The perverse health care system continues to thrive in the USA and now it is coming to Brazil...
This is a e-mail I received. It illustrates the state of health care in America under Managed Care
August 11, 2001
My name is Kiesha Raburn. I am a XXXX member with member #595-58-1381. I am 29 yo and suffering from Anorexia and Bulimia. I am hereby writing a grievance letter regarding XXXX's member options for treatment of eating disorders. I first phoned XXXX when I had reached my all- time lowest weight of 87lbs. My level of functional in society was severely impaired due to my illness. I either would eat nothing or would eat to a minimum and purge by vomiting. I was running 50 miles a week. I was going through severe binges consuming 5,000-10,000 calories a day and vomiting afterwards.
I was taking an excessive amount of diet pills (ephedrine), diuretics, and laxatives. I suffered from severe depression requiring a need for Prozac, an anti-depressant. I suffered from extreme mood swings, withdrew from all family and friends, isolated by remaining in my home for days at a time, suicidal thoughts, self-hate and worthlessness, and hopelessness.
Physically I suffered from hair loss, dysphasia (difficulty swallowing), enlarged salivary glands, irritated throat, constipation, diarrhea, hair loss, amenorrhoea, continuous fasciculation's in my legs (twitches), weakness, brittle nails, dehydration, electrolyte imbalance, oral lesions, dry skin, fatigue, bloating, and edema. My life had become so consumed in my illness and desire to lose weight that I was unable to function and I was slowly dying. I work as a registered nurse at Tampa General Hospital in the intensive care unit and went full-time in June by taking a drastic pay cut of several hundred dollars a month just to allow myself to obtain medical benefits to become available.
I was so incredibly sick that I decided that it was time to get help for my illness. I had to wait until July 2001 for my benefits to kick in and in the meantime I made several phone calls to various treatment centers to plan for my upcoming treatment. My medical doctor, Dr. Y; my psychiatrist, Dr. W; and my psychologist, Dr. K all agreed that I was in dire need of inpatient treatment for my eating disorder. My symptoms were unmanageable on the outside and had absolutely no control over my eating habits. I needed a well structured, controlled and safe environment where I would surrender my responsibility for self care and allow intense behavioral modifications to ensue. My psychiatrist and primary care physician both contacted XXXX and recommended this inpatient care. Upon speaking with XXXX's behavioral health representatives, P F, Dr. C, and D L, XXXX denied my coverage for inpatient or residential treatment and recommended outpatient treatment at T P. T P is a 12 step program, with group therapy among drug addicts, alcoholics, and compulsive overeaters. The group only met 3 times a week in 2 hour time frames. This treatment was obviously not appropriate for the care that I needed and was recommended. I refused to commit to this outpatient treatment, knowing that I needed more suitable care. I was also referred to SJ hospital since I felt so "out of control". SJ was contacted by myself and they recommended that I not come because they "don't treat eating disordered patients" and that I need specialty care. XXXX again denied me. The stress from all of this was making my disease worse and I became sicker requiring me to take a FMLA from work. I was hospitalized by Dr. C in a medical unit on July 5-9, 2001 for dehydration, fluid therapy, and tests.
XXXX continued to deny my treatment while I lay in the hospital bed making several phone calls trying to save "my life". I was told by XXXX that my employer does not have residential treatment facility benefits and there was nothing they could do but outpatient treatment. While in the hospital I looked through several of my books and found an inpatient hospital, R I in Atlanta, GA. I contacted their program and found that my insurance benefits includes "inpatient treatment" but R was "out-of-network" according to XXXX. HMO's hence do not cover out of network treatment. I was also told by XXXX behavioral health that I "did not meet the criteria for inpatient care" based on my height and weight of 93 lbs. I was devastated. I was discharged from the hospital on July 9, 2001 and was basically told "there was nothing they could do". XXXX would not pay. The costs for inpatient/residential care is $10,000-30,000 a month. I obviously do not have that kind of money. I feel as though I was sent home "to die". Here I was very eager to get well, helpless, and hopeless. After contacting XXXX, I agreed to go to TP for an evaluation. There I met with M B, admissions coordinator. Upon completing my evaluation she concluded that, "with my history of abuse and self -mutilating behavior, as well as increasing social isolation, it was indicated that I needed intense inpatient or residential treatment for a minimum of 30-60 days, and that I did not meet their criteria for treatment on an outpatient basis due to the severity of my symptoms". She too agreed with my primary care physician, psychiatrist, and psychologist. Days went by and fortunately I was able to convince my employer to pay for my treatment and so they paid $15,000 out of pocket and I was admitted to R on July 18, 2001 in the inpatient hospital. I was there for 5 days due to my high probability of medical complications, including heart and kidney failure during the dangerous "re-feeding" process. I was involved in intense therapy for 12 hours, 7 days a week. The doors were locked behind me. I was fed every 2 hours. I could not go to the bathroom alone in fear that I would throw up. I was weighed daily backwards so I couldn't see the weight. I had surrendered my self care. After spending 5 days inpatient and being closely medical monitored by a dietitian, physician's assistant, psychiatrist, and psychologist, I was sent to a half-way house for partial hospitalization at R. I was sent so soon because of the little money that I had for treatment. The partial program was cheaper yet was remained 12 hour therapy sessions 5 days a week. On August 3, 2001 I was discharged from R due to my limited financial means. That was 17 days of inpatient and residential care. The average length of stay for those with eating disorders are 60 days.
