Wednesday, August 27, 2014

Medical Billing and a Restaurant

Medical insurance and billing is a mess. That is one thing I think most people would agree upon. The difficult thing is to find a solution that most people agree upon.

photo source: Shutterstock

Since our office has started a new financial policy that includes sending credit card information for secure storage to be used for payment of money owed, we have been encouraged by many people. They realize that businesses must have a means to collect payments owed. Many businesses use a credit card storage system. For instance, when someone books a hotel room they must have a credit card on file with the hotel. That protects the hotel in case people never show up (so the hotel can collect per their cancellation policy), if they damage the room, or otherwise build charges for which the hotel needs to collect payment. Because the hotel industry has been doing this for so long, most people don't question the practice when booking a room. There have been a few (but vocal) people who are upset by our new financial policy. I am hopeful that they can begin to see from our perspective just why this is a much needed policy.

We see most collection issues with high deductible plans but can't pick and choose which patients need to give a credit card. It must be the same policy for everyone. If you never owe money, we will never charge your card. If you owe money, you owe money. Your insurance company lets you know how much after they make their adjustments on the Explanation of Benefits (EOB). That amount is not up to us. It is per your contract with your insurance company. We will save you time in processing the bill by submitting it to your credit card if it's under the amount stated in our policy. If it's a higher amount owed, out of courtesy we will contact you to alert you to the charge. If you need to work out a payment plan, we're happy to work with you. But you still owe the money for services already rendered. It's that simple.

Where else does someone make a purchase, but only find out how much it will cost them weeks later? That is exactly what happens when someone goes to the doctor or has a lab or procedure done. You don't know the cost to you (and neither does the office) because it depends on how your insurance adjusts the bill and what portion they pay versus what they state is expected from you. It is not my system nor my office's system. It is the insurance system.

Our office does have a "menu" of codes representing common procedures, vaccines, and more with the associated charges, but it doesn't really tell people how much they will owe. This menu is in every patient room and can be given to parents if requested. The charges listed are our charges, but the amount any family will owe depends on how their insurance company adjusts and pays for things. I think it would be ideal for people to have access to a standard set of codes on their insurance company website, with a clear depiction of how much their portion will be for each code. But this would be difficult since there are so many plans, people who owe a percentage that varies based on if their deductible is met or not, etc. It varies even to the point that your employer has a different contract with your insurance company than the next employer has with the same company.

When we get the adjustment report from the insurance company and there is a portion left to be paid by the patient, it is typically already weeks after the service was provided. We then are responsible for collecting that money from the family. Many practices (including my own) are starting to hold credit card information to help with collecting payments. We simply can't afford to track down the high volume of patients that owe money. It is often small amounts, sometimes so small that it would cost more to send the bill than the amount owed. But to simply not collect small amounts from hundreds of people adds up to a business in the red.

Think of it like this: "Pay Later Restaurant" doesn't have people pay immediately after dinner. They send the bill to one of the people who enjoyed the meal. About 2 - 4 weeks later, the restaurant receives a payment, but the customer first adjusted the bill down 80% because they have a contract that states they can. But even that payment of 80% of the bill doesn't all come. Since the payment will come from multiple people at the table, only a portion of that discounted price is paid. The remaining portion of the discounted price is owed by someone else at the table. That person wants to see the bill and have it explained to them. They still take a few weeks to pay because they didn't know they were going to pay for their portion of the bill. They thought it would be covered by their dining partner. During all these weeks of trying to decide if the diner really does owe the restaurant, the restaurant still has to pay their rent, pay salaries to their employees, buy new food to sell, and otherwise pay business expenses. How can they continue to stay in business if they don't collect? Businesses in the red close. This is exactly how medical offices must operate.

We want to keep seeing patients, so we need to collect money owed us to be able to pay our bills.

In my perfect world the insurance company would pay the office the full contracted amount owed, and if the patient had a responsibility for part of that fee, the insurance company would charge the family. This keeps it clear that the money is due per the insurance contract because the bill would be to the insurance company, not the doctor's office. This helps the doctor-patient relationship continue to be about medical care, not payments. The insurance company also would have the benefit of withholding coverage if patients don't pay their bills. That encourages people to stay current on payment of their fees. When patients owe the doctor, the doctor has little to do to collect payment other than send the patient to collections and discharge them from the practice - which is really hard for physicians who want to care for people, not worry about paying bills. But we need to think of the business bottom line. If we don't collect payments, we cannot pay our bills. Then we close (or sell to large hospital systems, as many offices have done) and we can't take care of patients the way we want.

