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  • #16
    They do it because it works. We use a similar practice in blood banking. It's also effective. Sorry, not sorry.

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    • #17
      I have been working in appeals for Big Health for 6 months. These are some of the things that I have learned.

      1. I rarely have to do peer-to-peers, but when I do, the ordering provider is generally way off the mark. On one occasion, a doc was asking me about my qualifications and such to put my name in the chart. I responded that if we are having this conversation, you should be more worried that your name is in the chart. Anyway, I no longer live in the world where I care if my name is in the chart.

      2. Most docs seem to learn the insurance game quickly and learn how to avoid the time-wasting pitfalls that ensnare them. A small minority, and I can think of two specific surgeons, seem to invite the chaos and confrontations that come with not going with the flow.

      3. I have zero incentive to block exams or procedures. Zero. My pay is not affected, not my bonus, not my promotional opportunities, etc. In fact, the only time I see that there is any grief in the job is when there is something that you deny that comes back to bite you.

      4. There is a ton of fraud, waste, and abuse in the system. If no one was pushing back on it, the healthcare system would implode the US economy. I have seen a bill for a $270,000 MRI. Not to buy the machine, just one exam. I have seen a neurosurgeon order MRIs of the cervical, thoracic, and lumbar spine and bilateral shoulder and hip MRI arthrograms based on a single encounter with an essentially normal, healthy patient with minor aches and pains. Or 49 OB ultrasounds done in the course of a normal pregnancy. I have seen dozens of completely bogus ultrasound exam submitted by chiros and on and on. If everyone were competent, ethical, and reasonable, there would be no need for managed care. Newsflash, they are not.

      5. An unfortunate side effect of utilization management is that due to technicalities of various kinds, well-intentioned people get held up in the process. Everyday, I see cases stuck in limbo because the office staff puts in the wrong information. You (the doc) might think that you have crossed all of your t's and dotted your i's, but if your MA puts in the wrong CPT code, everyone is screwed (you, the patient, and even the insurance staff).

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      • #18
        Originally posted by VagabondMD View Post
        I have been working in appeals for Big Health for 6 months. These are some of the things that I have learned.

        1. I rarely have to do peer-to-peers, but when I do, the ordering provider is generally way off the mark. On one occasion, a doc was asking me about my qualifications and such to put my name in the chart. I responded that if we are having this conversation, you should be more worried that your name is in the chart. Anyway, I no longer live in the world where I care if my name is in the chart.

        2. Most docs seem to learn the insurance game quickly and learn how to avoid the time-wasting pitfalls that ensnare them. A small minority, and I can think of two specific surgeons, seem to invite the chaos and confrontations that come with not going with the flow.

        3. I have zero incentive to block exams or procedures. Zero. My pay is not affected, not my bonus, not my promotional opportunities, etc. In fact, the only time I see that there is any grief in the job is when there is something that you deny that comes back to bite you.

        4. There is a ton of fraud, waste, and abuse in the system. If no one was pushing back on it, the healthcare system would implode the US economy. I have seen a bill for a $270,000 MRI. Not to buy the machine, just one exam. I have seen a neurosurgeon order MRIs of the cervical, thoracic, and lumbar spine and bilateral shoulder and hip MRI arthrograms based on a single encounter with an essentially normal, healthy patient with minor aches and pains. Or 49 OB ultrasounds done in the course of a normal pregnancy. I have seen dozens of completely bogus ultrasound exam submitted by chiros and on and on. If everyone were competent, ethical, and reasonable, there would be no need for managed care. Newsflash, they are not.

        5. An unfortunate side effect of utilization management is that due to technicalities of various kinds, well-intentioned people get held up in the process. Everyday, I see cases stuck in limbo because the office staff puts in the wrong information. You (the doc) might think that you have crossed all of your t's and dotted your i's, but if your MA puts in the wrong CPT code, everyone is screwed (you, the patient, and even the insurance staff).
        I was hoping you would chime in, vagabond. As with many things, it is a few bad apples that ruin the bunch. I am still stunned at the amount of effort it takes to write for 15 tablets of vicodin for the guy who just broke his leg.

        Comment


        • #19
          Originally posted by Sampter View Post
          I had a patient that used to work for one of the big insurance companies. Made 7 figures + bonuses depending on how much money they saved by blocking stuff. It was sickening when they told me about it, and likely was just the tip of the iceberg.
          Hopefully everything you wanted to do was blocked. For karma and stuff.