I have been home for one week now and continue to struggle. I still find myself engaging in my eating disorder behaviors and am terrified of re-living my life in this destructive disease. I reached a weight of 105lbs on discharge from R, where my usual set-point weight is 125lbs due to my extremely muscular body type. I agreed to attend TP a few days after my discharge and I sit in a room in a group setting where I am the only person with an eating disorder as the rest of the group are addicts. I can only hope that this will be enough to overcome my illness and I feel very hurt, angry, and dumbfounded at XXXX's lack of empathy and compassion and unwillingness to help me. I was left without options. I was left to die.
The following information was obtained from ANAD's (National Association of Anorexia Nervosa and Associated Disorders) web site (www.anad.org).
Eating Disorder Facts:
Eating disorders cause immeasurable suffering for victims and families.
Eating disorders have reached epidemic levels in America: all segments of society, young and old, rich and poor, all minorities, including African American and Latino
Seven million women
One million men
Victims lose the ability to function effectively -- great personal loss and loss to society
DURATION OF ILLNESS/MORTALITY
77% report duration from one to fifteen years
30% report duration from one to five years
31% report duration from six to ten years
16% report duration from eleven to fifteen years
It is estimated that six percent of serious cases die
Only 50% report being cured
COST OF TREATMENT
Treatment for anorexia nervosa and/or bulimia is often extremely expensive. Large numbers of victims require extensive medical monitoring and treatment, and therapy generally extends over two years or more.
Cost of inpatient treatment can be $30,000 or more a month. Many patients need repeated hospitalizations.
The cost of outpatient treatment, including therapy and medical monitoring, can extend to $100,000 or more.
Eating disorders are rampant in our society, yet few states in the nation have adequate programs or services to combat anorexia nervosa and bulimia. Only a small number of schools and colleges have programs to educate our youth about the dangers of eating disorders.
Every state in our nation and thousands of schools have extensive programs aimed to prevent alcoholism and drug abuse. The value of such programs, especially education programs, has been proven and accepted into school curricula. The immense suffering surrounding eating disorders, the high cost of treatment and the longevity of these illnesses make it imperative that vastly expanded education programs be implemented to prevent anorexia nervosa and related disorders.
Since 86 percent of victims report the onset of their illness by age 20, education programs should focus on these ages in order to maximize preventive efforts. ANAD education/early detection/prevention programs provide models for low cost outreach services that benefit hundreds of thousands of our youth. ANAD has urged federal and state governments to undertake and develop education programs for our citizens.
DATE: May 1, 2001
TO: ANAD MINNESOTA RESOURCE PEOPLE, GROUP LEADERS, MEMBERS AND
MENTAL HEALTH PROFESSIONALS
FROM: VIVIAN HANSON MEEHAN, PRESIDENT
JUDY TEPFER, LEGISLATIVE LIAISON
RE: IMPORTANT ACTION IN MINNESOTA
On October 3, 2000, Minnesota Attorney General MH filed suit against
BBBSS on behalf of children and young adults who were denied health insurance
coverage for eating disorders, mental illnesses and chemical dependency.
In the lawsuit, the state maintains that the insurance company, the largest
in the state, has engaged in an unlawful pattern and practice of misconduct
in denying and limiting medically necessary mental health, chemical dependency
and eating disorder treatment for Minnesota children and young adults,
in violation of Minnesota consumer and insurance laws. . . . [Their] illegal
conduct has resulted in significant harm to Minnesota consumers and unfair
shifting [of costs] to Minnesota taxpayers. Included in the lawsuit is
the personal testimony of a number of Minnesota parents whose children
have suffered because of BBBSS's denial of coverage.
