Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Friday, July 20, 2007

Great Alternative to a Busy Signal

Just when you thought you've seen it all:

We got a fax from a patient who had gone to a breast cancer risk assessment screening. Although she had tested negative for BRCA 1 & 2, her horrific family history qualified her -- according to the guidelines of this particular screening -- for annual breast MRI in addition to annual mammography.

Unfortunately, her insurance required pre-certification for the MRI.

My wonderful, woefully underpaid, long-suffering office manager spent 45 minutes on the phone answering dozens of questions over and over and over. Standard pre-cert shit. Their determination was that the patient didn't meet *their* guidelines for screening breast MRI. But I had options:
  • I could fax the letter saying that she met someone else's criteria for screening, or
  • I could call for "peer-review."
What the hell. I had a few minutes in the afternoon, so while finishing up charts I went ahead and used the speaker phone, dialed the peer reviewer number and hit option 4 as advised. I was then instructed to press 1 if I was a PA or NP, and 2 if I was a physician. Please don't be shocked to hear I was told that "All physicians are busy with other callers. Please hold."

At least the music wasn't too bad.

A minute or two later -- not long at all -- a woman got on the phone. She introduced herself as "Ms. So-and-so" (not "Doctor") and said this:
I apologize but all physicians are busy speaking with other physicians. Would you like to take the notification number or do you want to put your staff back on?
No questions; no nothing. Rather than keep me waiting or making me call back, because they didn't have a doctor available to speak with me right then, they APPROVED THE TEST.

WTF?

4 Comments:

At Fri Jul 20, 09:01:00 AM, Anonymous Jenn said...

I sold my soul and did UR for a few years. Sounds to me like they didn't expect to EVER get a physician on the phone. Where I worked the physician that did the peer reviews never would answer calls directly unless he had first left a message for the attending. I think it was his way of a complicated power struggle. He ended up getting fired eventually.

 
At Fri Jul 20, 11:29:00 AM, Anonymous Catron said...

The whole precert project is nothing more than a pretext to deny your claim if you fail for some reason to call it in.

The insurance companies usually provide a caveat to the effect that "this pre-authorization number is not a guarantee of payment."

This is one of the few areas where Medicare is superior to the managed care companies. Medicare doesn't (yet) require this charade.

 
At Fri Jul 20, 08:26:00 PM, Blogger Lynn Price said...

Oh, what a steaming pile of stale Twinkie cream. What a freaking sham. Why am I not surprised? Good on you, Dino. Will you be my doc?

 
At Sat Jul 21, 06:05:00 AM, Blogger Dr. Smak said...

My last precert fiasco involved a sinus CT. Yes, a sinus CT. It was denied, I called for the peer review, and spoke to someone who referred to herself as Dr. Jones. After I begged for a couple minutes (really, the situation was ridiculous and she was insulting to me as a clinician) she said "I can't approve it, I'll have to talk to my supervisor."

Your supervisor? Just how many layers of crap are we wading through? I'm beginning to think that they scoured the phone book for someone with a first name of Dahktre to answer the freakin' phone.

Anyway, I was assured it would be resolved in a timely manner.

Two and a half weeks later the sinus CT was approved and, as I suspected, negative. However, without the clinical information that I needed, the patient was well into a 4 week course of Levaquin, which likely cost more than the damn CT.

I've got my first screening breast MRI pending on a patient in a similar situation as yours. Here's hoping...

 

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