While this can be helpful to nudge doctors who might not follow standard guidelines, it is annoying for those of us who try to.
It is not uncommon for me to get a letter from an insurance company telling me that my patient is not being cared for properly. Usually it is because a child with a diagnosis of obesity has not had a lipid panel (cholesterol) drawn despite my ordering it months ago (or even multiple times with many reminders). Or a patient with asthma is not on a controller medicine or hasn't had an asthma check in 6 months.
The letter includes something like this (sorry for the poor focus):
These letters frustrate me because what am I supposed to do with them? I note it in the chart to discuss at the next visit and often have a nurse call for a parent to schedule a visit or go to the lab or pharmacy to get the tests or medications previously ordered, but typically it doesn't make a difference. Parents still do not follow through with recommendations.
Doctors are graded by insurance companies. We are supposed to follow guidelines to provide appropriate care in a cost -saving manner to the clients of the insurance company. Insurance companies can use the information they have about patient compliance (through coding and billing submitted by the doctor, the lab, the radiology facility, and the pharmacy) with standard guidelines to pay physicians various amounts (i.e. higher payments for "top notch" docs and lower payments for those who don't meet compliance standards) or they might simply stop allowing a doctor to be one of their providers. Remember it doesn't matter if a doctor orders a test or medication, only if those orders are completed. The insurance company only knows about the order if the code is submitted at the time the test is done or the medication is filled. They have no idea if the patient got samples in the office (therefore doesn't need to fill a script) or if the doctor gave a prescription, but the patient can't afford to pick it up or doesn't fill it for any number of other reasons.
Unless you were under a rock or never watch the news, you probably heard about the thousands of doctors recently removed from certain insurance panels. Some of this is probably unrelated to following the guidelines, but it is very possible that your favorite doctor might not be invited to participate in an insurance plan because enough of their patients do not get the recommended tests and treatments. Whether this is due to the physician not following guidelines or patients not following the doctor's recommendations does not matter. If a prescription is unfilled, the insurance company never knows it was written. If you fail complete the autism screen, do the lung function test, or go to the lab to have the labs drawn, the insurance company does not know they were recommended and ordered. If you do not follow up as requested by your doctor, the doctor gets dinged by the insurance company.
Part of the new healthcare laws includes that physicians must show follow up of referrals, completion of labs, and in general follow up on all orders.
Insurance is in a general state of uncertainty at this time. Pediatricians and other physicians around the country are nervous with all of the recent and upcoming changes. No one is certain how we will be paid. I know everyone thinks doctors are rich, but that is often not true and another discussion entirely. The truth is that any business needs an influx of cash to survive.
New high deductible plans mean that we will need to collect payment from patient families instead of the insurance company, which will likely decrease collections and increase the time to collect. This affects the bottom line. In October, a new coding and billing system is due to be implemented. Many experts expect that payments will be delayed by insurance companies for 3-6 months. What business can survive without any income for 3-6 months? New healthcare laws make it possible for patients to appear that they have active insurance, but if they haven't' paid their premium, the insurance company can refuse to pay. If insurance companies grade us on a "lower" quality scale or cut us from their panels, an office will bring in less income. All of these variables will make it more difficult for physician's offices to pay their bills (rent, insurance, staff salaries, purchase supplies, etc). Many private physicians are already selling out to big hospital or other medical systems. With this they lose control over their practice and become employees. I do not want to go that route.
What can you do to help insure that your favorite doctor's office stays in business?
The letter includes something like this (sorry for the poor focus):
 |
| picture from actual letter |
Doctors are graded by insurance companies. We are supposed to follow guidelines to provide appropriate care in a cost -saving manner to the clients of the insurance company. Insurance companies can use the information they have about patient compliance (through coding and billing submitted by the doctor, the lab, the radiology facility, and the pharmacy) with standard guidelines to pay physicians various amounts (i.e. higher payments for "top notch" docs and lower payments for those who don't meet compliance standards) or they might simply stop allowing a doctor to be one of their providers. Remember it doesn't matter if a doctor orders a test or medication, only if those orders are completed. The insurance company only knows about the order if the code is submitted at the time the test is done or the medication is filled. They have no idea if the patient got samples in the office (therefore doesn't need to fill a script) or if the doctor gave a prescription, but the patient can't afford to pick it up or doesn't fill it for any number of other reasons.
Unless you were under a rock or never watch the news, you probably heard about the thousands of doctors recently removed from certain insurance panels. Some of this is probably unrelated to following the guidelines, but it is very possible that your favorite doctor might not be invited to participate in an insurance plan because enough of their patients do not get the recommended tests and treatments. Whether this is due to the physician not following guidelines or patients not following the doctor's recommendations does not matter. If a prescription is unfilled, the insurance company never knows it was written. If you fail complete the autism screen, do the lung function test, or go to the lab to have the labs drawn, the insurance company does not know they were recommended and ordered. If you do not follow up as requested by your doctor, the doctor gets dinged by the insurance company.
Part of the new healthcare laws includes that physicians must show follow up of referrals, completion of labs, and in general follow up on all orders.
Insurance is in a general state of uncertainty at this time. Pediatricians and other physicians around the country are nervous with all of the recent and upcoming changes. No one is certain how we will be paid. I know everyone thinks doctors are rich, but that is often not true and another discussion entirely. The truth is that any business needs an influx of cash to survive.
New high deductible plans mean that we will need to collect payment from patient families instead of the insurance company, which will likely decrease collections and increase the time to collect. This affects the bottom line. In October, a new coding and billing system is due to be implemented. Many experts expect that payments will be delayed by insurance companies for 3-6 months. What business can survive without any income for 3-6 months? New healthcare laws make it possible for patients to appear that they have active insurance, but if they haven't' paid their premium, the insurance company can refuse to pay. If insurance companies grade us on a "lower" quality scale or cut us from their panels, an office will bring in less income. All of these variables will make it more difficult for physician's offices to pay their bills (rent, insurance, staff salaries, purchase supplies, etc). Many private physicians are already selling out to big hospital or other medical systems. With this they lose control over their practice and become employees. I do not want to go that route.
What can you do to help insure that your favorite doctor's office stays in business?
- Schedule and keep appointments as recommended. This includes all routine well visits, follow up visits for chronic illnesses, and rechecks of acute illnesses as recommended. If you don't intend to do the recommended follow up, talk to your doctor about why.
- Know your insurance plan to estimate your medical costs. I know this is very difficult because there is little transparency in medical billing. What a doctor charges, what an insurance company has the doctor's office write off, what insurance pays, and what insurance requires the patient to pay is usually not clear. Believe me, I wish the system was different too, but we must work within the system until it changes. Take the time to ask the doctor's office about charges and call your insurance company ahead of time if there is question about your percentage of that charge.
- Pay bills on time. If you question a bill, call your doctor's billing office for an explanation. If you are unable to pay the full amount, call the billing office to set up a payment plan. Don't simply ignore a bill! It won't go away if you don't address it.
- If you disagree with a recommended lab, test, prescription, referral, or follow up: tell the doctor at that visit! Either we can change the recommendation and document in the chart why we are changing it, or we can discuss with you further why it is important.
- If you cannot pay for the recommended lab, X-ray, or prescription, tell your doctor. We might have ideas of how to get help.
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