Evidence shows that the insurance company has consistently tried to shift responsibility to taxpayers and/or families:
(1) telling policyholders to seek help through the juvenile justice system (suggesting parents should have their children
arrested) or the foster care system;
(2) denying or severely limiting coverage for court-ordered treatment;
(3) denying or severely limiting treatment as "not medically necessary" contradicting recommendations of their own
network's physicians who have examined and treated the patients;
(4) forcing subscribers into unwarranted appeals of denials of coverage for medically necessary and pre authorized
(5) misrepresenting and omitting material facts regarding coverage of authorized treatment; and
(6) hiding from subscribers the true criteria for its denial of coverage, placing subscribers at an unfair disadvantage during the
Among the testimonials are the stories of children and young adults suffering severe eating disorders, who were told variously that treatment was not "medically necessary", that "proper channels" had not been followed, and/or that their contract did not allow "this type of treatment." A former employee of BHS, Inc. (BHSI), the supposedly independent mental health clinic which was wholly owned by BBBSS and which carried out its case reviews, stated that the BHSI medical directors instructed its employees that "there was no effective treatment for eating disorders." One of the young people whose story is told eventually committed suicide, distraught, among other things, over the great financial burden to her family.
Attorney General H won the first round when his motion to force BBBSS
to turn over records was approved by the court. But help is still needed.
More testimonies of affected people have been requested. ANAD believes
that if this is successful in Minnesota, this lawsuit will have repercussions
around the country. Already Attorneys General in other states
are being contacted, in the hope that they will follow Attorney General H's lead.
I plan to do everything in my power to advocate treatment for those
of us with eating disorders. The laws have to change. We need coverage
and treatment before we are on our death bed. We do not deserve a death
sentence. We do not deserve to be
over-looked. Eating disorders are a disease which only outcome is death or appropriate treatment.
Which would you chose?
504 S. Melville Ave
Tampa, Fl 33606
A big decision! (7/27/2001)
Nobody can say that I did not try. I did. For years I worked with patients covered by Behavior Managed
Care. But I came to the conclusion that it is not possible to be a self respecting and responsible psychiatrists
working under the hassles, constraints and restraints of these perverse corporations whose profits depend on
the denial of care. So, starting on August 31, 2001 I will be closing my office. Here are some reasons why
I am doing it (there are many more):
1. It is abusive to be asked to renew my "credentials"
every two years, individually for
each corporation, when I am already licensed to practice medicine in my State and
this itself is renewed every two years!
2. It is abusive to subtly push me to become a
"med-checker" by financially rewarding
me to see four patients in one hour rather than one. This cuts through what I have of
most precious: my clinical judgment. I have no desire to be a med checker because
I don't see how it is possible to see people only for medication without psychotherapy.
3. It is abusive to "authorize" me to do 12 sessions
for "med-checks" while "authorizing"
me only 3 to 6 sessions when I propose to do medication and psychotherapy.
4. It is abusive to keep me on the phone for hours
trying to persuade someone to
approve my patient to be admitted to a hospital. Worse yet when this is denied against
my best judgment. It becomes appalling when the denier is not liable in courts of law
and to the Physician Board Of Quality Assurance, as I am.
5. It is abusive to discharge a patient back to
me without this being discussed previously
6. It is abusive to me to have a system of care
where I work with psychotherapists
and do "med-checks", in a "split treatment". In the case of severely ill patients this can
have dramatic consequences and I am not sure to what extent this is ethical.
8. It is abusive to me to require that I ask permission
to a Primary Care Physician to treat
a psychiatrically ill patient, having to detail the number of sessions I need, the length of the
sessions and for how long. This becomes even more abusive when I am authorized to treat
a patient for six months if I do "med-checks" but only for three months if I do medication and
WHAT IS COMING UNDER MANAGED CARE... (4/17/2001)
My guess is simple: high risk patients "covered" by managed care are not going to find
outpatient doctors. And they will suffer more than they are already suffering.
Let me explain:
A front line clinician needs a supportive environment
to be able to take care of high risk
patients. He needs the back up of hospitals and day hospitals. He needs the flexibility to
spend longer and more frequent time with the patient when this becomes an unpredictable
necessary. "Treatment plans" can't predict these crises and need for more and longer
This is no longer happening, thanks to Behavioral
Managed Care For Profits who now
tells the doctor what is and what is not "medically" necessary, without being liable for
these decisions. The doctor, of course, is.
A front line psychiatrist no longer feels secure
that a patient under his care will be hospitalized
if he recommends it. He may spend 6 or more unpaid hours in the phone arguing with
a "colleague" in the other end - who had never met the patient - stating that the hospitalization
is not "medically necessary". Fortunately, many don't kill themselves but when they do guess
who would be liable?