          Comment


          • #20
            What percentage of the time is health insurance actually utilized as insurance?(ie unexpected accident). If 85% of us are just unhealthy persons and have chronic disease or have no resiliency to recover from xyz, isn't the insurance just groupon for health care?

            Comment


            • #21
              I got an ERA for no payment today on a surgery I did last week. (Of course) my staff actually DID obtain a PA as required. Insurance companies can't pay their multi-million CEO salaries if they don't screw us every which way until we give up.

              More man hours (and pay from me to my staff) for tracking down a payment we already jumped through hoops to get.

              It's all bullsh$* imo.

              Comment


              • #22
                Originally posted by VagabondMD View Post
                I have been working in appeals for Big Health for 6 months. These are some of the things that I have learned.

                1. I rarely have to do peer-to-peers, but when I do, the ordering provider is generally way off the mark. On one occasion, a doc was asking me about my qualifications and such to put my name in the chart. I responded that if we are having this conversation, you should be more worried that your name is in the chart. Anyway, I no longer live in the world where I care if my name is in the chart.

                2. Most docs seem to learn the insurance game quickly and learn how to avoid the time-wasting pitfalls that ensnare them. A small minority, and I can think of two specific surgeons, seem to invite the chaos and confrontations that come with not going with the flow.

                3. I have zero incentive to block exams or procedures. Zero. My pay is not affected, not my bonus, not my promotional opportunities, etc. In fact, the only time I see that there is any grief in the job is when there is something that you deny that comes back to bite you.

                4. There is a ton of fraud, waste, and abuse in the system. If no one was pushing back on it, the healthcare system would implode the US economy. I have seen a bill for a $270,000 MRI. Not to buy the machine, just one exam. I have seen a neurosurgeon order MRIs of the cervical, thoracic, and lumbar spine and bilateral shoulder and hip MRI arthrograms based on a single encounter with an essentially normal, healthy patient with minor aches and pains. Or 49 OB ultrasounds done in the course of a normal pregnancy. I have seen dozens of completely bogus ultrasound exam submitted by chiros and on and on. If everyone were competent, ethical, and reasonable, there would be no need for managed care. Newsflash, they are not.

                5. An unfortunate side effect of utilization management is that due to technicalities of various kinds, well-intentioned people get held up in the process. Everyday, I see cases stuck in limbo because the office staff puts in the wrong information. You (the doc) might think that you have crossed all of your t's and dotted your i's, but if your MA puts in the wrong CPT code, everyone is screwed (you, the patient, and even the insurance staff).
                Agree 100%, some people invite and love the confrontation. Efficient people will learn whats required, have an intake form the pt fills out, know the ratios/etc..., and you'll know whether or not a pt is a candidate and who/which one is most likely to give trouble. If you do this its super rare. The sloppy, over reaching, cant bother to learn system, etc...is unfortunately pretty common, and goes for everyone who writes a 5 page note and then says 45mins level 4, etc...when you can learn the 200 words necessary to get the same that are more relevant.

                Insurance places love to build frictions in, but they can be mostly avoided with good systems. Have never done a peer-peer, but only 3 years of insurance experience. Have your pa, np, ma, do it.

                Comment


                • #23
                  Originally posted by burritos View Post
                  What percentage of the time is health insurance actually utilized as insurance?(ie unexpected accident). If 85% of us are just unhealthy persons and have chronic disease or have no resiliency to recover from xyz, isn't the insurance just groupon for health care?
                  No, its just improperly named. Its bankruptcy insurance.

                  Comment


                  • #24
                    Originally posted by Zaphod View Post

                    No, its just improperly named. Its bankruptcy insurance.
                    When I talk to work comp adjusters about why certain chronic claims persist, I basically tell them that if it weren't for the persistent benefits, these patients would be homeless. They usually get a laugh out of that even though I'm not joking, though I am trying to be funny.

                    Comment


                    • #25
                      Originally posted by Yowza View Post
                      I got an ERA for no payment today on a surgery I did last week. (Of course) my staff actually DID obtain a PA as required. Insurance companies can't pay their multi-million CEO salaries if they don't screw us every which way until we give up.

                      More man hours (and pay from me to my staff) for tracking down a payment we already jumped through hoops to get.