My friend, Suzanne Berman, MD, FAAP, of Plateau Pediatrics in Crossville, Tennessee, has written this list of similarities between a restaurant and medical care. It might just help clear up some of the issues we have with competition of walk in clinics, office scheduling, billing, and collecting.

1)      A meal at Hardee’s is different than a meal at the Palm, in many ways (including costs).
2)      Sometimes it’s just cheaper to eat at home.
3)      Most restaurants are a la carte.   The more you order, even if you don’t eat it all, the more you pay. 
4)      Yes, some restaurants are all-you-can-eat for one price, but drinks are still extra.
5)      Just because you had to wait for a table doesn’t entitle you to a free meal.
6)      Some places bring you chips for free.  Other places charge for chips.
7)      Plate sharing and corkage fees have legitimate reasons behind them, even if you don’t like the idea of them.
8)      Just because there are no prices posted on the menu does not mean that the chateaubriand is free.
9)      Your total does not include tax.
10)   Your total does not include tip.
11)   Liquor is always a very expensive add-on relative to the wholesale price of spirits. 
12)   Even if you don’t like how the shrimp makes your pasta taste, you’re still obliged to pay.
13)   Do you treat your own house like you treat our establishment?
14)   If you want a soufflĂ©, you need to declare that BEFORE you order your meal.  Adding on an “oh by the way” does not work with soufflĂ©s.
15)   We can help you split the bill and decide which party owes how much, but before you leave the restaurant, the bill must be paid in full by SOMEONE.

Monday, August 18, 2014

Flu Vaccine 2014-15 Season

Every year it's something.

Flu vaccine causes distress every year for physician offices around the country.

I wrote about some of the issues last year here and here.

This year's flu vaccine is identical to the trivalent and quadrivalent vaccines of last season, so it should be easier.

But as always, there's a hitch.

This year there is a delay in shipping but no one really knows why. I've heard pharmacies are starting to advertise they have flu vaccine. From a business standpoint, we start to worry when we hear people say "I'll just do it at the pharmacy." We've already ordered more doses than last year and don't want to get stuck with supplies we can't use. Bad for business...

How flu vaccine makers choose their shipping times to various offices around the country is unknown to me. We order nearly a year in advance so they can make the requested number of doses. We must project how many infant vs child injectable doses of vaccine we will need and how many nasal spray doses we will need. Some years we can add to our order, but other years there are shortages. There are several makers of various brands, but in pediatrics we are limited to what types we order based on the ages for which it can be used.

As soon as we start getting the vaccine we will begin to offer them in the office. Typically we start getting a few doses at a time, so we can't advertise with those first small shipments. It will simply be patients who are in the office and eligible for the type we have will be offered flu vaccine. When we get enough to hold a flu vaccine clinic, we will send out e-newsletters to patients who are registered, as well as post on our website and Facebook page. Our flu clinics run smoothly because parents sign up on line. We will send paperwork ahead of time for you to fill out at home. Bringing that really helps. You will need to have signed our financial policy before the flu vaccine. To keep things running smoothly, we encourage you to do that ahead of time if you have not already done so. We also ask that your child is current on well visits in order to use our flu clinic. If your child needs a well visit, simply schedule one and he can get the vaccine at that visit. We will always give flu vaccine to patients and their siblings who are in the office for a visit (but without significant illness, such as fever) as long as supply lasts.

Who needs a flu vaccine and when should it be given?

It is recommended that everyone over 6 months of age get a flu vaccine each year. As soon as the vaccine is available, it can be given. Ideally the vaccine is given before the influenza season starts. Flu season usually peaks in January, but influenza can occur at any time of the year. I must put a plug in for getting the vaccine in your medical home if at all possible. This keeps vaccine records all in one place and helps support your doctor's office.

Which vaccine should my child get?

Children 6 months to 2 years should get the injectable vaccine. They are not eligible for the nasal spray (FluMist).

Starting in 2014-2015, the CDC recommends use of the nasal spray vaccine (FluMist) in healthy children 2 - 8 years of age, when it is immediately available and if the child has no contraindications or precautions to that vaccine.