Worse yet, even when very high risk patients are
admitted, the hospital, under enormous
pressure from managed care sends him back to the outside psychiatrist after one or two days,
often after reducing or starting a new medications. The outside psychiatrists is not consulted
before the patient is sent back to him, frequently in the same condition he went in. If a patient
feels better BECAUSE HE OR SHE IS SAFER IS IN A HOSPITAL, the hasty conclusion of our
"colleagues" from Behavior Managed Care (who don't know the patient) is that HE DOESN'T
NEED TO BE IN THE HOSPITAL. See what money can do?...
Finally I don't have to mention the complications
of split treatments for these high risk patients.
We all know them.
Outpatient psychiatrists will no longer accept
patients these high risk patients. They also will no
longer accept new patients sent to them by the hospitals.
Predictable: These high risks patients "covered"
by managed are going to suffer as they
are pushed from sector to sector in the system in order to increase MCOs' profits. And
more will hurt themselves or others.
Marcio V. Pinheiro MD
Caucus For Psychiatrists Treating Patients Covered By Managed Care
Saw a patient twice... (2/14/2001)
I saw a difficult and potentially suicidal patient twice. I thought that things were going well despite a very long history of severe depression who did not respond to treatment with the previous doctor. Then without me knowing he made a serious suicidal gesture and the wife got him into a hospital. As far as I can tell they did not take a history and they did not contact me to get my impressions and knowledge of the patient. After one day and half they discharged the patient back to me with letting me know, with disastrous consequences.
I have not been here lately (1/27/2001)
I have not been here lately. Too busy. I continue to try to deal with the Managed
Behavioral Care Corporations For Profits. Lately there has been one good news:
we now have an Unified Treatment Plan in the State of Maryland and the Behavioral
Managed Care organizations will have to accept it. This will simplify the paper
work for the front line "provider" as I am. However the main problems remain.
It is a nightmare to keep track of Treatment Plans. Some MCOs only allow
me to treat patients for 3 to 6 sessions and I then have to write another treatment
Plan. Then there is the question of the MCOs discouraging me - I am a psychiatrist -
to do psychotherapy with my patients. They "push" me towards becoming a
"medication manager", that is, gave 15 minutes sessions with my patients to
review their medication. How they "push" me? Well by their fee schedule. If I
see a patient for medication checks for 15 minutes. let's say they will pay me
X. If I see the patient for medication and psychotherapy for 30 minutes they
will not pay me 2X. If I see the patient for medication and psychotherapy
for 45 minutes they will not pay me 3X. The idea then is for me to do
4, 15 minutes medication checks an hour and this will be much more
financially rewarding than me working with a patient 45 minutes. But so far I
have been refusing to do this. The minimum amount of time I spend with a
patient, regardless of what the Behavioral Managed Care pays me, is
30 minutes. I could go on and on...
Here come the "Site Surveys" (06/01/2000)
A Managed Care Corporation just told me that their nurse will come to my office to make a "Site Survey". My God, another chunk of my time will go into this. I am a little scared to see if my office will "pass" the survey. Will let you all know.
Seamless care II... (4/27/2000)
My God. Do things have to be this complicated? Mother was concerned. I called the hospital doctor and he said that the patient did not talk about suicide when he was in the hospital. Only that he was insecure at home because of his step father. Mother called the hospital too. The doctor told her that if he was insecure at home she should bring him to a family member. The mother then brought him to an aunt who lives in a different county. In this aunt house he continued to be insecure and ended up taking one bottle of medication. Was then hospitalized in the local hospital (not the previous hospital).
Mother called me this AM. She is upset because she feels that the patient should be transferred to the first and previous hospital because he has established some ties with the therapist there. But the managed care physician feels that it is bad for the patient to be "too attached to the hospital", hence he should stay one more night where he is.
I then called the managed care doctor. I explained to him that this patient is a high risk. There have been suicide in the family. That maybe he should be back in the previous hospital where he had established some ties. He said that this patient was "manipulative" and may get too attached to the hospital. That they were going to let him go to the intensive outpatient program there after he left the present hospital.
The mother is concerned that they will discharge him from this second hospital and he is going to be at home. She is worried for his life even he is going to go to the intensive outpatient unit of the first hospital.
I don't really know what to say at this point...
What health care system...
Seamless care... (4/25/2000)
The other day I saw a teenager (17). He was quite distressed. A few days latter the mother called me that he was tearing the house down and cutting his wrists. I advised her to go to an Emergency Room and to have the doctor there call me.
The patient was hospitalized at a local hospital.
Yesterday, to my surprise, he called me from his home. He sounded in despair. He said that he was going to blow up! I called the mother. She said that they discharged him from the hospital. I told her to call them back because I had no seen him, and as far as I understood the laws he was their patient.
She did. She said that they told her that, no, he was not their patient because he had been discharged. He was discharged because he was not suicidal or homicidal. That if he did not improve she should take him to an Emergency Room again, and to prove that he was not their patient they said that from the E.R. he could even be sent to another hospital.
