Tuesday, September 30, 2008
The Patient Who Cries "Hemorrhage!"
There seems to be a common misunderstanding among patients of the term, hemorrhage. Frankly, to hemorrhage means to spew blood, internally or externally, from a bodily orifice or laceration so heavily that the flow cannot be stanched, thus requiring the sufferer to seek immediate, emergent care to avoid bleeding to death. That’s BLEEDING TO DEATH, people! Not a trickle, not bleeding that’s been occurring off and on for many days or months, definitely NOT bleeding despite which you can go about your daily business, including work and pigging out at your neighborhood barbecue joint, while your husband calls to tell me you’re presently hemorrhaging, and can I please call you. Say, what? And, if you’re truly hemorrhaging, you need to call 911, not the physician’s office. We aren’t equipped to care for hemorrhaging patients, so for those of you who like to use this term because you’ve seen how it snaps heads to attention on ER and Grey’s Anatomy and you think that uttering it will result in a same-day appointment at 3:30 on a Friday afternoon, let me be clear—say “hemorrhage,” and you’ll buy yourself an immediate directive to the ER. It’s at this point you usually concede, perhaps you’re not actually hemorrhaging, but you need to be seen because you’re off work today or you’re going out of town tomorrow. Too bad, you already said the magic word, and we do not negotiate with hemorrhaging patients.
Sunday, September 28, 2008
All Eyes on Your BMI, and That's Just the Least of It
For those of you who feel content that your chronic illness and/or health information is safe from the prying eyes of employers thanks to so-called privacy laws such as HIPAA, I have bad news for you. The truth is if your employer is self-insured, and many large employers are, the administrators of your health plan (executive level employees in your company) have access to the most sensitive information in your medical file due to a loophole giving carte-blanche access to plan administrators. Nothing is safe, and I should know since I worked on a corporate account for a private insurance company where a team of nurses was purchased along with the insurer’s administrative services basically to keep tabs on employees.
Now, in all fairness, the nurse team’s function was supposed to be all about health promotion and case management with the intention of cost-containment, not an unreasonable goal. The nurse team would telephone all plan members who were hospitalized or received services requiring preauthorization (e.g., elective surgeries, home health services, and durable medical equipment), again with the well-meaning goal of preventing readmission due to lapses in care or to ensure network compliance, both of which have been shown to dramatically decrease healthcare costs to the employer and in the long-term, for employees by reducing or at least steadying premiums. The team would also contact a list of plan members who had been identified via claims data as having certain “high-dollar” or “at risk” diagnoses, multiple hospital admissions, and variations in ancillary services, such as extensive physical or occupational therapy visits or other outpatient services. The most crucial list of people to contact were those poor souls unlucky enough to appear on the quarterly “high-dollar” claims list, meaning they exceeded an employer-set threshold and thus, required investigation.
Some might contend that it’s perfectly reasonable for an employer footing the monstrous bills of its employees to want to know what’s going on with them, namely how come these people are costing so much and what can be done to stop the bleeding. I can tell you that the answer is usually “nothing,” as a significant number of these individuals will likely be dead by the next quarter or are so acutely ill they require the most expensive treatment regimens (e.g., transplants, premature births, and lengthy intensive care stays). The problem comes in when a nurse team is directed to collect incidental information, such as one’s height and weight (enabling calculation of the fated BMI), lifestyle habits (namely smoking and alcohol use), and use of certain medications like antidepressants and enter it into an electronic health record that is made available to the employer’s plan administrators. This data doesn’t pose a problem in aggregate, but where I’ve seen it potentially blow employees’ cover and rip their privacy to shreds is when a plan member appears on one of the aforementioned trigger lists.
The plan administrators can pore over this individual information when assessing a high-dollar claim, and despite measures to conceal demographic information, I can attest that it’s not too difficult to decipher a member’s identity, and if this member has been particularly forthright and chatty with the nurse team, the employer has an even more complete picture of their “ill” health status. Of course, the information is supposed to be held in strict confidence, but when the plan administrators are your colleagues, there are far weightier issues at stake, such as job security and the potential for any number of discriminatory practices (e.g., denial of promotions, vacation/sick time, future benefits). Who’s to say your information won’t be leaked to your immediate supervisor, who then might become much more thorough in scrutinizing your job performance and presenteeism. I’ve been privy to many a conversation among plan administrators lamenting the number of sick employees on the payroll and how to avoid employing such people. The issue makes me squirm, and I’m in good health. Here’s hoping I remain so.
How do you keep your medical information secure from your employer’s prying eyes? First, be aware that self-insured employers have access to claims data, and whenever you consent to treatment that will be paid by your insurance company, you give consent for the treating provider to release all medical information necessary to get the claim paid. There’s nothing you can do to secure this information other than pay out of pocket in full for all of your healthcare costs, essentially going without insurance. However, what you can do is:
1) Keep mum when the nurse calls unless you have a compelling need for case management (i.e., you need complex care coordination among multiple providers or need a contact person for healthcare providers seeking preauthorization for urgent services). Be wary of courtesy or so-called health promotion calls where the nurse asks you seemingly innocuous questions about your health habits and offers wellness programs or incentives sponsored by your organization in exchange for your information. The truth is if the insurance company who employs the nurses really needed the information they were seeking to pay a claim, they would request it from the health care provider, not you. And, you can get information on employer-sponsored wellness incentives by contacting your human resources department directly or by actually reviewing your annual benefit enrollment information. There is some value in reading this document! When the phone rings, simply state that you don’t wish to discuss your healthcare information.
2) Avoid soliciting your employer’s help with a medical claim issue unless your condition really warrants it. When you ask your self-insured employer to become an intermediary between you and the insurance company, you essentially lay your health history bare. Be certain the care you’re seeking is worth the leverage your employer now enjoys by having your critical information. I was amazed at the random, copious, and often irrelevant medical information plan members divulged to their employers in written form in a desperate attempt to get their claims paid, many of which were for relatively small amounts.
3) Opt out of employer-sponsored wellness programs that require you to complete medical history or health questionnaires as a condition of participation. These programs are becoming increasingly popular with employers seeking to reduce healthcare costs. They give financial incentives, usually discounted premiums or gift certificates for health-related products and services. The rub is that the incentives are more often than not a pittance compared to what you have to give up—your medical privacy! Again, you have to decide if a $4 discount on your biweekly premium (in my individual case) or a $25 gift certificate is a fair exchange for your critical health information.
The last tip is probably the hardest for employees to resist because they so rarely get any “carrots” from their employers, and after all, it’s all in the name of health promotion, right? Umm, yes and no. Of course, employers recognize that a healthier workforce will reduce costs, and they give great lip-service to the health promotion/preventative care paradigm, but they fail to implement long-term, holistic solutions. I’ll discuss this issue in greater detail in a future post. For now, beware to whom you bare your healthcare stats, especially that nice nurse on the phone. She’s not just calling out of the goodness of her heart. She’s calling to check on yours, and she’s taking names.
