insurance, insurance insanity, Medicaid, primary care

Well, no chance of confusion here.

You know how insurance companies drive me crazy with their drug approval forms?  Well combine an insurance company with the government, and you get Medicaid. And when you get Medicaid, you get gems like this:

Approved?  Unable to approve?  Which is it???

On a side note…the best thing someone can do for their health is quit smoking.  Forget about losing weight, exercising, getting a Pap smear.  If you want to get the best bang for your buck, quit smoking.  With this in mind, why is it that Medicaid will cover Buproprion and nicotine replacement like the patch or gum, but won’t cover Chantix?  After all, the results for Chantix are superior to those for nicotine replacement.  In the long term, it’s even cheaper than trying and failing other therapies.  So, what gives, Medicaid?  I don’t like requirements that my patients “try and fail” medications.  I aim for success the first time out.

coding, ICD-10, insurance insanity

Well, I stand corrected.

I recently posted about the absurdity of the new ICD-10 coding system, which features various crucial codes, such as “bitten by orca” and “sucked into jet engine.”  In my usual sarcastic manner, I pointed out how silly the level of detail of the coding system is.

Well, I stand corrected after reading this article today.  It appears that Harrison Ford was injured on the set of the new Star Wars film, when the hydraulic door of the Millennium Falcon starship fell on his ankle.  Poor guy.  He was airlifted to the hospital and is expected to do ok (and I must say that Harrison Ford is looking mighty good at 71).

But now we’re left with a conundrum.  How should we code this encounter?  See, using ICD 9, I would code it as 928.21 (crush injury, ankle).  But now…there are so many choices!  How about… W23.0XXA (Caught, crushed or pinched between inanimate objects).  Oh, but wait.  That code excludes inanimate mechanical forces involving military or war operations, so that’s out.  I mean, the is Han Solo we’re talking about, and he’s fighting the forces of the Empire.  So….Y36.101 (war operations involving destruction of an aircraft, civilian)?  Maybe…

Wait!  I’ve got it!  V95.40XA (unspecified spacecraft accident injuring occupant, initial encounter)!!!

Whew.  That was close.  Thank heavens for ICD-10!

insurance insanity, pharmacies

Highway Robbery

I recently had a patient ask me to change his medication for his insomnia.  He had been using it on an intermittent, as needed basis with no problem, so I was surprised and asked him why he wanted to change.  He responded that he didn’t want to, since it worked fine.  However the price for the medication was going up from $10 a month to $85.   He showed me what his insurance company had sent him:

His company “helpfully” suggested an alternative.  Just to be clear- trazodone is in no way a similar drug to temazepam.  They are not in the same class of medications, and have different efficacies and side effects.

Now, I was surprised that temazepam, a drug that has been generic for quite a while, was so expensive.  So I decided to find out what the retail cost was.  Sure enough, you can get a month’s supply at Costco for $9.33.

What could possibly be the excuse for this?  I understand that a store like Costco might use cheap prescriptions as a loss leader for people to shop there (although anyone can use their pharmacy, you don’t need to be a member).  However, I would like to point out that UnitedHealthcare Insurance Company had a 2012 profit of $5.1 billion.  That’s $5.1 billion.  Just wanted to make sure you got that.

Most of us have noticed that our insurance premiums have gone up quite a bit this year.  That’s why this stings even more- it appears that some insurance companies are actually profiting off of our medication expenses.

As for my patient, I kept him on his temazepam, and told him to fill the prescription at CostCo and to pay cash.

insurance insanity, medications, PBMs, pharmacies, primary care

Even my paperwork has paperwork

Happy New Year!  For me, the new year brings a new onslaught of those lovely prior approval forms– that oh-so-crucial paperwork that insurance companies make me fill out to prove that the medication I prescribe is really, truly indicated (because I like to put people on prescription meds just for kicks, right?) and the absolutely, positively, cheapest thing around.  