My question... in case someone gets hurt, who will be responsible?...
90862 X 90805 (4/25/2000)
One Managed Care Organization listened to my questions and has increased the fees for 90805.
The 90862 X 90805 dance...
I have been doing this for many days now. The code 90862 means "Medication Management, 15 minutes". The code 90805 means "Medication Management
with Psychotherapy, 30 minutes". Some managed care organizations pay $ 2 dollars
more for 90805 Others pay a little more. But there are the ones who pay less for
90805 than for 90862. I have written to one of these asking about the rational for
this fee schedule. So far nobody has been able to explain.
Running in circles... (3/28/2000)
For two or three months now I have been told by an MCO that I am not in the panel of of one of its subsidiaries.. Hmmm, I have been working with this sunsidiary patients for years and nobody ever told me this. The problem is that it belonged to another corporation that was bought by the present one.
Today I have spent one hour trying to find someone to explain to me why I am not in subsidiary list of providers. I called the MCO first. They sent me to their "provider line". They then send me to the subsidiary. The subsidiary sent me back to another national number of the MCO. MCO said that I should contact the subsidiary. Them back to the MCO. When she was sending me back to subsidiary I said to her that all I wanted was to find out if I was in the the subsidiary plan. That the MCO had said that they were the ones who knew this.
She then said seriously... Wait let me transfer you to someone here...
The phone rang and somebody answered...
I started my long story... all I wanted was to know if I was in the subsidiary panel and if not, why not.
The guy in the other end of the line said: "Sir... this is a jewelry store... Can I sell you a watch?..."
Finally, the phone call... (3/28/2000)
Yesterday finally a "manager" called me about my geriatric patient. They are going to authorize one Initial Evaluation with a geriatric clinic. Not the one I asked for...
So far... no phone calls (3/25/2000).
The patient's daughter called me to find out if her mother could have the consultation.
I told her that I continue to wait for the Managed Care to call me as they promised.
So far... no calls...
In the mean time I received today a packet for Re-Certificaton from a Managed Care
Organization. It is a book! I am already licensed by Maryland Physicians Board of
Quality Assurance. My license is renewed every two years Not enough! They
want for me to spend hours and hours filling this new packet. They claim that this
is a requirement from the NCQA, their "certifying" organization. Guess what?
40% of the NCQA budget comes from the Managed Care Organizations that they
So far.. no phone calls... (3/24/2000)... BTW...
yesterday I was paid by a Managed
Care Organization: $13.04 for a 30 minutes session of psychotherapy and medication management.. Do you know what was the patient's co-pay? Another $13.04... I was embarrassed when the patient paid me...
So far. no phone calls from the managers...
So far, no phone calls from the managers...
My God, how much do I wait?... (3/15/2000)
I have a 87 years old woman who has Alzheimer's Disease. She lives with her daughter
and she goes to a Senior Center. She is becoming agitated. The nurse at the Day Center is feeling helpless. The family is helpless. I have tried 4 medications to no avail. She had side effects with three of them. I suggested to the family that we should have a consultation with a Geriatric Center close by with a doctor who have a lot of experience with these cases. I learned that I can't make a referral before talking to a "Care Manager". I called the Managed Care Corporation and spoke with a nice lady there. I gave my name, the patient's name, her insurance, her insurance number and all. I explained the case and the need for the consultation. She said that I would have to talk to a "Care Manager" but "they all were very busy". She then asked for my phone promising that one of them would call me back. The day has gone by and... nobody called so far. It is now 7 PM. I made the call at 1 PM.
Remember this case below? So far... no calls.
I will wait... (3/10/2000)
I have this patient that is transferring to me. He belongs to an HMO and he is under Managed Care. My billing lady tells me that I must call the Managed Care Corporation to have "authorization". For the past week I have called three times. Things always go the same way: "Sir, let me connect you with one of our case managers". Then I wait. Then she comes back and say that "all our case managers are busy, please leave your number and one of them will call you". I leave three numbers: my office, my cellular phone and my pager. So far they did not call back. One week has gone by. Today I called again... The same story. My God, what has happened to my noble profession?...
Saturday Struggle (3/4/2000)
These are my notes. I changed names to protect confidentiality.
Patient not doing well. She is not sleeping. She is worried about her heart because of pains and palpitations. She wants to be checked in an E.R. I said that this is OK. I had increased her Trazodone to 150 mg HS and she is still not sleeping. She was resisting taking the Celexa but this AM she took 10 mg. I am encouraging her to take 20 mg tomorrow. I am going to prescribe for her Restoril 15 mg, take one or two at bed time. Will keep the Celexa and the Xanax. It seems to me that we are now dealing with a full fledge Major Depression. I will see her tomorrow.