Now, in all fairness, the nurse team’s function was supposed to be all about health promotion and case management with the intention of cost-containment, not an unreasonable goal. The nurse team would telephone all plan members who were hospitalized or received services requiring preauthorization (e.g., elective surgeries, home health services, and durable medical equipment), again with the well-meaning goal of preventing readmission due to lapses in care or to ensure network compliance, both of which have been shown to dramatically decrease healthcare costs to the employer and in the long-term, for employees by reducing or at least steadying premiums. The team would also contact a list of plan members who had been identified via claims data as having certain “high-dollar” or “at risk” diagnoses, multiple hospital admissions, and variations in ancillary services, such as extensive physical or occupational therapy visits or other outpatient services. The most crucial list of people to contact were those poor souls unlucky enough to appear on the quarterly “high-dollar” claims list, meaning they exceeded an employer-set threshold and thus, required investigation.
Some might contend that it’s perfectly reasonable for an employer footing the monstrous bills of its employees to want to know what’s going on with them, namely how come these people are costing so much and what can be done to stop the bleeding. I can tell you that the answer is usually “nothing,” as a significant number of these individuals will likely be dead by the next quarter or are so acutely ill they require the most expensive treatment regimens (e.g., transplants, premature births, and lengthy intensive care stays). The problem comes in when a nurse team is directed to collect incidental information, such as one’s height and weight (enabling calculation of the fated BMI), lifestyle habits (namely smoking and alcohol use), and use of certain medications like antidepressants and enter it into an electronic health record that is made available to the employer’s plan administrators. This data doesn’t pose a problem in aggregate, but where I’ve seen it potentially blow employees’ cover and rip their privacy to shreds is when a plan member appears on one of the aforementioned trigger lists.
The plan administrators can pore over this individual information when assessing a high-dollar claim, and despite measures to conceal demographic information, I can attest that it’s not too difficult to decipher a member’s identity, and if this member has been particularly forthright and chatty with the nurse team, the employer has an even more complete picture of their “ill” health status. Of course, the information is supposed to be held in strict confidence, but when the plan administrators are your colleagues, there are far weightier issues at stake, such as job security and the potential for any number of discriminatory practices (e.g., denial of promotions, vacation/sick time, future benefits). Who’s to say your information won’t be leaked to your immediate supervisor, who then might become much more thorough in scrutinizing your job performance and presenteeism. I’ve been privy to many a conversation among plan administrators lamenting the number of sick employees on the payroll and how to avoid employing such people. The issue makes me squirm, and I’m in good health. Here’s hoping I remain so.
How do you keep your medical information secure from your employer’s prying eyes? First, be aware that self-insured employers have access to claims data, and whenever you consent to treatment that will be paid by your insurance company, you give consent for the treating provider to release all medical information necessary to get the claim paid. There’s nothing you can do to secure this information other than pay out of pocket in full for all of your healthcare costs, essentially going without insurance. However, what you can do is:
1) Keep mum when the nurse calls unless you have a compelling need for case management (i.e., you need complex care coordination among multiple providers or need a contact person for healthcare providers seeking preauthorization for urgent services). Be wary of courtesy or so-called health promotion calls where the nurse asks you seemingly innocuous questions about your health habits and offers wellness programs or incentives sponsored by your organization in exchange for your information. The truth is if the insurance company who employs the nurses really needed the information they were seeking to pay a claim, they would request it from the health care provider, not you. And, you can get information on employer-sponsored wellness incentives by contacting your human resources department directly or by actually reviewing your annual benefit enrollment information. There is some value in reading this document! When the phone rings, simply state that you don’t wish to discuss your healthcare information.
2) Avoid soliciting your employer’s help with a medical claim issue unless your condition really warrants it. When you ask your self-insured employer to become an intermediary between you and the insurance company, you essentially lay your health history bare. Be certain the care you’re seeking is worth the leverage your employer now enjoys by having your critical information. I was amazed at the random, copious, and often irrelevant medical information plan members divulged to their employers in written form in a desperate attempt to get their claims paid, many of which were for relatively small amounts.
3) Opt out of employer-sponsored wellness programs that require you to complete medical history or health questionnaires as a condition of participation. These programs are becoming increasingly popular with employers seeking to reduce healthcare costs. They give financial incentives, usually discounted premiums or gift certificates for health-related products and services. The rub is that the incentives are more often than not a pittance compared to what you have to give up—your medical privacy! Again, you have to decide if a $4 discount on your biweekly premium (in my individual case) or a $25 gift certificate is a fair exchange for your critical health information.
The last tip is probably the hardest for employees to resist because they so rarely get any “carrots” from their employers, and after all, it’s all in the name of health promotion, right? Umm, yes and no. Of course, employers recognize that a healthier workforce will reduce costs, and they give great lip-service to the health promotion/preventative care paradigm, but they fail to implement long-term, holistic solutions. I’ll discuss this issue in greater detail in a future post. For now, beware to whom you bare your healthcare stats, especially that nice nurse on the phone. She’s not just calling out of the goodness of her heart. She’s calling to check on yours, and she’s taking names.
Wednesday, September 24, 2008
How to Escape the Hospital Alive: Some Practical Tips
1) Indulge your germ-phobic tendencies. Quite frankly, hospitals are filthy places, and the people who work in them can easily pass the muck among patients as they go about their daily jobs. This includes nurses, nurse aides, physical and respiratory therapists, laboratory/radiology personnel, dietary workers, custodians, and most certainly physicians. In response to alarming outbreaks of multi-drug resistant bacteria, many facilities have established infection control protocols to combat the problem. Nevertheless, you should insist that all staff wash their hands before touching you, especially if they are assessing IV lines, open wounds, urinary catheters, or any tubing that enters your body. Donning a pair of gloves alone is not sufficient, and you should not be shy about voicing your opinion. Moreover, ask physicians or anyone with a stethoscope to swab the diaphragm (the circle-shaped part that touches the body) with an alcohol prep before they place it on your skin. These practices will reduce your chances of acquiring a potentially life-threatening nosocomial (hospital-acquired) infection.
2) Question all medications before you take them or before they’re administered to you. ALL personnel should ask you to state your name (if able) and should double-check your demographic wrist band before administering any medication. The same goes for drug allergies. If you are given a pill that looks unfamiliar, ask the name, why it was prescribed, and how long you will be taking it. If the nurse comes in to give you an injection or IV medication, definitely question the medication. Drugs administered by injection into the subcutaneous tissue, the muscle, or directly into a vein take effect much more quickly than those given orally, and errors can prove fatal in a matter of seconds. This is especially true for blood products. At least two licensed individuals (usually nurses) should match the blood product information to your identification and “blood” band information. Wrist bands are critical for identification purposes, particularly if you become incapacitated. You may find them unfashionable, but you literally risk your life by refusing to wear them.
3) Demand a healing itinerary and question deviations from the plan. You have the right to participate in your health care plan and to question it at any time. Physicians, nurses, and ancillary personnel should explain every step in the healing process, including your diagnosis, procedures and services to alleviate your problem, as well as the expected healing trajectory. For instance, if someone comes to draw your blood or take you for an x-ray when your physician or nurse has not informed you that these services are needed, do not hesitate to refuse and ask for clarification. With multiple physicians and several nursing shifts involved in a patient’s care, orders can be duplicated, cancelled, or changed within a short period of time, thereby increasing the chance of miscommunication. Your care plan is constantly evolving, and despite how powerless you may feel in the hospital setting, you remain the captain of your healing ship. By speaking up, you could very well avoid an unneeded and potentially harmful test!