Contraindications to the FluMist are:
  • Children younger than 2 years
  • Adults 50 years and older
  • People with a history of severe allergic reaction to any component of the vaccine or to a previous dose of any influenza vaccine
  • Young children with asthma
  • Children or adolescents on long-term aspirin treatment
  • Children and adults who have chronic pulmonary, cardiovascular (except isolated hypertension), renal, hepatic, neurologic/neuromuscular, hematologic, or metabolic disorders
  • Children and adults who have immunosuppression (including immunosuppression caused by medications or by HIV)
  • Pregnant women
  • Live virus vaccine (such as MMR or Varicella/chickenpox) within the past 4 weeks. The vaccines can be given together on the same day, but if not on the same day they must be given 28 days apart from one another.
  • Most people with the above contraindications can still be vaccinated with the injectable vaccine - ask your doctor

Recent studies suggest that the nasal spray flu vaccine may work better than the flu shot in younger children. However, if the nasal spray vaccine is not immediately available and the flu shot is, children should get the flu shot. Don’t delay vaccination to find the nasal spray flu vaccine.

How many doses does my child need?

In young children who have never received a flu vaccine, two doses of the same strain should be given. If they've had two doses of the same strain previously, they only need one dose. In children over 9 years of age, regardless of previous vaccines, only one dose is needed. This is because it is presumed that by 9 years of age a child has been exposed to the influenza virus previously. Think of it as the first vaccine is the initial body's exposure to the virus in young children, then everyone needs a booster dose for the season, including the first season if a child has never had one before.

The CDC has put together a flow chart of how many doses are needed:

Can a person still get the flu even after getting the vaccine?

Each year experts pick the most likely strains of influenza virus that are expected. Some years they do a great job, other years it is not as accurate. There is some cross-reactivity among strains, so even in years that the wrong strains are in the vaccine, there is some protection against severe flu illness. So yes, it is possible to still get influenza, but usually the illness is mild.

Can a person get the flu from the vaccine?

No. I have heard many people say they get the flu from the vaccine, but this is not possible. People who get the nasal vaccine can get mild congestion (cold like symptoms), but they do not get the flu from the vaccine. It is possible that they were exposed to the actual flu virus and get sick before the vaccine has a chance to provide protection. Or they have a viral illness that isn't the flu. People with influenza often say they feel like they were run over by a train. They are sick. It is not just a cold.

Can I get the flu vaccine even though I have an egg allergy?

The following recommendations come from the Advisory Committee on Immunization Practices (ACIP):

People with a history of egg allergy who have experienced only hives after exposure to egg should receive the injectable influenza vaccine. Because there is limited data in the use of live attenuated influenza vaccine (FluMist) in egg allergic people, inactivated influenza vaccines (shots) either the IIV or trivalent recombinant influenza vaccine (RIV3) should be used.

Where can I get more information? 

Each year the CDC provides summary information about the current influenza vaccine season. You can read about the 2014-15 season, information on flu vaccine myths and misconceptions, and you can even see where the flu has hit.


Wednesday, August 13, 2014

Formulary Fun

I have filled out more prior authorizations in the past few months than in the entire last year. Most insurance companies seem to be requiring them for more medicines than ever. They are often denied because people have not tried "preferred" medications first. As the physician I don't have access to the "preferred" list of medications on a patient's formulary, and I find that when I tell parents to look up alternatives on their formulary, they don't know what they're looking for. Insurance companies don't make it easy. Why should they?

Screen shot from Google Search

I decided that some of the most common medicines should be listed somewhere for easy access by patients so they can look up alternatives on their insurance websites. That way they can help themselves. This list is organized by diagnosis and then generic medicines for that diagnosis in alphabetical order with the brand names in parentheses. If you have other medicines or categories you'd like added, please comment below. This will be a work in progress! There are hyperlinks for more information for several of the topics. While it is most accurate to log into your own insurance company's formulary list, if you cannot you can try Fingertip Formulary.

Many of these are quite expensive as monthly costs despite insurance. For help, check out the drug company's website for any coupons or special offers.


Topical Medicines

  • Adapalene (Differin)
  • Adapalene + benzoyl peroxide (Epiduo)
  • Benzoil peroxide (Benzac AC, Brevoxyl, Triaz, many OTC brands)
  • Benzoil peroxide + clindamycin (Benzaclin)
  • Benzoil peroxide + erythromycin (Benzamycin)
  • Clindamycin (Cleocin T, Clinda-derm, Clindets)
  • Clindamycin phosphate and benzoyl peroxide (Duac)
  • Erythromycin (Akne-Mycin, A/T/S, Emgel, Erycette, Eryderm, Erygel, Erymax, Ery-Sol, Erythra-Derm, ETS, Staticin, Theramycin Z, T-Stat)
  • Tazarotene (Tazorac)
  • Tretinoin (Retin-A)