The patient came with her husband. She has lost weight. She is shaking. She is crying. She has not slept for the past week (or slept very little). She is pacing the house. She is full of guilt. She is very worried about her body, close to a delusional state. She is afraid that she had a stroke and that she is having a heart attack. She is in panic. She doesn't want to be seen by anyone. I advised her to go to the hospital to be checked physically and to have a psychiatric consultation for admission. Later on the hospital called me and they were checking her physically. They were going to call the "mental health people". A Social Worker then called me and said that "we know that she will not meet criteria for admission because she is not talking about killing herself or other people". I said that this woman was deeply depressed, and becoming delusional fast, that she was not responding to medication, that she had lost weight fast and that she was not sleeping for one week and was in a state of panic. She was a high risk to her physical health. That she needed to be in a hospital to be monitored, supported and to have her medication adjusted. The Social Worker said that she was going to "try to sell the case to the insurance company, but you know how they are...". Actually she
was talking about the Managed Care Organization that does the mental health carved out for this insurance company (for profit).
Social Worker called back. She said that she consulted with Dr. XXXX XXXXX (888-XXX-XXXX) from the MCO, and he said that the patient "did not meet the medical necessity criteria for admission". She said that I could page him if I needed. I did. He called me back. He said that she did not meet criteria for inpatient treatment. I explained that she was not responding to medications, she was becoming delusional, she was without sleep for one week, that she was alone during the day at home, and she was losing weight rapidly. That she was a high risk in terms of her health and safety.. He suggested that maybe she could go to a Day Program. I said to him that if she and her husband agreed to go to the Day Program I would give it a try. He then said that he would call and talk to the Social. He did. Then the Social Worker called me back and said that the patient and her husband were willing to go to the Day Program. I asked to talk with the husband. He said to me that No, he would not be able to take the wife to the hospital for the Day Program because this was her main anxiety: he stopping work. With she not working this would add to her worries. He feels that she will not go with him. I then spoke with the Social Worker again and said, the man is saying that he will not be able to drive her back and forth to the day hospital and she will refuse to go. He is very angry at the insurance company saying that "there is nothing I can do". The Social Worker was ready to discharge the patient back to my care and wanted to know what I would like for them to do for the patient. I explained that they will not go to the Day Program. She is going to call him back (10.16 PM)
3/4/2000 (10.49 PM)
Social Worker called me back, She informed the doctor that the patient and the husband would not be able to attend the Day Program. She said that the doctor said that even though "we should give it a try" and he would not accept the admission despite the fact that he told me that if she refused to go to the day hospital that then he would admit her. The Social Worker told me that he was going "to appeal" to another doctor of XXXXXXX and that this would be final. He would tell the Social Worker the result of the appeal. She will then call me.
3/4/2000 (11.59 PM)
Dr. XXXXXXX who works for XXXXXXX listened to the appeal and decided that "she doesn’t meet the criteria for admission". He then said that I had two options: either accept their decision or admit her and she would appeal after she leaves and they would judge if the hospitalization was necessary. But if they denied it the patient would have to pay the bill. So here we have a case where not only me, but the Psychiatric Social Worker and the Somatic Physician in the Emergency Room feel that the patient needs to be admitted. But the two doctors from XXXXXXX from a distance decided that "she doesn’t meet the criteria". So she is going home and we hope that Monday her husband will leave his work in order to take her to the Day Center approved by the insurance. The patient has been in the Emergency Room now for at least 6 hours.
I saw a MCO patient yesterday. I need to know how often and for how long can I see her. That is, what the Managed Care Corporation will "authorize" me to do. I called then today. After going through two people and listening to a lot of music I spoke with someone. She "authorized" me to see her that first time. For me to see her more I will have to send a two pages "Treatment Plan" for them to "approve". Usually they will "approve" 90862 because I am a psychiatrist. That is 15 minutes sessions for "medication management". If I want to see the patient a little longer and be more supportive in a psychotherapeutic way and I ask for 90805 (Psychotherapy with Medication) they may pay me less than they will 90862. Of they may pay me the same or one or two dollars more. So this is one of the ways I am discouraged to spend more time with my patients even if it is 15 minutes more...
