behind the scenes, insurance insanity

Watch an Insurance Company Try to Drive Me Insane..Yet Again

Well, I guess I’m sort of creating a series about insurance company insanity.  I didn’t start out meaning to do it, but so many opportunities keep presenting themselves!  Here’s a new one.  One of my patients needed to get a specific type of stress test.  Of course, I can’t just order it.  No.  It has to be approved by her insurance company, via a middleman company that runs their approval process.  So, first we call them for approval.  Then we send a copy of my office notes.  Then, without fail, this happens.

This message  says that my office notes that I sent them don’t meet their clinical guidelines for approval.  I need to call them and talk to the physician reviewer to plead my case.  Note that the message was received at 4:45 PM.  Convenient.  I was not able to return the call that business day.  A good thing, too, since the next morning first thing off the fax, is this:

A notice saying they’ve approved the stress test, even though about 12 hours before they had denied it.  I never called them.  So, what happened between 4:45 PM on April 23 and 8 AM on April 24?   I have no idea.  Nor do I wish to look a gift horse in the mouth.  However, the best part of that approval fax is that right after we got it, we got this:

Yup.  You read it right.  Another request for additional clinical information, for the test they had already approved.

Just another day at the office.  Just another gray hair.

Marni’s Army is Hitting the Road

It’s hard for me to believe, but it’s been 8 years since I started the Beacon Runners (AKA Marni’s Army).  Back then, I was young and idealistic.  More importantly, I didn’t have kids yet and had loads of free time.  At the time, I had been running for about 4 years- I started running during my residency so I could get some exercise and stress relief.  During my first year in practice here in NH, I got tired of just lecturing all my patients on the importance of exercise.  I decided to put my money where my mouth was and actually get out there and exercise with my them.  Every year the group has gotten bigger, and it’s wonderful to see familiar faces returning year after year.  It’s great that eight years later we are still going strong, meeting every Tuesday and Saturday in April and May.

There was a great turnout tonight- how can you beat 80 degree weather and a great evening run at the beach?

behind the scenes, insurance insanity

Watch an Insurance company try to drive me insane…again

More formulary exemption/prior authorization fun!  This one says that the patient’s blood pressure pill, Cardizem CD, is not covered and it is non-formulary.  They helpfully tell me what the formulary alternative is: diltiazem CD, which is the generic form of Cardizem.

That’s all pretty reasonable, right?  Except here’s a copy of the script I wrote.  IT’S ALREADY WRITTEN FOR DILTIAZEM CD!!!  $@#*^!!!

I really think that these companies hire people whose only job is to sit around and figure out how to make our lives harder.
study of the week

Choose…But Choose Wisely PART 9

Yay!  The light at the end of the tunnel nears.  Tonight I can conclude this 9 part series with the American Society of Nuclear Cardiology’s list.

1. Don’t perform stress cardiac imaging or coronary angiography in patients without cardiac symptoms unless high risk markers are present.
This has pretty much been covered, both by the ACP, the AAFP and the ACC.  If you don’t believe it by now, I guess there’s nothing that will convince you.

2.  Don’t perform cardiac imaging for patients who are low risk.
Ditto to the above.

3.  Don’t perform radionuclide imaging as routine follow up in asymptomatic patients.  
Already covered by the ACC.

4.  Don’t perform cardiac imaging as a pre-operative assessment in patients scheduled to undergo low or intermediate risk surgery.
Already covered by the ACC.

5.  Use methods to reduce radiation exposure in cardiac imaging, whenever possible, including not performing such tests when limited benefits are likely.
Always.  We always need to watch radiation exposure and aim for ALARA (as low as reasonably achievable).

That’s all, folks!  More lists will be released throughout the year, and I’ll be sure to review them for you!

study of the week

Choose…But Choose Wisely, Part 8

On to the American Academy of Allergy, Asthma & Immunology’s list.

1.  Don’t perform unproven diagnostic tests, such as immunoglobulin G (IgG) testing or an indiscriminate battery of immunoglobulin E (IgE) tests, in the evaluation of allergy.
There’s a lot of talk out there about food allergies.  IgE- mediated food allergies are the scary kind- the kind you think about when you think of peanut allergies.  Face swelling, hives, throat closing up stuff.  Scary.  Hey, I can show you what it looks like.  My son Alex is allergic to fish, as we discovered last year when we fed him stuffed cod.  Here’s a picture.  Note the swollen eyes and lips and the hives around his eyes and nose.  I think I aged about 10 years that night.

Anyway, that’s an IgE-mediated food allergy.  This recommendation states that when a child has a suspected food allergy, do targeted IgE testing.  For example, Alex was tested for shellfish, crustaceans, and fin fish.  Nothing else was checked.  However, there’s also a lot of talk, especially among the alternative medicine crowd, about IgG testing.  These are blood tests that claim to show sensitivities to a bunch of different foods.  I’ve had patients bring in blood tests results done by other practitioners that claim to show that they are allergic to literally dozens of foods.  They are basically eating brown rice and boiled chicken.  No joke.  These tests have NO evidence to support them.  None.  Don’t do them, and don’t get them done.
2.  Don’t order sinus computed tomography (CT) or indiscriminately
prescribe antibiotics for uncomplicated acute rhino sinusitis.
Already discussed here, but takes it one step further by reminding us that CT scans are not needed in the management of sinusitis. 