4) Have a friend or family member stay with you as much as possible. Hospitals vary in their visitation policies, and specialized units like critical or intensive care areas may be very strict, but having a personal advocate or a second pair of vicarious eyes to watch after you where allowed is in your best interest. He or she can help ease your mind that your care is going as planned, especially in the immediate hours following a surgery or procedure when you are still heavily sedated. Your advocate can also ensure that your needs are met in a timely fashion, such as summoning help when you are in pain or need assistance using the restroom and cannot find the call button. Many a hip has been broken and a hospital stay prolonged when an incoherent, weak patient attempted to get out of bed on her own because she could not get help for any number of reasons. An advocate is often a family member who is aware of your medical history and can act as a decision-maker should you be come incapacitated. However, you should be aware that due to privacy concerns, the healthcare team cannot discuss your care in detail with anyone at your bedside unless you have given express permission.
5) Check out of the “hosp-i-tel” as soon as you’re medically stable. The more time you spend in the hospital, the more likely you are to develop complications, such as pneumonia and urinary tract infections, and to become a victim of a dreaded medication error. Everyone excoriates managed care for encouraging ever-shorter hospital stays, but at least part of their reasoning is sound—people get sicker the longer they stay, which leads to poorer health outcomes and higher costs. In fact, the Centers for Medicare and Medicaid Services (CMS) recently announced it will no longer reimburse hospitals for multiple hospital-acquired complications, and private insurers are following suit. The hospital is no place to stay well, and since many services including long-term IV antibiotics, complex wound care, and physical therapy can be done on an outpatient basis, even within the home setting, it pays financially and physically to leave without delay as soon as the acute phase of your illness/injury has been resolved.
These tips are not meant to imply that hospitals are places to avoid at all costs, nor that you should be exceedingly paranoid when you enter one. Hospitals are great places to be when you are acutely ill or injured, and most healthcare workers strive to provide the highest quality of care. Housing many patients with nasty bugs and compromised immune systems in close quarters presents a significant challenge—how to not only heal the sick, but keep them from getting even sicker. It is no easy task given the unique environment and other factors like the critical nursing shortage. You may think that by asserting yourself you will be labeled a “problem” patient. If you express your concerns politely, most personnel will be happy to explain things in detail and comply with your requests. Some of us will be downright delighted to interact with such a well-informed patient! Keep in mind that in most cases, you are only asking healthcare workers to do their jobs correctly. This is not an unreasonable request. In all honesty, after all your effort you may be labeled a “problem” patient. Still, better to be a “problem” patient than a dead or maimed one, no?
2) Question all medications before you take them or before they’re administered to you. ALL personnel should ask you to state your name (if able) and should double-check your demographic wrist band before administering any medication. The same goes for drug allergies. If you are given a pill that looks unfamiliar, ask the name, why it was prescribed, and how long you will be taking it. If the nurse comes in to give you an injection or IV medication, definitely question the medication. Drugs administered by injection into the subcutaneous tissue, the muscle, or directly into a vein take effect much more quickly than those given orally, and errors can prove fatal in a matter of seconds. This is especially true for blood products. At least two licensed individuals (usually nurses) should match the blood product information to your identification and “blood” band information. Wrist bands are critical for identification purposes, particularly if you become incapacitated. You may find them unfashionable, but you literally risk your life by refusing to wear them.
3) Demand a healing itinerary and question deviations from the plan. You have the right to participate in your health care plan and to question it at any time. Physicians, nurses, and ancillary personnel should explain every step in the healing process, including your diagnosis, procedures and services to alleviate your problem, as well as the expected healing trajectory. For instance, if someone comes to draw your blood or take you for an x-ray when your physician or nurse has not informed you that these services are needed, do not hesitate to refuse and ask for clarification. With multiple physicians and several nursing shifts involved in a patient’s care, orders can be duplicated, cancelled, or changed within a short period of time, thereby increasing the chance of miscommunication. Your care plan is constantly evolving, and despite how powerless you may feel in the hospital setting, you remain the captain of your healing ship. By speaking up, you could very well avoid an unneeded and potentially harmful test!
4) Have a friend or family member stay with you as much as possible. Hospitals vary in their visitation policies, and specialized units like critical or intensive care areas may be very strict, but having a personal advocate or a second pair of vicarious eyes to watch after you where allowed is in your best interest. He or she can help ease your mind that your care is going as planned, especially in the immediate hours following a surgery or procedure when you are still heavily sedated. Your advocate can also ensure that your needs are met in a timely fashion, such as summoning help when you are in pain or need assistance using the restroom and cannot find the call button. Many a hip has been broken and a hospital stay prolonged when an incoherent, weak patient attempted to get out of bed on her own because she could not get help for any number of reasons. An advocate is often a family member who is aware of your medical history and can act as a decision-maker should you be come incapacitated. However, you should be aware that due to privacy concerns, the healthcare team cannot discuss your care in detail with anyone at your bedside unless you have given express permission.
5) Check out of the “hosp-i-tel” as soon as you’re medically stable. The more time you spend in the hospital, the more likely you are to develop complications, such as pneumonia and urinary tract infections, and to become a victim of a dreaded medication error. Everyone excoriates managed care for encouraging ever-shorter hospital stays, but at least part of their reasoning is sound—people get sicker the longer they stay, which leads to poorer health outcomes and higher costs. In fact, the Centers for Medicare and Medicaid Services (CMS) recently announced it will no longer reimburse hospitals for multiple hospital-acquired complications, and private insurers are following suit. The hospital is no place to stay well, and since many services including long-term IV antibiotics, complex wound care, and physical therapy can be done on an outpatient basis, even within the home setting, it pays financially and physically to leave without delay as soon as the acute phase of your illness/injury has been resolved.
These tips are not meant to imply that hospitals are places to avoid at all costs, nor that you should be exceedingly paranoid when you enter one. Hospitals are great places to be when you are acutely ill or injured, and most healthcare workers strive to provide the highest quality of care. Housing many patients with nasty bugs and compromised immune systems in close quarters presents a significant challenge—how to not only heal the sick, but keep them from getting even sicker. It is no easy task given the unique environment and other factors like the critical nursing shortage. You may think that by asserting yourself you will be labeled a “problem” patient. If you express your concerns politely, most personnel will be happy to explain things in detail and comply with your requests. Some of us will be downright delighted to interact with such a well-informed patient! Keep in mind that in most cases, you are only asking healthcare workers to do their jobs correctly. This is not an unreasonable request. In all honesty, after all your effort you may be labeled a “problem” patient. Still, better to be a “problem” patient than a dead or maimed one, no?
Sunday, September 21, 2008
An Open Letter to the Department of Health and Human Services Regarding Proposed Rule "Provider Conscience Regulation"
I am writing in opposition to the Department of Health and Human Services’ proposed “Provider Conscience Regulation.” This rule represents nothing more than another dastardly attempt by the current administration to pander to its right-wing base under the disingenuous guise of ensuring a more diverse healthcare workforce. This rule, if enacted, will violate the public’s right to receive unbiased medical information, all to assuage the so-called consciences of ideological bigots.