Med-checks x Psychotherapy (3/12000)
I asked the secretary to find out for me how much the MCOs pay for 90862 (15 minutes Med-Check) versus 90805 (30 minutes psychotherapy and medication check) and 90807 (45 minutes psychotherapy and med check). Here is what she faxed me back:
" The Xxxxxx xxxxx ssss allowable for 90862 $45.00, 90805 $42.00, 90807 $70.00. The person I spoke to said that he believes the rates are 42 and 70, but could not give me an exact figure. These rates are different than the other MCO's accounts. Other rates: Levell II Key Group: 90862 $45.00, 90805 $47.00, 90807 $50.00. HMO, 90862 $40.00, 90805 42.00, 90807 $45.00. State of Maryland: 90862 $45.00, 90805 $45.00, 90807 $50.00."
Can you all see how psychotherapy has no value?...
I am in the panel of a health insurance.. That is in most of their plans... Today I learned that one of my young patients, fifteen years old who had been suicidal some time ago and is still very depressed, no longer can be in treatment with me. Yes, I am in their panels. But not on in itsHMO. The mother changed her insurance. Why I am not there? I don't know. The patient is distressed, her mother and grand mother came to talk to me. They are distressed with the prospect of having to look for another doctor. They are willing to pay out of pocket for the continuity of the treatment. I am not sure if this is the way to go. They paid their premiums. They ought to have what Aetna promised them. Really don't know why I am not in the Aetna HMO if I am in all other Aetnas. I really don't know what to do. Will call the insurance company tomorrow (my God...will stay in the phone for how long?...)
More nightmare... (2/25/2000)
If you are not in the field you will think that I am exaggerating. I am not. The bill a carved out Managed Care Corporation is close to impossible. I am back to paying 12% of my gross to a billing corporation after spending more than o thousand dollars with software. Despite it all I continue to get denials, authorizations for three sessions, and all kinds of harassment's. Of course they want my charts to be perfect and from time to time they want to audit them to see if they look good. The charts I mean. Sickening... Today I discovered that two Managed Care organizations will pay me less if I see a patient for 30 minutes than if I see him or her for 15 minutes. They want to make a "med-checker" (90862) out of me but I keep trying to do psychotherapy and medication in 30 minutes (90805). No way. They will pay me less for working 30 minutes than for working 15. Now, please let me know: does this makes sense?...
I hate to admit... but... good news... (2/23/2000)
Recently I had a pleasant surprised coming from a managed care corporation. First, when the time came for me to send the endless and repetitious forms for re-credentialing, I felt that I was being more respected. Instead of asking the same repetitious questions that they already know the answer - for instance my medical school - they only asked WHAT CHANGED SINCE THE LAST TIME I WAS RE_CREDENTIALED. Second, they now have a WEB page. Instead of me being in the phone listening to piped music to ask about my claims they allow me to check on line this information. It takes minutes! You know, despite my profound disgust with managed care in general I must be just when I see changes like this for the better.
Billing: a new industry in the USA (2/15/2000)
It has become so difficult to collect from the Insurance Companies and their contracted Managed Care Corporations that now there is a new industry in the US: Medical Billing. If you doubt what I am saying please to to any WEB SEARCHER (Yahoo for example) and look for "Medical Billing". You will be amazed. Not only there are now a large number of organizations that offer billing services for physicians, but there are also a number of computer software with the same purpose. They of course cost money. And they are forever falling behind because it is indeed close to impossible to deal with "Treatment Plans", "Denials on the Basis of Medical Necessity", different co-pays even for the same patient and denials of payments. Just to follow up the denials and lack of response from the claims it takes a very long time in the telephone waiting in line while listening to music and a computerized message that "Your call is important to us, please stay in the line while our attendants are servicing other customers". I am not exaggerating. Everything is done to minimize care and maximize profits.
Recredentialing... (better called harassment)
Today I received another package from a MCO. Now I must send to them within 30 days all the information they ask in order for me to be "re-credentialed". The "forms" have six pages. Each MCO sends me this every two years. I already have to do this to renew my license with the Board of Physicians Quality Assurance for my State. Can you imagine the amount of time and paper work involved?...
Nightmare II (2/7/2000)
I have been considering retiring from my loved
profession. It seems impossible to continue to work under managed care.
In order to do so I must be able to bill the MCOs, keep track of the treatment
plans and call the MCOs when they don't pay my claims. I also have to work
under their constraints, for instance, more often then not they don't allow
me to do psychotherapy with my patients. Instead they force me to refer
these cases to social workers and psychologists and only allow me to do
what they call "medication management", that is, to meet with the patients
for 15 minutes to "review their medications". Of course by doing four medication
checks an hour I will make more money than if I do one session of medication
and psychotherapy in one hour. This is a way that they want to give me
"incentives" to see four patients an hour without psychotherapy. But money
should not be the only consideration when a good professional works with
his patients. In order to keep track of all of this I must have a full
time expert secretary that will cost about half of my income in the part
time private practice I have. Or I can contract with a billing corporation
at 12%. I can't do it alone even though there are computerized programs
that try to do the work for me. But they don't call the MCOs to ask about
delayed or non payments. When I do this I must stay in the phone from 5
to 60 minutes listening to recorded music.
