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.

demonizing doctors, insurance, medicare, Washington Post

Can’t win for losing

The Washington Post recently decided to demonize doctors, with a headline trumpeting, “An effective eye drug is available for $50, but many doctors choose a $2000 alternative.”  The article tells the story of a miracle drug treatment for wet macular degeneration, which is one of the leading causes of blindness.  Avastin was approved in 2004 for treatment of colon cancer.  It targets a protein called VGEF, thereby decreasing harmful blood vessel growth in cancer.  This same protein is linked to wet macular degeneration.  The company that makes Avastin, Genentech, has created a slightly different molecule and development process to make Lucentis, which is FDA approved to treat macular degeneration.  For all intents and purposes, the drugs are the same.  Both target VGEF.  Both are effective for macular degeneration, according to several independent trials.  However, Genentech has only sought FDA approval for Lucentis to treat MD.  It does not produce Avastin in the proper size to treat MD.

Despite this, many ophthalmologists still use Avastin to treat MD.  They have to have a compounding pharmacy separate it out into the proper dose, which does introduce a risk of contamination, though the risk is slight.  However, using Avastin this way is certainly considered off-label, meaning using a medication in a way that is not FDA approved.

The newspaper clearly implies that doctors should use Avastin, and that there is no good reason not to. It implies that doctors who chose not to take the risk of using an unapproved drug are greedy, stating that the medicare reimbursement of 6% of the cost of the drug (a whopping $120) is driving their decision.

And yet, just a few months ago, The Washington Post published this article.  It decries the lack of oversight of pharmaceutical drug use in the elderly, specifically targeting the off-label use of drugs in Alzheimer’s patients.

So, which is it, Washington Post?  Am I a saint or a sinner?  Is off-label use good or bad?  Or maybe, just maybe, doctors are using their clinical judgment in individual situations to guide their decisions.


h/t to

coding, humor, insurance, medical billing, medicare

ICD-10 Crazy Codes

Medical coding.  It’s an entirely separate language that distills all medical problems down to a “code.”  Currently, ICD-9 is in use.  Every time you receive medical care, your diagnosis is translated to a code which is then used for billing purposes, among other things.   Your hypertension and high cholesterol? 401.9 and 272.4.  Your hypothyroidism? 244.9.

And so on.

ICD-10 is going into effect next year.  It will increase the number of possible codes from 17,000 to 141,000.  No potential for confusion or complications there.

Now, has medical practice become so much more complicated over the past 30 years that there are now 124,000 new diagnoses?  Of course not.  ICD-10 is just more specific than ICD-9.  Much more specific.

For example, if you were to present to your doctor now after getting bit by, say, a squirrel, the code would be E906.3 (bite of an animal other than an arthropod).  But under ICD-10, your doctor can actually code that it was a W53.21XD (bitten by squirrel) to make sure that it is not confused with a W55.42XD (bitten by pig).

Or, after that ill-conceived ocean swim, your doctor can bill appropriately for W56.01XD (bitten by dolphin) vs W56.11XD (bitten by sea lion) vs. W56.21XD (bitten by orca).

Do you see the importance of these distinctions??

There are other codes that I’m sure are crucial.  V9733XD (sucked into jet engine, subsequent encounter).  Got that?  Subsequent encounter.  They made a code to cover someone who got sucked into a jet engine, not once, but twice.


For those of you that worry about worst-case scenarios, there are also codes for you.  For example- T71224A (asphyxiation from being trapped in a car trunk).  This is to be distinguished from T71234A (asphyxiation from being trapped in a discarded refrigerator).  There are also codes to clarify if the fridge asphyxiation was accidental, assault, attempted suicide, or “undetermined.”  If you’re really unlucky, you might have to use V9020xA (drowning or submersion due to falling or jumping from a burning merchant ship- initial encounter).

By the way, I apologize for any typos.  I have a big bandage on my index finger, having done a W920xxA this morning (contact with powered kitchen appliance).

Actually, there’s one ICD-10 code that probably covers this whole coding thing quite nicely- K62.89 (pain, anus).

1984, insurance, medicine, PBMs, pharmacies, primary care

Big Brother is watching.