First, the proposed rule indicates that there exists a pervasive attitude of discriminatory hostility toward healthcare workers who refuse to participate in procedures to which they are morally opposed. As a registered nurse with over twelve years of experience who has worked in various practice settings in multiple states, I have never witnessed such an attitude. Where is the widespread evidence that healthcare workers are being fired and/or barred from professional organizations because of their individual beliefs? The rule also implies that professional organizations are misguided in setting standards for their practitioners that trump individual conscience. Professional standards are designed to encompass the broadest scope of ethical practice that serves the greatest public good. If practitioners cannot adhere to these standards due to conscientious objection, they need not belong to them.
Second, the proposed rule purports to create a more diverse healthcare workforce by ensuring that workers’ individual consciences, however biased or medically inaccurate they may be, will not be an issue in their employment. This is the most disingenuous portion of the entire regulation. A genuine way to create and sustain a more diverse healthcare workforce would involve a federal and state commitment to funding educational and mentoring programs, namely within communities of color and lower-income regions. In its current form, the only diversity the proposed rule aims to ensure is the unfettered tolerance of workers who oppose abortion and certain forms of birth control, both of which are critical women’s health issues.
Indeed, since abortion and sterilization are the only specific procedures mentioned throughout the proposed rule, one can only assume that these services are the ones the rule was designed to address. In this case, the rule is needless since regulations already exist to protect morally-opposed practitioners from being required to participate in the aforementioned procedures. Nevertheless, since the proposed rule does refer to “other medical procedures” to which practitioners may be opposed, I proffer the following situations for consideration. Does this rule aim to protect healthcare workers who refuse to administer blood products, participate in organ procurement and donation, perform CPR on a terminally ill patient, or assist with the provision of life-preserving care to a brain-dead patient on the basis of individual conscience and/or religious conviction? Furthermore, does it aim to protect those individual workers who wish to provide information about birth control, abortion, and sterilization to patients on the basis of their individual consciences within an organization that is wholly opposed on religious grounds, such as the many religious-affiliated hospitals referred to in the proposed rule?
Third, the proposed rule erroneously states that it will not limit patient access to healthcare. In fact, it will further reduce access to care, particularly for women seeking family-planning services, in rural areas where practitioners are few and far between or where religious-affiliated healthcare organizations dominate. It will disproportionately impact poor women who lack transportation and resources to travel to receive unbiased healthcare they rightfully deserve within their own communities.
This rule is concerned about the violation of individual conscience; I am concerned about the violation of public trust in the healthcare profession. As a nurse who witnesses firsthand the disastrous effects of federally funded abstinence-only education programs and faith-based organizations (i.e., crisis pregnancy centers) committed to ideological extremism, I am appalled that this administration condones clinical misinformation and the omission of critical healthcare options to the public in the name of individual conscience. Since when in a civilized democracy do the ideological persuasions of a select few get to determine the dissemination of information that impacts public health on such a grand scale? I implore the Department of Health and Human Services to consider the dire ramifications of championing the ideological extremism of individual workers, as well as state-sponsored coercion of healthcare entities to comply with this extremism as a condition for receiving federal funds. If enacted, the “Provider Conscience Regulation” will deal a direct blow to the public’s right to receive medically accurate information and options. It will flout professional standards of ethical practice and particularly endanger the lives of women and girls who will be at the mercy of ideological extremists in the examination room when they are most vulnerable. I strongly urge the Department of Health and Human Services to retract this proposed regulation. To do otherwise would dishonor and violate the public trust in the healthcare professions, a truly unconscionable act.
First, the proposed rule indicates that there exists a pervasive attitude of discriminatory hostility toward healthcare workers who refuse to participate in procedures to which they are morally opposed. As a registered nurse with over twelve years of experience who has worked in various practice settings in multiple states, I have never witnessed such an attitude. Where is the widespread evidence that healthcare workers are being fired and/or barred from professional organizations because of their individual beliefs? The rule also implies that professional organizations are misguided in setting standards for their practitioners that trump individual conscience. Professional standards are designed to encompass the broadest scope of ethical practice that serves the greatest public good. If practitioners cannot adhere to these standards due to conscientious objection, they need not belong to them.
Second, the proposed rule purports to create a more diverse healthcare workforce by ensuring that workers’ individual consciences, however biased or medically inaccurate they may be, will not be an issue in their employment. This is the most disingenuous portion of the entire regulation. A genuine way to create and sustain a more diverse healthcare workforce would involve a federal and state commitment to funding educational and mentoring programs, namely within communities of color and lower-income regions. In its current form, the only diversity the proposed rule aims to ensure is the unfettered tolerance of workers who oppose abortion and certain forms of birth control, both of which are critical women’s health issues.
Indeed, since abortion and sterilization are the only specific procedures mentioned throughout the proposed rule, one can only assume that these services are the ones the rule was designed to address. In this case, the rule is needless since regulations already exist to protect morally-opposed practitioners from being required to participate in the aforementioned procedures. Nevertheless, since the proposed rule does refer to “other medical procedures” to which practitioners may be opposed, I proffer the following situations for consideration. Does this rule aim to protect healthcare workers who refuse to administer blood products, participate in organ procurement and donation, perform CPR on a terminally ill patient, or assist with the provision of life-preserving care to a brain-dead patient on the basis of individual conscience and/or religious conviction? Furthermore, does it aim to protect those individual workers who wish to provide information about birth control, abortion, and sterilization to patients on the basis of their individual consciences within an organization that is wholly opposed on religious grounds, such as the many religious-affiliated hospitals referred to in the proposed rule?
Third, the proposed rule erroneously states that it will not limit patient access to healthcare. In fact, it will further reduce access to care, particularly for women seeking family-planning services, in rural areas where practitioners are few and far between or where religious-affiliated healthcare organizations dominate. It will disproportionately impact poor women who lack transportation and resources to travel to receive unbiased healthcare they rightfully deserve within their own communities.
This rule is concerned about the violation of individual conscience; I am concerned about the violation of public trust in the healthcare profession. As a nurse who witnesses firsthand the disastrous effects of federally funded abstinence-only education programs and faith-based organizations (i.e., crisis pregnancy centers) committed to ideological extremism, I am appalled that this administration condones clinical misinformation and the omission of critical healthcare options to the public in the name of individual conscience. Since when in a civilized democracy do the ideological persuasions of a select few get to determine the dissemination of information that impacts public health on such a grand scale? I implore the Department of Health and Human Services to consider the dire ramifications of championing the ideological extremism of individual workers, as well as state-sponsored coercion of healthcare entities to comply with this extremism as a condition for receiving federal funds. If enacted, the “Provider Conscience Regulation” will deal a direct blow to the public’s right to receive medically accurate information and options. It will flout professional standards of ethical practice and particularly endanger the lives of women and girls who will be at the mercy of ideological extremists in the examination room when they are most vulnerable. I strongly urge the Department of Health and Human Services to retract this proposed regulation. To do otherwise would dishonor and violate the public trust in the healthcare professions, a truly unconscionable act.