I moved my office in the middle of August. I changed
my billing agent. Yes, you will
have to have a billing agent to take care of your billing and keep track of your treatment
plans and authorizations. A nightmare. My new billing agent did not do too well. The consequence is that I have not been receiving payments from the MCOs and I am falling
behind. When they send a wrong billing, or fill the HCFA form with a mistake, the
MCO will not pay and many will not say anything. So I must track when I sent the claim
and when I am paid. When I am not paid I must call the insurance company to find
out why. If I make a mistake and see a patient after the "authorization" has ran off
I am not paid. Some colleagues are using special billing and tracking software. Others
have to have secretary (ies) only for this purpose. It is a nightmare. I don't know what
I am going to do to recover all these payments that were denied in the last six months.
A nightmare. Lately I have been thinking frequently about leaving the field that I have
loved for a long time. It is becoming impossible to work under the MCOs.
I read in the paper today that the old, historical buildings of a traditional hospital in Baltimore will be closing. New buildings will be coming. So far, so good. But then, in the paper the writer says that this is a consequence of Managed Care. That in the past patients could stay longer in the hospital, some would stay even for 1 year or more. Now the average stay is... 8 days! Instead of the old home like buildings, most likely there will be places where people will stay up to 8 days to be discharged or moved to other caretakers, going from hand to hand without ever connecting to one human being. Of course the heavy emphasis is on medication... the quick fix. People no longer have time to learn about their difficulties, they no longer have histories. Only brains...
17 years old. His father committed suicide three years ago while talking with him in the phone, He has been depressed and suicidal. In May went to the hospital voluntarily seeking treatment. They kept him as inpatient for 4 days and then kept him in a Partial Hospitalization Program for one month. Discharged him to continue with individual psychotherapy. In September became suicidal again. Went to the hospital. Was kept 4 days in the inpatient and 2 days in the Partial Hospitalization Program. Now he is trying to go back to school. Remains depressed. Can't tolerate school. I called the hospital and asked why they discharged him so soon. Managed Care is an important factor. Here we go...
I have to pay a billing agency because with so many co-pays and deductibles, plus treatment plans to keep track of I would not be able to do my work by myself. Now...do you want to know how fast Managed Care pays my bills? Take a look here. Look how long it takes to me to collect. Look how much they pay me. Look the variety of fees. Isn't this a mess? 90805 means 30 minutes with the patient. 90807 forty five minutes.
Date Paid Insurance Code Amount Date of Service
9/2/l999 $5.00 5/ 3/1999
9/2/1999 $5.00 7/ 6/1999
9/2/1999 $5.00 6/ 5/1999
9/2/1999 $5.00 6/26/1999
9/ 3/1999 90805 $28.62 8/ 7/1999
9/ 3/1999 90805 $21.09 7/19/1999
9/ 3/1999 90805 $30.95 3/ 1/1999
9/ 3/1999 90862 $43.87 10/ 3/1998
9/ 3/1999 90862 $43.87 11/ 7/1998
9/ 3/1999 90862 $43.87 9/ 5/1998
9/ 3/999 90805 $47.70 8/ 2/1999
9/ 3/1999 90805 $32.00 5/ 8/1999
9/ 3/1999 90807 $60.00 7/ 6/1999
9 3/1999 90805 $33.60 8/ 2/1999
9/ 3/1999 90843 $37.00 11/22/1997
9/ 3/1999 90844 $65.00 2/ 7/1998
9/ 3/1999 90843 $37.00 5/ 2/1998
9/ 3/1999 90843 $37.00 6/ 6/1998
9/ 3/1999 90843 $28.00 11/22/1997
9/ 3/1999 90805 $22.00 8/ 7/1999
9/ 3/1999 $0.00 6/28/1999
9/ 3/1999 $15.00 0/ 0/ 0
9/ 3/1999 $15.00 6/28/1999
9/ 3/1999 $0.00 2/ 2/1999
9/ 3/1999 90805 $16.15 3/15/1999
9/ 3/1999 90805 $16.15 3/23/1999
9/ 3/1999 90805 $9.84 4/24/1999
9/ 3/1999 90805 $9.84 4/24/1999
9/ 3/1999 $15.00 0/ 0/ 0
9/ 3/1999 $15.00 4/24/1999
9/ 3/1999 90805 $9.84 5/22/1999
9/3/1999 $15.00 0/ 0/ 0
9/ 3/1999 $15.00 5/22/1999
9/ 7/1999 90805 $16.15 8/ 3/1999