Mrs. F. is accompanied by her husband of 57 years. They became my patients 19 years ago when they still cultivated a large garden, put up hundreds of jars of produce every summer, and took in three grandchildren for several years because their daughter and son-in-law were in trouble.
Now Mrs. F. is in trouble. She laughs continuously when I ask how she's doing. She stares into space when I ask if she ate breakfast. Yesterday she fell and injured her hip. She is pale and frail. A bone marrow cancer I diagnosed ten years ago is now responsible for reduced production of blood cells, causing her to feel weak and tired most of the time.
"There's nothing wrong with her!" Mr. F. insists. "They want to put her in a home! But I can take care of her! It's my decision, isn't it?"
Although he's upset, Mr. F. is a kind man who at 81 is enviably healthy and robust.
"Don't let them take her away!"
The home nurse, whom I petitioned through a home health agency to visit Mrs. F. every week, has been insisting that Mrs. F. be placed in a nursing home.
I examine Mrs. F.'s entire body carefully and perform an x-ray, which does not show a fracture. I also get a chest x-ray and a urine test because very often a fall in the elderly is the first sign of pneumonia, a urinary infection, or dehydration. Luckily these tests are also normal.
Except for the last two visits I have not seen Mr. and Mrs. F. for a year. This is because Medicare, the couple's insurance company, has not paid me for patient services for more than a year. After seven months of seeing patients without getting paid for the work I did, I made the sad decision to stop seeing Medicare patients. I made an exception for this couple because they sounded so desperate in their telephone call.
Despite dozens of phone calls, certified letters, and appeals by my office the representatives at Medicare cannot say why I am not being paid, only that I am under "prepayment review." This amounts to a perpetual audit of 100% of my chart records. The civil servants who answer the phone seem completely unaware of and uninterested in my predicament. The company that Medicare hires to do audits on Medicare providers like me is Safeguard. Even after sending Safeguard the thousands of pages of patient records they required as a condition for payment, we are still not being paid. I wonder: Who reads these patient records we send, as proof that we saw patients and needed to do the tests we did? Anyone? Who decides whether I get paid or not? Is anyone in charge?
For several months I sent one or two letters a week to all the head administrators and their subordinates at Medicare and Safeguard. Eventually I received a reply: "We will not be responding to your letters, and we will not agree to your request for a face-to-face meeting to go over the reasons for your not getting paid."
I consulted a healthcare lawyer, who said, "You have to follow the Medicare appeals process."
"What is that process?" I asked? Where do I find it?"
"I don't really know," he said.
While this is a topic for further discussion at a later date, today I am concerned about what tests and services I can provide Mrs. F. in the interests of making a correct diagnosis and helping her. I know that Medicare will not cover them and that I will not find out why not. Mr. and Mrs. F. do not understand any of this. "Why aren't they paying you? What's going on?" Mr. F. asks in a loud voice. "You've helped us so much. We need you to help us now."
Since Mrs. F. doesn't have a cough or urinary symptoms, and since otherwise there isn't an acceptable insurance diagnostic code to explain my reasons for doing these tests within Medicare's billing system, I doubt I would get paid for the chest x-ray or urinalysis anyway. Medicare would ask: Why would I do a chest x-ray and urine test on a patient who had a fall? She doesn't have pneumonia. She doesn't have a urinary infection. I am at a loss as to how to explain my thought processes using the numerical codes which are the only means of communicating my intentions. Therefore, Medicare auditors may assume that I am billing fraudulently. Now I wonder if this is the entire basis for their audit. A doctor's thought processes with patients are more complex than can be quantified by the numerically based software Medicare uses.
"Mr. F.," I say, resting my hand on his shoulder, "It certainly is your decision whether your wife goes into a nursing home or not." We both know that nursing homes are hotbeds of contagious disease, and that Mrs. F.'s life expectancy would go down if she were sent to one. Why does the home health nurse keep recommending it? Perhaps she hasn't visited a nursing home recently? Perhaps she knows about a nursing home where life is fun and the trade-off of husband and home is worth it? Perhaps she thinks Mrs. F. is less likely to have a fall or to be disoriented in a nursing home?
"You're doing a fine job," I reassure him. Let's talk about what you're going to buy at the grocery store to keep your wife's weight up. And how about you? Are you getting enough sleep? Do you still have those neighbors who look in on you? Can you come back to see me next week?"