Wednesday, September 10, 2008
Renegade RN Mouths Off to Big Pharma
Working in an office-based setting, I frequently encounter pharmaceutical reps hawking their expensive brand-name drugs all in the name of improved health outcomes or some other lofty, disingenuous goal. While I don’t fault them for doing their job in trying to sell their company’s product, I always feel like I’m being hustled, and I regard whatever they say with a huge dose of skepticism. I don’t like being inundated with useless branded paraphernalia. I mean, who really wants to write with a pen that has the words “bacterial vaginosis” and “trichomoniasis” in bold letters? Talk about inducing one heck of a writer’s block. How many tape measures and two-ounce lotion bottles does one person need, and it’s cheap, nasty-smelling lotion to boot? No offense to the oral contraceptive hustlers, but do you really think women can’t wait to get their hands on a cheap, neon-colored, zippered bag emblazoned with a drug logo, much less carry one around? Trust me, it’s not Louis Vuitton, so don’t play it up as some darling freebie. I will be embarrassed for you and shove your samples to the back of the cabinet. It serves you right for wasting my time with your endless, inane questions, such as:
1) What kind of feedback are you getting on my Product X? Ummm, none. What did you expect? It’s a vitamin, not a cure for cancer.
2) What will it take to increase prescriptions for my Product X? Duh, decrease your price point. We both know there are almost always comparable generics at greatly reduced prices, and insurance companies’ Tier II and III drug co-pays are prohibitively high for most people. Don’t make me state the obvious; it only annoys me further.
3) Why are you prescribing my competitor’s Product Y when my Product X is superior? Well, you see there’s really no definitive evidence that Product X is superior to Product Y, and in fact, your competitor was just here and gave me the same spiel, but his product was, of course, the superior one. Yeah, yeah, I know you’ve got your studies, but they were partially, if not fully, funded by your company, and your company had a vested interest in the results, and in some cases even controlled whether negative results were reported, so you have zero credibility with me on this basis. Tell it to the FDA. I’m sure they’ll get right on it. Better yet, advertise this superiority fallacy to the uninformed and apathetic public. Then, I’ll get the chance to reeducate all of them, which I relish.
4) Why aren’t you eating the lunch I brought? Because I’m vegetarian, and you brought barbecue. You hawk blood pressure medication. Do you have any idea how much fat and salt are in that cured beef? What kind of health paradigm are you pushing? Yeah, I said paradigm.
5) When will the doctor be available to speak with me? I don’t know. I’m not his keeper, and I’ve already got first, second, and third dibs on speaking with him.
6) Can I put up a poster, leave some flyers, staple my card to the wall by the samples? Knock yourself out, but please, as tempted as you may be, don’t screw around with your competitor’s stuff. They’ll complain and retaliate, and it creates a mess for me to clean up. Do us all a favor and duke it out in the parking lot before you come to the office. Whoever wins gets to decorate for the day!
I concede that your samples do help some people initially with the cost of their medications, the key word being initially. But, the truth is that many of these people will not be able to afford the out-of-pocket cost of the drug once the samples run out, even if they have insurance. This should not be a shock to you, so please spare me the deer-in-the-headlights look of surprise. Inevitably, we will have to switch these people to a generic alternative or keep giving them samples, neither of which, I realize, makes any money for you or your company. I am fully cognizant of your conundrum, but I DON’T care. My duty is to the patient and his/her holistic well-being, not to your personal profit margin or your company’s bottom line. No amount of cheap crap you dump on my desk, company-sponsored literature you shove in my face, or food you provide, even if it’s vegetarian, will influence me to favor your branded product over any other, unless there’s some absolutely compelling reason, which there rarely is. You need a reality check, and this is it. It’s time to embrace a new paradigm. Give all the drama a rest, leave your samples, and go in peace.
1) What kind of feedback are you getting on my Product X? Ummm, none. What did you expect? It’s a vitamin, not a cure for cancer.
2) What will it take to increase prescriptions for my Product X? Duh, decrease your price point. We both know there are almost always comparable generics at greatly reduced prices, and insurance companies’ Tier II and III drug co-pays are prohibitively high for most people. Don’t make me state the obvious; it only annoys me further.
3) Why are you prescribing my competitor’s Product Y when my Product X is superior? Well, you see there’s really no definitive evidence that Product X is superior to Product Y, and in fact, your competitor was just here and gave me the same spiel, but his product was, of course, the superior one. Yeah, yeah, I know you’ve got your studies, but they were partially, if not fully, funded by your company, and your company had a vested interest in the results, and in some cases even controlled whether negative results were reported, so you have zero credibility with me on this basis. Tell it to the FDA. I’m sure they’ll get right on it. Better yet, advertise this superiority fallacy to the uninformed and apathetic public. Then, I’ll get the chance to reeducate all of them, which I relish.
4) Why aren’t you eating the lunch I brought? Because I’m vegetarian, and you brought barbecue. You hawk blood pressure medication. Do you have any idea how much fat and salt are in that cured beef? What kind of health paradigm are you pushing? Yeah, I said paradigm.
5) When will the doctor be available to speak with me? I don’t know. I’m not his keeper, and I’ve already got first, second, and third dibs on speaking with him.
6) Can I put up a poster, leave some flyers, staple my card to the wall by the samples? Knock yourself out, but please, as tempted as you may be, don’t screw around with your competitor’s stuff. They’ll complain and retaliate, and it creates a mess for me to clean up. Do us all a favor and duke it out in the parking lot before you come to the office. Whoever wins gets to decorate for the day!
I concede that your samples do help some people initially with the cost of their medications, the key word being initially. But, the truth is that many of these people will not be able to afford the out-of-pocket cost of the drug once the samples run out, even if they have insurance. This should not be a shock to you, so please spare me the deer-in-the-headlights look of surprise. Inevitably, we will have to switch these people to a generic alternative or keep giving them samples, neither of which, I realize, makes any money for you or your company. I am fully cognizant of your conundrum, but I DON’T care. My duty is to the patient and his/her holistic well-being, not to your personal profit margin or your company’s bottom line. No amount of cheap crap you dump on my desk, company-sponsored literature you shove in my face, or food you provide, even if it’s vegetarian, will influence me to favor your branded product over any other, unless there’s some absolutely compelling reason, which there rarely is. You need a reality check, and this is it. It’s time to embrace a new paradigm. Give all the drama a rest, leave your samples, and go in peace.
Tuesday, September 9, 2008
I Love My HSA, So Far.
When I decided to work as a contractor at the beginning of this year, I faced the daunting task of buying an individual health insurance policy. Since I am relatively young and healthy and need only to insure myself, I opted for a high deductible health plan (HDHP) with a health savings account (HSA). My individual plan has a $2500 annual deductible, 10% coinsurance for in-network care, and a lifetime maximum of $5 million for the bargain price of $145 per month—not too shabby a deal with continuously escalating healthcare costs. The downside is, of course, that I must pay out-of-pocket costs upfront until I meet the deductible, and there is no out-of-pocket yearly maximum for my policy. Also, preventative care is subject to the deductible on my individual plan, whereas employer-sponsored HDHPs with associated HSAs often cover these services at 100% to encourage their employees not to forgo crucial screening check-ups. I don’t have mental health or maternity coverage, and the former, I could certainly use!
My prescription medications are subject to the deductible before tier level co-pays kick in, which means I’ve done a lot of shopping around at online pharmacies and large retail chains to find the best price on the generic medication that I take regularly. I just scored an awesome three-month supply deal for only $12 at Walgreens. It entails purchasing a yearly membership for $20, but the savings alone slashes my annual drug bill by 75%. I probably won’t even bother submitting these claims to the insurance company. Unless I face a serious illness or injury, I don’t anticipate ever meeting my annual deductible.