For some reason, insurance companies seem to think that sometime between 11:59 PM on December 31 and 12:00 AM on January 1, everyone’s medical problems are instantaneously cured.  They must think that, right?  Otherwise, why else would everyone seem to need new prior approval forms on January 1?  And new referrals to other doctors?  It makes perfect sense.
Here is a new and annoying trend that I’m seeing.  Instead of just making the prior approval form available to me, Caremark now makes me fill out a form to get the correct form.  You read that right.  I now have to do paperwork so I can get more paperwork.
So, I have to fill out this form with all of the drug information and fax it to them so they can send me an even more specific form.  And while they’re playing these games, on the other end there is a real live human being waiting for their medication.
By the way, the drug that I’m ordering?  Costs $15.99 cash.  
And we wonder why the cost of American health care is so expensive.  
annual physical, insurance, insurance insanity, medicine, primary care, wellness exam

Physicals, Billing and Insurance: Coding 101

The “annual physical exam” is somewhat sacrosanct. It’s also a bit contentious. Often doctors and patients swear by its importance, while lots of research shows that the annual physical does not really show any evidence of contributing to better health.

I’m not going to talk about the values of the annual physical today- that would be a post for another day. What I am going to talk about is how we charge for an annual physical and how an insurance company pays for it.

First off- it is imperative to understand a bit about how we charge for medical visits.  We do this by a process called coding.  Every diagnosis under the sun is assigned a “code.”  There are literally tens of thousands of codes.  The code for an annual physical is V70.0.  Every time I see someone in the office, I have to write down the codes for all of the diagnoses that I am dealing with at that visit.   Then, based on the complexity of the visit, I assign an “evaluation and management code” to the visit.  This basically grades the complexity of the visit on a scale of 1 to 5, with 5 being the most complex.  How I reach that number is totally complicated and nuts, but again, that’s a post for another day.

Physicals are billed using a V code.  V codes signify that medical care is taking place that does not involve an E&M level.  Preventative care, such as the annual physical, falls into this category.

What does all of this blather mean?  It means that an annual physical is purely a “wellness” visit.  Coding guidelines specifically state that there are “no complaints” for an annual physical, meaning that the patient is healthy and only preventative care is being discussed.

Why is this important?  Most insurance companies, and Medicare, pay for an annual wellness physical with no copay and no out-of-pocket expenses.  There is no deductible for most plans.  However, the only thing covered is the wellness exam.  Technically, if you have an acute complaint the day of a physical, one of two things should happen.  Option one- the appointment is no longer a physical and should be charged as a regular office visit and assigned an E&M level.  Option two- the appointment is still a physical and is charged as a physical with what is called a modifier code.  A modifier code allows both a physical and an acute office visit to be charged at the same time.  With either option one or two, you are going to have your regular copay and deductible apply, because it is no longer just a routine physical.

I don’t usually take option two.  If someones acute complaints are severe enough for me to consider either of these options, I take option one.  The visit becomes a regular office visit, and we re-schedule the annual physical to another day.

Here’s an example.  Let’s say someone schedules an annual physical with me.  While reviewing their general health, I find out that they’ve had uncontrolled thirst and urination for a month.  I check their blood sugar and it’s 300.  They have new-onset diabetes.  At this point, this is no longer a routine wellness visit.  I need to get lab work, start medications, and educate the patient regarding diabetes.  This needs the patient’s full attention, and mine, and it deserves a visit all of its own.

Here’s another example.  A patient comes in for an annual physical.  She is visibly anxious.  She just found a breast lump and is very concerned because her mother died of breast cancer.  Again, this is no longer a routine annual physical.  It is now an acute visit for a breast lump.  The patient needs some tests, possibly a referral to a surgeon, and counseling.

Get it? Here’s the crux of the matter.  Just because you want a physical doesn’t mean you’re going to get one.  Just because you booked a physical doesn’t mean you’re going to get one.  What you are going to get is appropriate medical care.  The rest is just semantics.  However, if you get appropriate medical care that is NOT a routine physical, chances are your insurance company is going to want you to pay your copay and deductible.