                      It's all bullsh$* imo.
                      I am fairly certain that you will get paid. If possible, can you update on what went wrong?
                      I doubt the CEO was involved but it is possible to eliminate glitches. Just because you had a PA, what kicked it out? Just curious and trying to cut your frustrations. My guess is irrelevant.

                      Comment


                      • #26
                        Originally posted by VagabondMD View Post
                        I have been working in appeals for Big Health for 6 months. These are some of the things that I have learned.

                        1. I rarely have to do peer-to-peers, but when I do, the ordering provider is generally way off the mark. On one occasion, a doc was asking me about my qualifications and such to put my name in the chart. I responded that if we are having this conversation, you should be more worried that your name is in the chart. Anyway, I no longer live in the world where I care if my name is in the chart.

                        2. Most docs seem to learn the insurance game quickly and learn how to avoid the time-wasting pitfalls that ensnare them. A small minority, and I can think of two specific surgeons, seem to invite the chaos and confrontations that come with not going with the flow.

                        3. I have zero incentive to block exams or procedures. Zero. My pay is not affected, not my bonus, not my promotional opportunities, etc. In fact, the only time I see that there is any grief in the job is when there is something that you deny that comes back to bite you.

                        4. There is a ton of fraud, waste, and abuse in the system. If no one was pushing back on it, the healthcare system would implode the US economy. I have seen a bill for a $270,000 MRI. Not to buy the machine, just one exam. I have seen a neurosurgeon order MRIs of the cervical, thoracic, and lumbar spine and bilateral shoulder and hip MRI arthrograms based on a single encounter with an essentially normal, healthy patient with minor aches and pains. Or 49 OB ultrasounds done in the course of a normal pregnancy. I have seen dozens of completely bogus ultrasound exam submitted by chiros and on and on. If everyone were competent, ethical, and reasonable, there would be no need for managed care. Newsflash, they are not.

                        5. An unfortunate side effect of utilization management is that due to technicalities of various kinds, well-intentioned people get held up in the process. Everyday, I see cases stuck in limbo because the office staff puts in the wrong information. You (the doc) might think that you have crossed all of your t's and dotted your i's, but if your MA puts in the wrong CPT code, everyone is screwed (you, the patient, and even the insurance staff).
                        Nice post, interesting to see perspective from the “other side”. Bilateral hip AND shoulder arthrograms, from a neurosurgeon… that’s incredible.

                        Comment


                        • #27
                          This year in particular, the denials we have been getting for procedures have been asinine. I received a denial for treatment, and the reason for denial was the exact reason the procedure is indicated. No option for appeal, no option for peer to peer. So patient gets screwed for a nonsensical denial with no recourse. On top of this, with some plans, if a pt offers to pay out of pocket for the treatment, their insurance can drop them from the policy. I have no idea how this is legal honestly.

                          Comment


                          • #28
                            Almost every one knows the buzz words to get tests covered from CT and MRIs. As a physician, I honestly do not feel it is my job to lie or pad the note in order to get a test covered. I think it is more appropriate to be honest and put an accurate reflection of the patients problems and my exam in the chart. I am personally not going to game the system, to play the insurance game. If the insurance does not cover it , it is more between the patient and their insurance than me as a physician.

                            Comment


                            • #29
                              Originally posted by Random1 View Post
                              Almost every one knows the buzz words to get tests covered from CT and MRIs. As a physician, I honestly do not feel it is my job to lie or pad the note in order to get a test covered. I think it is more appropriate to be honest and put an accurate reflection of the patients problems and my exam in the chart. I am personally not going to game the system, to play the insurance game. If the insurance does not cover it , it is more between the patient and their insurance than me as a physician.
                              Yep. Totally agree. I mean individually it just isnt enough to matter. Make a form prompting pts or your note should prompt you to inquire about all key things, if its there it is if not, oh well.

                              Comment


                              • #30
                                Thankfully, most of my payor mix is relatively reasonable and I don't have to do many P2P. However, united and cigna are just awful. The peer is another radiation oncologist but they don't get to use their judgement. They just tell me it is not in policy. The peer will not tell what their opinion of my treatment plan; they just read the policy. The other day I got a peer review that stated patient could only have radiosurgery for brain mets if less than 13 lesions were treated in the last year. When I asked where this came from (never heard anything remotely like that in the literature) the peer just said I don't know it is just the policy. I've had peers basically say what I want to do is reasonable but not in policy.

                                What's the point of a peer review if they aren't actually allowed to use their medical judgment?

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