Why am I in love with my HSA so far? I enjoy a relatively low monthly premium in exchange for paying my medical costs upfront, which are few and far between and hopefully will remain that way. Given my genetic luck and consistent lifestyle habits (e.g., healthy diet, regular and strenuous exercise, and multiple stress-relieving activities—yoga, psychotherapy, journaling) thus far, I stand to gain financially by investing my HSA money for the long-term while budgeting for generally predictable healthcare costs on a yearly basis. Should I incur any medical expenses that I can’t pay without going into debt, I can always access the tax-free money in my HSA account by submitting my meticulously-kept receipts. I contributed the 2008 yearly maximum of $2900 to my HSA account earlier this year, which reduces my taxable income, and I plan to continue contributing the yearly maximum in the future. My HSA is currently invested in Vanguard’s Total Stock Market Index Fund. My goal is to use this fund as another retirement planning vehicle. With approximately 30 years to go until I reach full retirement age, I could amass a pretty substantial kitty that would cover healthcare costs on a tax-free basis.
Do I recommend HDHPs/HSAs for everyone? Of course, not. They are terrible for the working poor, which includes many so-called “middle-class” people and certainly for people with chronic medical conditions that require expensive treatment regimens. I’m also concerned that this model of healthcare coverage disincentivizes wellness screenings and routine care among people who desperately need it, but cannot afford it. If these plans become the norm, and they are being aggressively marketed by the big insurance companies (I should know since I worked for one), I worry that we’ll see a marked decrease in public health over the long-term. Who do HDHPs/HSAs benefit? The healthy and wealthy. I’m by no means wealthy, but I’m privileged socioeconomically in that I wouldn’t be destroyed financially if I had a health-related setback. For the record, I fully support universal, single-payer healthcare. Until then, I have chosen the most beneficial coverage option for my individual situation.
My prescription medications are subject to the deductible before tier level co-pays kick in, which means I’ve done a lot of shopping around at online pharmacies and large retail chains to find the best price on the generic medication that I take regularly. I just scored an awesome three-month supply deal for only $12 at Walgreens. It entails purchasing a yearly membership for $20, but the savings alone slashes my annual drug bill by 75%. I probably won’t even bother submitting these claims to the insurance company. Unless I face a serious illness or injury, I don’t anticipate ever meeting my annual deductible.
Why am I in love with my HSA so far? I enjoy a relatively low monthly premium in exchange for paying my medical costs upfront, which are few and far between and hopefully will remain that way. Given my genetic luck and consistent lifestyle habits (e.g., healthy diet, regular and strenuous exercise, and multiple stress-relieving activities—yoga, psychotherapy, journaling) thus far, I stand to gain financially by investing my HSA money for the long-term while budgeting for generally predictable healthcare costs on a yearly basis. Should I incur any medical expenses that I can’t pay without going into debt, I can always access the tax-free money in my HSA account by submitting my meticulously-kept receipts. I contributed the 2008 yearly maximum of $2900 to my HSA account earlier this year, which reduces my taxable income, and I plan to continue contributing the yearly maximum in the future. My HSA is currently invested in Vanguard’s Total Stock Market Index Fund. My goal is to use this fund as another retirement planning vehicle. With approximately 30 years to go until I reach full retirement age, I could amass a pretty substantial kitty that would cover healthcare costs on a tax-free basis.
Do I recommend HDHPs/HSAs for everyone? Of course, not. They are terrible for the working poor, which includes many so-called “middle-class” people and certainly for people with chronic medical conditions that require expensive treatment regimens. I’m also concerned that this model of healthcare coverage disincentivizes wellness screenings and routine care among people who desperately need it, but cannot afford it. If these plans become the norm, and they are being aggressively marketed by the big insurance companies (I should know since I worked for one), I worry that we’ll see a marked decrease in public health over the long-term. Who do HDHPs/HSAs benefit? The healthy and wealthy. I’m by no means wealthy, but I’m privileged socioeconomically in that I wouldn’t be destroyed financially if I had a health-related setback. For the record, I fully support universal, single-payer healthcare. Until then, I have chosen the most beneficial coverage option for my individual situation.
Thursday, September 4, 2008
We Appreciate Your Call! For Call-In Concerns, Make Nice with the Nurse.
If you are an established and generally compliant (clinically and financially) patient, your physician’s office will often be willing to handle minor concerns over the phone by issuing medical device, calling in prescriptions, and making referrals to other providers. You will usually speak with an office nurse or other designated personnel who follow protocols approved by your provider. As someone who’s been on the receiving end of countless call-in requests, I give the following nuggets of wisdom that will greatly enhance your chances of a successful outcome (i.e., no in-person visit and no co-pay required).
The nurse is not your BFF, your confidante, or your personal concierge. Nurse Ratched acolytes aside, most of us are professionals who endeavor to alleviate your concerns in as timely and compassionate a manner as possible. Your story is important, but we need only the high points. Be prepared to give a concise account of a specific problem. A litany of complaints always requires face time with a practitioner, and you will need to make an appointment no matter how vehemently you protest. Likewise, a problem that’s been going on for months means you must be seen. Do NOT call the office for information that can easily be found elsewhere (i.e., phone numbers to local hospitals, other health care providers, pharmacies, or insurance companies). We are not 411.
The nurse is not a repository for your ever-changing demographic information. In large practices particularly, or if you have failed to make regular appearances at the office, she will likely not recognize you by any of your first and/or last name combinations, much less your nick- or preferred name. Choose a name and stick with it. As much as it may pain you, use the name on your insurance card. This makes finding your chart easier and lessens the likelihood that your records will be misfiled and that your insurance claim will be rejected. Always use the same name when you call in and provide other demographic information, such as your date of birth or social security number, to help with identification.
If you call for a prescription refill or believe your condition may warrant a prescription, be prepared to provide a pharmacy number. Likewise, if you want an order faxed for outpatient testing, provide the fax number. I cannot emphasize enough how much more quickly your concern will be handled, if you follow this step. Leaving me a message indicating that you want a prescription called in to the pharmacy “on the corner of such and such” means that your concern goes to the bottom of the 20-deep message pile where I will research it at my leisure.
Do your own bureaucratic homework and know your insurance coverage. The nurse cannot be expected to know offhand what services your policy covers or which pharmacies and providers are in-network. This is your responsibility.
Answer the phone when the nurse returns your call. If you cannot take the call, listen to your message before calling the office again as it may address your concern in full. Resist the temptation to express indignation that the nurse is not available to talk with you when she “just called.” I assure you she’s already on the phone with someone else in the 20-deep message pile.
Be courteous to the receptionist and all other administrative staff. Trust me, when your concern falls into the gray area between handling over the phone versus needing an in-person evaluation, we’re all more likely to bend over backward to help you if you’re nice to everyone. Acting like a petulant child or pulling a Medusa-on-Crack routine will get you noticed, but not in a good way. Most likely, you’ll get an invitation to perform your routine in the office as we won’t be doing you any phone favors.
Be mindful of the timing of your call. Calling at 3:30 p.m. on a Friday afternoon probably means you won’t be called back until after the weekend. Call the office when it first opens for the best chance of having your call returned promptly. Be aware that some offices have designated call-back times or triage schedules, meaning that some callbacks may not occur for 24-48 hours.