Oral Medicines

  • Co-trimoxazole AKA sulfamethoxazole-trimethoprim (Bactrim, Septra)
  • Doxycycline (Vibramycin)
  • Isotretinoin (Accutane)
  • Minocycline (Minocin) 
  • Progesterone/Estrogen (oral contraceptives): Ortho Tri-Cyclen, Estrostep, Yaz, many others
  • Spironolactone (Aldactone)

ADHD- pay attention to duration of action and if pill needs to be swallowed

Brand Name
Active Ingredient
Duration of Action
Time Release Pattern
Can be opened or chewed?
3-4 hrs

Adderall XR
10-12 hours
50% am, 50% pm
Beads can be sprinkled
10-12 hours
10-15 min first effect, 30% am, 70% pm (*)
No, must swallow whole
2 hours after removal (**)
Up to 2 hours for first effect, then consistent release
N/A: patch
Dexadrine spansule
6-8 hours
initial immediate release/ then gradual release over prolonged time

4-6 hours

Focalin XR
DexMethylphenidate XR
6-10 hours
50% am, 50% pm
May be sprinkled
Metadate CD
6-10 hours
30% am, 70% pm
Beads can be sprinkled
Metadate ER
6-8 hours
Gradual decrease after 3 hours, may need to be given more than once/day

3-4 hours

Quillivant XR
8-12 hours

N/A: liquid

Ritalin LA
6-10 hours
50% am, 50% pm
May be sprinkled
10-12 hours
Onset in 30-45 min, then slow release

Quillivant XR
methylphenidate hydrochloride
8-12 hours
20% immediate/ 80% delayed

*Concerta is unique: it has a coating of medicine on the outside, so within 10 or 15 minutes you'll be getting some effects of the medication. On the inside, there's a push compartment filled with a polymer fiber that expands like a sponge as it gets wet, and pushes out the medicine through a laser hole on one end. The capsule itself doesn't get absorbed. Concerta has two compartments of the drug, 30% in the first, and 70% in the second. This is called an "ascending dose," and it is designed to offset a decline in the impact of the medication that can occur the second half of the day. Some of the generics for Concerta do not use this technology.

**Daytrana is a patch. It is recommended to leave it on up to 9 hours, and the medicine effect wears off about 2 hours after the patch is removed. If it is needed for less time, it can be removed earlier. Some teens with long days note benefit if they leave it on longer, though it is not tested beyond the 9 hours.


Antihistamines and other oral formulations

  • Cetirizine (Zyrtec) (OTC)
  • Fexofenadine (Allegra) (OTC)
  • Levocetirizine (Xyzal)
  • Loratidine (Claritin) (OTC)
  • Monoleukast (Singulair) - not an antihistamine, also sometimes used for asthma prevention

Eye drops

  • Azelastine (Optivar)
  • Ketotifen (Zaditor)
  • Olopatadine (Patanol)
  • OTC decongestant eye drops (phenylephrine, naphazoline, or tetrahydrozoline) 
  • OTC antihistamine eye drops (pheniramine or antazoline) 

Inhaled nasal corticosteroids (nose sprays)

  • Beclomethasone (Qnasl, Beconase, Vancenase)
  • Budesonide (Rhinocort)
  • Ciclesonide(Omnaris, Zetonna)
  • Flunisolide (Nasalide, Nasarel)
  • Fluticasone (Flonase) (OTC)
  • Fluticasone furoate (Veramyst)
  • Mometasone (Nasonex)
  • Triamcinolone (Nasacort) (OTC)


Bronchodilators (quick relief medicines)

  • Albuterol (Proair, Proventil, Ventolin, Ventolin HFA)
  • Levalbuterol (Xopenex)

Inhaled Corticosteroids (prevention medicines) - many come in various strengths, be sure to check that too!

  • Beclomethasone (QVAR)
  • Budesonide (Pulmicort Flexhaler, Pulmicort Respules)
  • Ciclesonide (Alvesco)
  • Flunisolide (Aerobid)
  • Fluticasone (Flovent HFA, Flovent Discus)
  • Mometasone (Asmanex Twisthaler)
  • Triamcinolone (Azmacort)

Inhaled Corticosteroid + Bronchodilator combination medicines

  • Budesonide + Formoterol (Symbicort)
  • Fluticasone + salmeterol (Advair Discus, Advair HFA)
  • Mometasone + Formoterol (Dulera)