3.  Don’t routinely do diagnostic testing in patients with chronic urticaria.

Chronic urticaria is a fancy way of saying hives.  Chronic hives are miserable.  The constant itching can drive you nuts.  Hmmm…might I be speaking from personal experience?  I had hives in med school.  Luckily, they seemed to go away after a year or two.  Like most people with hives, I never figured out what caused them.  Testing is rarely helpful- time and effort should be spent on managing symptoms.
4.  Don’t recommend replacement immunoglobulin therapy for recurrent infections unless impaired antibody responses to vaccines

are demonstrated.
Some people have an immunoglobulin deficiency, which can lead to increased susceptibility to infections.  However, low immunoglobulin levels don’t always need to be treated- the levels need to be clinically significant.

5.  Don’t diagnose or manage asthma without spirometry.
 Spirometry is a test that can be done in the office.  It measures how much air is getting out of the lungs in a breath.  It’s a great test to diagnose and monitor asthma, and can help guide treatment.

Wow, one list left!  Still with the weird formatting.  I should just pretend that I’m doing it intentionally.

Choose…But Choose Wisely, Part 7

Wow, up to Part 7 today.  Up today- the American Society of Nephrology- the kidney doctors.

1.  Don’t perform routine cancer screening for dialysis patients with

limited life expectancies without signs or symptoms.
This could be a tad bit controversial.  The recommendation is that routine cancer screening (mammograms and colonoscopies, for example) not be performed in dialysis patients unless they are transplant candidates.  The reason for this is that the life expectancy of a dialysis patient is very limited, unless they will be getting a transplant.  A table of the expected remaining lifetime can be found here.  For example, the average 50 year old has 30.7 years of life remaining.  The average 50 year old on dialysis has 6.2 years of life remaining.  Looking at those statistics, it just doesn’t make sense to do routine cancer screening in those cases.  I’m sure some people will read that and scream, “Rationing!” and “Death Panels!”  I suppose in a way it is rationing.  I’m not sure there’s anything wrong with that.  However, that’s a post for another day.

2.  Don’t administer erythropoiesis-stimulating agents (ESAs) to chronic kidney disease (CKD) patients with hemoglobin levels greater than or equal to 10 g/dL without symptoms of anemia.
 This recommendation is regarding drugs that stimulate the production of red blood cells.  Many patients with kidney disease are anemic- that’s because the hormone that stimulates red cell production is made in the kidneys.  In the past, ESAs were given with the goal of getting the hemoglobin to a normal range (around 12.0).  However, many studies have been done that actually show worse outcomes when the hemoglobin is “normal.”  The recommendation is to not aim for a hemoglobin of greater than 10.

3.  Avoid nonsteroidal anti-inflammatory drugs (NSAIDS) in individuals with

hypertension or heart failure or CKD of all causes, including diabetes.
NSAIDS (ibuprofen, Celebrex, Mobic, naproxen, etc) are bad in people with kidney disease.  ‘Nuff said. 

4.  Don’t place peripherally inserted central catheters (PICC) in stage

III–V CKD patients without consulting nephrology.
A PICC is a type of IV line.  It is inserted into the arm and runs into the central veins.  It’s not a good idea to put them in someone who might be needing dialysis in the near future, because it can mess up their veins and limit options for access for dialysis. 

5.  Don’t initiate chronic dialysis without ensuring a shared decision-

making process between patients, their families, and their physicians.
This one is likely to be the most controversial recommendation of all, and the one most likely to make the death panel crew pick up their pitchforks.  However, I think it’s spot on.  Not every patient who has end-stage renal disease should get dialysis.  Remember that chart I showed you before?  It’s here. A healthy 80 year old has an average of 8.4 years left.   A person who is a candidate for dialysis almost certainly has many other medical issues, and it’s unlikely they are looking at 8.4 years- they might be looking at half of that.  The life expectancy for an 80 year old on dialysis is 2.3 years.  So, we’re looking at a potential gain of perhaps 2 years, maybe a bit more or less.  Of those years, they will be in a dialysis unit for 3 to 4 hours at a time three times a week.  In 2008, one year of dialysis cost $72,000 per patient.  That’s just for the dialysis, not the associated medications and treatment for other illness.  This is a big burden for patients, their families, and society- it needs to be carefully looked at.

Again with the weird formatting.  I give up.  HTML, you are my nemesis.
study of the week

Choose…But Choose Wisely, Part 6

On to the American College of Radiology’s list.

1.  Don’t do imaging for uncomplicated headache.
This means, don’t get an MRI or CT scan on everyone with a run of the mill headache.  Most people with headaches don’t need imaging.  There is a lot of evidence out there to support this- it’s very rare that imaging will change the outcome or management of a case.  If you’re interested in learning more about this, check out this article.

2.  Don’t image for suspected pulmonary embolism (PE) without moderate


or high pre-test probability. 

Already discussed here.

3.  Avoid admission or preoperative chest x-rays for ambulatory patients 

with unremarkable history and physical exam. 
Already discussed here.

4.  Don’t do computed tomography (CT) for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option.

 I’ll take their word for this.   I don’t practice pediatrics.  Never liked it, even in med school.  

5.  Don’t recommend follow-up imaging for clinically inconsequential adnexal cysts. 

Good one!  Everyone who ovulates gets ovarian cysts.  It’s part of normal physiology.  Sometimes they cause pain and a ultrasound gets ordered.  If it’s just a simple cyst, it’s nothing to worry about and doesn’t need to be followed up.  

I apologize for the completely bizarre formatting in this post.  I have no idea what that’s about, and I’m too tired to figure it out now.