Call for yourself, not your friends. The nurse cannot comment on your friend’s condition because s/he is not our patient, nor would we discuss it with you anyway. Besides, the nurse knows it’s really “you” you’re calling about. And, for the record, a thorough nurse will make a notation in your chart about your “friend’s” problem, so that we can compare it to your strangely similar complaint in the future.
Show up for your regular appointments. Don’t even think of calling in a request or concern when you’ve “no-showed” for your last three scheduled appointments. Moreover, don’t give me the “I’ve-been-his/her-patient-for-ten-years line,” especially if you haven’t been seen in the last twelve months. This leads me to believe you’re probably going to ask for something unreasonable, and you are.
Last but not least, keep up with your stuff, namely the prescriptions given to you at your last visit. There’s a reason we ask you to submit them to the pharmacy right away. You lose them like errant children who can never find their homework! We then have to call them in to your pharmacy. You have created double work for us in this situation. We realize mistakes happen, and a gracious request certainly works in your favor, but a haughty, adolescent attitude, not so much.
If you keep it short, real, and together, you'll more than likely get what you want and need without the face-time hassle.
The nurse is not your BFF, your confidante, or your personal concierge. Nurse Ratched acolytes aside, most of us are professionals who endeavor to alleviate your concerns in as timely and compassionate a manner as possible. Your story is important, but we need only the high points. Be prepared to give a concise account of a specific problem. A litany of complaints always requires face time with a practitioner, and you will need to make an appointment no matter how vehemently you protest. Likewise, a problem that’s been going on for months means you must be seen. Do NOT call the office for information that can easily be found elsewhere (i.e., phone numbers to local hospitals, other health care providers, pharmacies, or insurance companies). We are not 411.
The nurse is not a repository for your ever-changing demographic information. In large practices particularly, or if you have failed to make regular appearances at the office, she will likely not recognize you by any of your first and/or last name combinations, much less your nick- or preferred name. Choose a name and stick with it. As much as it may pain you, use the name on your insurance card. This makes finding your chart easier and lessens the likelihood that your records will be misfiled and that your insurance claim will be rejected. Always use the same name when you call in and provide other demographic information, such as your date of birth or social security number, to help with identification.
If you call for a prescription refill or believe your condition may warrant a prescription, be prepared to provide a pharmacy number. Likewise, if you want an order faxed for outpatient testing, provide the fax number. I cannot emphasize enough how much more quickly your concern will be handled, if you follow this step. Leaving me a message indicating that you want a prescription called in to the pharmacy “on the corner of such and such” means that your concern goes to the bottom of the 20-deep message pile where I will research it at my leisure.
Do your own bureaucratic homework and know your insurance coverage. The nurse cannot be expected to know offhand what services your policy covers or which pharmacies and providers are in-network. This is your responsibility.
Answer the phone when the nurse returns your call. If you cannot take the call, listen to your message before calling the office again as it may address your concern in full. Resist the temptation to express indignation that the nurse is not available to talk with you when she “just called.” I assure you she’s already on the phone with someone else in the 20-deep message pile.
Be courteous to the receptionist and all other administrative staff. Trust me, when your concern falls into the gray area between handling over the phone versus needing an in-person evaluation, we’re all more likely to bend over backward to help you if you’re nice to everyone. Acting like a petulant child or pulling a Medusa-on-Crack routine will get you noticed, but not in a good way. Most likely, you’ll get an invitation to perform your routine in the office as we won’t be doing you any phone favors.
Be mindful of the timing of your call. Calling at 3:30 p.m. on a Friday afternoon probably means you won’t be called back until after the weekend. Call the office when it first opens for the best chance of having your call returned promptly. Be aware that some offices have designated call-back times or triage schedules, meaning that some callbacks may not occur for 24-48 hours.
Call for yourself, not your friends. The nurse cannot comment on your friend’s condition because s/he is not our patient, nor would we discuss it with you anyway. Besides, the nurse knows it’s really “you” you’re calling about. And, for the record, a thorough nurse will make a notation in your chart about your “friend’s” problem, so that we can compare it to your strangely similar complaint in the future.
Show up for your regular appointments. Don’t even think of calling in a request or concern when you’ve “no-showed” for your last three scheduled appointments. Moreover, don’t give me the “I’ve-been-his/her-patient-for-ten-years line,” especially if you haven’t been seen in the last twelve months. This leads me to believe you’re probably going to ask for something unreasonable, and you are.
Last but not least, keep up with your stuff, namely the prescriptions given to you at your last visit. There’s a reason we ask you to submit them to the pharmacy right away. You lose them like errant children who can never find their homework! We then have to call them in to your pharmacy. You have created double work for us in this situation. We realize mistakes happen, and a gracious request certainly works in your favor, but a haughty, adolescent attitude, not so much.
If you keep it short, real, and together, you'll more than likely get what you want and need without the face-time hassle.
Tuesday, September 2, 2008
Mind Your P's and D's: Preventative Versus Diagnostic Care
With the surging popularity of high deductible health plans (HDHPs), many employer-based and even some individual policies include the exception of an annual physical or wellness exam that is covered in full and not subject to the deductible, coinsurance, or co-pay. This exception is designed to encourage members to seek recommended health screenings, rather than forgoing them due to the high cost burden of paying upfront and out-of-pocket for what many might regard as a non-priority . Members are understandably aggravated when they are billed for services they thought were for preventative purposes only and thus, covered in full by their health plan. Understanding the difference between preventative and diagnostic care is key to minimizing the impact on your wallet.
Preventative care includes examinations and/or services performed in the absence of signs and symptoms of illness. Diagnostic care refers to examinations and/or services performed to diagnose a condition when the patient presents with signs and symptoms. Although a preventative exam and a brief, problem-focused exam can be done simultaneously, most insurance plans will not pay for both at the same time. Moreover, healthcare providers often receive less reimbursement for providing time-intensive, preventative care than they do in conducting a 10-minute, problem-focused visit. They have little incentive to bill exclusively for preventative care even if it comprises the majority of a given visit. What does this mean for the discerning patient?
If your insurance plan covers preventative care at 100% and you schedule an appointment for an annual physical exam and express no health complaints, your claim should be billed as preventative, and your plan should pay the provider in full. You incur no costs for the services. On the other hand, given the same scenario, if you express complaints and especially if services are ordered to address those complaints (e.g., specific laboratory or radiology tests), your entire visit is now considered diagnostic, and the deductible, coinsurance, and/or co-pay will apply to all billed services.
Clever, yet unsuspecting, patients may assume they can address health problems at their “free” preventative care visit and avoid the time and expense of additional visits, but this practice is a gamble because insurance companies carefully review claims that fall outside designated parameters (i.e., CDC guidelines in the case of preventative care. If your claim reflects any irregularities, the insurer may ask for clinical documentation to review the claim further or in all likelihood, will deem the visit diagnostic and pay accordingly, which means you will receive an EOB (Explanation of Benefits) showing that you now owe a portion of the allowed amount to the provider. So much for that free visit!
What happens if your plan covers preventative care at 100% and this is what you received, but your EOB says you owe a portion of the claim? Contact your health care provider’s billing department and confirm that the claim was submitted with the appropriate ICD-9 (diagnosis) and CPT (procedure/service) codes indicating preventative care. Health care payers and providers use these codes to communicate diagnoses and services performed in a concise format. One omitted or transposed digit or simply the wrong code can cause a claim to be denied or paid differently within the electronic claims processing system. Before leaving your provider’s office, get a copy of the requisition or charge sheet that will be used to bill your insurance company. It contains the ICD-9 and CPT codes for your visit and can prove invaluable in sorting out billing errors with the healthcare provider and insurance plan.