And that’s not my fault.  I don’t make these Byzantine rules, but I do need to follow them.  My job is to provide the correct medical care.  My contract with your insurance company requires me to bill them appropriately.  So, DO NOT ask me to bill an acute visit as a routine physical so that your insurance will cover it.  That’s called fraud.  And I won’t do it.  Period.  End of discussion.  Even if you’re my favoritest patient in the whole wide world.  No matter how much I love you, I won’t commit fraud and risk prison time for you.  Sorry.

insurance insanity

Watch an Insurance Company Try To Drive Me Insane- Algebra Edition

Wow.  Express Scripts/Medco must really HATE people who have herpes.  This is the second post in a row about trying to get proper treatment for this condition.  This time I wrote a prescription for acyclovir, a generic anti-viral.  The correct dose for suppression of herpes is 400mg twice a day.  That’s what I wrote for.

Of course, they asked me to fill out a prior approval form for it.  Now, please note, acyclovir is CHEAP.  It’s like, $30 a month cash.  It’s the cheapest option for treatment.  But, again, like a good little soldier, I filled out their form.  And got back this:

Ok.  First of all, who the HELL figures out dosages like this?  80,000 mg of acyclovir every three months?  What????  So, I did a couple of quick calculations in my head.

400 mg x twice a day = 800 mg/day.  800 mg/day x 90 days = 72,000 mg.

So, this is what I sent back to them.

It’ll be interesting to see what they say.  
Also:
80,000 mg per 90 days = 888 mg/day.  Acyclovir comes in 200, 400 and 800 mg tablets.  How do they expect anyone to take 888 mg/day?
insurance insanity

Watch an Insurance Company Try to Drive Me Insane, Again

As you may or may not know, Express Scripts and Medco merged last year.  What are Express Scripts and Medco?  They are what’s known as Pharmacy Benefits Management companies (PBMs).  Basically, they are a third party that processes prescription claims.  They are the ones who create the charming prior approval forms that I’m always complaining about.

Anyway, two of the largest companies, Express Scripts and Medco, merged. They made sure to reassure customers that they would continue to “receive the high-quality care you expect.”  Well, my expectations were pretty damn low, and I’m happy to report that the newly merged company has more than met them.

Oh, I hope you enjoy my new Post-It notes that I’ve used to block out identifying information.  They eloquently express my feelings.

This saga started on January 8, when I received a PA form for valacyclovir, an anti-viral medication that is generic.

On January 10, I received a letter from Medco, stating that the PA was not even needed.  Please note, THE PATIENT HAD ALREADY PICKED UP THE MEDICATION ON JANUARY 8, THE SAME DAY I WAS MADE TO FILL OUT THE DAMN FORM IN THE FIRST PLACE.
Then the patient’s pharmacy (CVS) called me asking, “Where the hell is the PA for this patient’s medication?” despite the fact that they HAD ALREADY DISPENSED THE MEDICATION TO HER!
I faxed them the form form back saying that no PA was needed and faxed a copy of the letter to them.  They apparently didn’t really care, because they sent me another request for a PA on February 5.
I faxed them a copy of the letter again.
Then, today, I received another PA from Express Scripts for the medication!  Two months into this saga.  Like a good little soldier, I filled it out again.
After I filled it out today (since I received it today), I got this fax, sent today but dated yesterday.

Apparently, they are unable to approve the medication that they have already approved.  Why not? Because apparently my evil twin withdrew the PA request.  So, Medco tells me it’s not needed, Express scripts tells me it is, and hours of time are wasted.

Read what Express Scripts had to say in their press release about the merger:

“Our merger is exactly what the country needs now,” said George Paz, chairman and chief executive officer, Express Scripts. “It represents the next chapter of our mission to lower costs, drive out waste in healthcare and improve patient health. We remain focused on formulary management, channel management and closing gaps in care, which will allow us to further improve the health of people with chronic and complex medical conditions.

Yup.  Tell me another one.

I can’t wait to see what’s waiting on the fax for me on Monday.