, it is our responsibility to treat individuals and to openly acknowledge our biases and inform the patient that we are biased and why we are biased.  Equally important, we need to be able to present the opposing viewpoints of others just as passionately as we present our personal views.  We need to be able to teach our patients what the theory behind each alternative is. 


In my practice, after explaining all the options, I usually tell the patient that there is one last option on the table.  That last option enables the patient to put the choice of therapy in the physician’s hands.  As your family doc, the physician recognizes that there are times when you do not want to or cannot make a decision.  The last option is to leave the choice to me.  It is my least favorite option.


“As it stands, each man must decide for himself how he wants to play the odds.”  According to the New York Times’ article, “The solution, in Welch’s view, and in that of a growing number of physicians, including Brawley, is to make sure men fully grasp the downstream decisions they may face as a result of screening — the risk of knowing too much,” and, according to me, the risk of knowing too little.