I’m willing to bet that most people think that what happens in the exam room is just between them and their doctor.

How wrong they are.

The Health Insurance Portability and Accountability Act (HIPAA), which came into effect in 2003, states:  A covered entity (that’s your doctor) may disclose PHI (Protected Health Information) to facilitate treatment, payment, or health care operations without a patient’s express written authorization.”

That means that all of your private health information can and is shared with your insurance company, pharmacy, and pharmacy benefits management company (like Caremark and ExpressScripts).  Don’t think they’re interested in what you’re doing?  Wrong again.  I am constantly getting “helpful” communications from them regarding what you’re doing.  Here’s an example:

Not taking your medication?  Don’t think I’m not going to find out!  Your pharmacy keeps track of how often you refill your pills.  They pass on this information to your insurance company.  They pass it on to me so I can…scold you?  Rap your knuckles?  Send you to bed without dessert?

I don’t find these communications helpful.  I find them insulting to my intelligence.  I know people don’t take their medications all the time.  No one does.  There’s lots of research to back this up.  Because I know this, I monitor their chronic issues.  I bring them in for blood pressure checks.  I do lab work.  I do physical exams.  If something is not as it should be, I address it and work with my patients to make changes they can live with.  If everything is A-OK, we leave it alone.  I don’t need to parent my patients.  That’s insulting to them.  I’m an internist- I take care of adults.  If I wanted to treat people like children, I would have been a pediatrician.

So, I’ll keep on adding on my own little check box that states “I find this communication to be useless.” 

Even if Big Brother wants me to scold and nag.  

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, insurance insanity, medications, primary care

Watch an Insurance Company Try to Drive Me Insane

It’s been a while since I posted one of these. Here’s another ridiculous prior approval form. It’s for zolpidem- the generic version of Ambien. Of course, this begs the question of why I need an approval form for a generic drug in the first place.
At the top of the form it says: Drug Name- Zolpidem.
The rest of the form goes on to ask the following questions:
1.  Is the drug Cialis, Levitra or Viagra?
     No, dumbass. The drug is Zolpidem, as written just a few lines above.

2.  Is the requested therapy Zyban?
     No, dumbass. The drug is Zolpidem, as written just a few lines above.

3.  Is the request for Aloxi, ondansentron, zofran, or Kytril?
     No, dumbass. The drug is Zolpidem, as written just a few lines above.

4.  Does the patient have hyperemesis gravidarum?
      What??? Where did that even come from? I write a prescription for a sleeping pill for a 65 year old woman and you ask me if she has uncontrolled vomiting from pregnancy????
And that’s it.  Those are the questions asked. Nothing actually related to the medication I had prescribed.  It was basically like playing a long game of 20 Questions, except I don’t think we ever got to the answer.
insurance, medicine, primary care

Because everyone is asking me what I think…

…here it is.

Unless you live under a rock, you know that today the Supreme Court ruled on the constitutionality of the individual mandate of the Affordable Care Act.  They upheld that the federal government does have a right to require citizens to purchase health insurance.

The question everyone has been asking me today is “What do I think of ObamaCare?”

My answer is, “I don’t know.”  Sorry to disappoint you.  That’s my answer.  Not because I’m uninformed on the subject, because I’m not.  Here is the reason why- I am interested in health care reform that will bring quality health care to my patients at an affordable cost.  Will the ACA allow that?  I don’t know.  No one knows.  We won’t know for several years.

Today’s decision only ruled on the individual mandate to purchase insurance.  Overall, I think this decision was the right one.  I’ll trust the SCOTUS on the specifics- they’re the experts on constitutional law.  From a health care provider point of view, I think everyone should have health insurance.  The only way there’s a prayer of that being affordable for everyone is for all people to have to purchase it.  The individual mandate has the ability to potentially lower costs, by spreading out the risk and bringing down premiums.  The ACA, in theory, does provide a way for all Americans to have health insurance, which is a good thing.  Will it work in real life?  Only time will tell.

 I will tell you one thing, in no uncertain terms.  Things have to change.  One way or another, the health care system needs to change.  It is no longer sustainable.  Will the ACA be the way to do it?  We’ll know in about 5 years.  Until then, I’m reserving judgment.