Preventative care includes examinations and/or services performed in the absence of signs and symptoms of illness. Diagnostic care refers to examinations and/or services performed to diagnose a condition when the patient presents with signs and symptoms. Although a preventative exam and a brief, problem-focused exam can be done simultaneously, most insurance plans will not pay for both at the same time. Moreover, healthcare providers often receive less reimbursement for providing time-intensive, preventative care than they do in conducting a 10-minute, problem-focused visit. They have little incentive to bill exclusively for preventative care even if it comprises the majority of a given visit. What does this mean for the discerning patient?
If your insurance plan covers preventative care at 100% and you schedule an appointment for an annual physical exam and express no health complaints, your claim should be billed as preventative, and your plan should pay the provider in full. You incur no costs for the services. On the other hand, given the same scenario, if you express complaints and especially if services are ordered to address those complaints (e.g., specific laboratory or radiology tests), your entire visit is now considered diagnostic, and the deductible, coinsurance, and/or co-pay will apply to all billed services.
Clever, yet unsuspecting, patients may assume they can address health problems at their “free” preventative care visit and avoid the time and expense of additional visits, but this practice is a gamble because insurance companies carefully review claims that fall outside designated parameters (i.e., CDC guidelines in the case of preventative care. If your claim reflects any irregularities, the insurer may ask for clinical documentation to review the claim further or in all likelihood, will deem the visit diagnostic and pay accordingly, which means you will receive an EOB (Explanation of Benefits) showing that you now owe a portion of the allowed amount to the provider. So much for that free visit!
What happens if your plan covers preventative care at 100% and this is what you received, but your EOB says you owe a portion of the claim? Contact your health care provider’s billing department and confirm that the claim was submitted with the appropriate ICD-9 (diagnosis) and CPT (procedure/service) codes indicating preventative care. Health care payers and providers use these codes to communicate diagnoses and services performed in a concise format. One omitted or transposed digit or simply the wrong code can cause a claim to be denied or paid differently within the electronic claims processing system. Before leaving your provider’s office, get a copy of the requisition or charge sheet that will be used to bill your insurance company. It contains the ICD-9 and CPT codes for your visit and can prove invaluable in sorting out billing errors with the healthcare provider and insurance plan.
Monday, September 1, 2008
In and Out in a Flash, Sort of: How to Have the Most Efficient Physician Office Visit
1) Arrive on time. Yes, maybe you’re only five minutes late, but here’s the thing—so was everyone else, and now we’re all behind. Many offices will refuse to see tardy patients and will charge for the inconvenience. And, should you fail to grace us with your presence without the customary 24-hour notice, be prepared for a bill equal to at least the amount of your co-pay, if not more. If you’re a new patient, plan to arrive 15 minutes prior to your scheduled appointment time to complete the necessary paperwork. Better yet, download the forms from the physician’s website or ask the receptionist to mail them to you when you make the initial appointment. Completing paperwork beforehand saves everyone valuable time.
2) Know the doctor’s schedule. Some doctors perform hospital rounds or surgeries at given times during the day or are out of the office completely on certain days of the week. It’s usually best to book the first appointment of the day or the first after lunch, so as to avoid delays from previous patients who were only five minutes late.
3) Bring your insurance card and driver’s license. Even if you’ve provided the information in the past, the office has made copies in the past, blah, blah, blah…personnel changes, charts get lost, and computer glitches occur. Unless you wish to spend precious time negotiating a payment plan because your insurance coverage cannot be verified rather than being evaluated by your provider, come prepared.
4) Allow plenty of time between your daily appointments. You booked an appointment across town within an hour of this one and you’re in danger of missing it. NOT. OUR. PROBLEM. You do not hesitate to tell us how we are causing you to miss this other appointment. NOT. OUR. PROBLEM. Trust me, your other obligations, however pressing they may be, will not make your time here pass more quickly. Be realistic about your time constraints for the day and plan accordingly.
5) Hold your water. Before you use the restroom, inquire about whether you will need to give a urine specimen or need a full bladder for a specific test (e.g., a sonogram). Failing to do so means you’ll almost certainly be asked to provide one with your now empty bladder, which only increases your idle time in the office or lab.
6) Ask whether and/or for how long you should fast prior to your appointment. This simple clarification will prevent an additional trip to the office or lab to have your blood drawn because you absentmindedly gulped down a grease-laden, sugar coma-inducing meal before your previous appointment.
7) Focus on a specific complaint or a discreet list of symptoms. A single office visit cannot possibly address the myriad whole-body aches and pains you’ve accumulated since your last visit, which could have easily been a year or more ago. Honing in on your main concern gives the physician and the healthcare team a target to work toward a healing game plan. A point worth remembering is that modern Western medicine is increasingly specialized. Multiple, disparate complaints often leads to referrals to multiple specialists, which results in fragmented, more costly, and time-intensive care. This approach is sometimes necessary if a patient has a complex constellation of problems, but for those of you who are prone to complain about everything and for whom every symptom is the proverbial nail in your coffin, you know who you are—the same folks who complain about how long everything is taking—this tip is for you.
8) Keep a list of all current prescription, over-the-counter medications, vitamins, and herbal remedies on your person. Don’t forget to include any drug, food, and contact (e.g., intravenous contrast dye, latex, iodine) allergies on this list. A list drastically cuts the time necessary to compare what you were taking previously with your current regimen. It helps the healthcare team quickly scan your drug regimen for appropriate dosages, duplicates, or contraindications (i.e., two drugs that interfere with one another in a harmful way). Honestly, telling us you take a “blue” pill for your heart means nothing but wasted time for everyone involved. Be informed about your health; make a list and update it regularly.
9) Bring a short list of specific questions or someone who can quote these questions verbatim and take notes. This list will help everyone focus on your main concern and ensure you have a satisfactory visit. If you bring someone with you, be prepared to discuss all of your healthcare history in front of this person. This includes sexually transmitted illnesses, birth control use, pregnancies, abortions, psychiatric care, alcohol, illegal drug use, and any other potentially embarrassing or stigmatizing information in your file. The healthcare team cannot be expected to navigate the minefield of each particular patient’s relationship dynamic and refrain from discussing certain issues. If you’re not completely open with your support person, get another one or get a short list.
10) Avoid bringing small children, unless of course, they are the patients. They will inevitably disturb other patients and the staff. The staff is not a temporary babysitting service and cannot be expected to control your squirming, projectile snot-snorting toddler while you discuss your infinite, nonspecific symptoms with the physician. The other patients don’t take too kindly to it either as the time we spend with your bundle of yuck means less time spent attending to their needs for which they are paying.
11) Turn your phone off and pay attention. We know you can multi-task like a champ, but demonstrating your Olympic-caliber texting skills while getting a pap smear and then asking the nurse to spend additional time answering your questions for the physician after s/he is long gone and you’ve signed off with the BFF is unacceptable. Stay in the present; it saves us all invaluable time.
Will adhering to these tips guarantee a quick visit? No, but it will mean you’re not contributing to delays, which translates into a more efficient process for everyone involved.
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