Friday, August 31, 2012

More on Lawyers

     It is as though they wanted to seal my mouth shut with thick bands of duct tape.  I have a strict gag order from my lawyers.  Whatever I say could be twisted like long black cords of electrical wire into grotesque shapes that could then stand for me, they would be me in the minds of the federal prosecutors, and those government agents could hang bulbs on it, plug it in, and light up my effigy for all the world to see:  criminal, terrible person, nemesis of society.  
     My lawyers and I were seated in another one of those mahogany-stained conference rooms, with framed images of the scales of justice alongside halcyon north Florida landscapes.  We exchanged stories about what we had done over the summer, like schoolchildren, and then we were back at work.
     The lawyers cautioned me not give away what we talk about.  It doesn't matter that I have nothing to hide.  They were not happy about the article that was just published in the Gainesville Sun.
     "It made the federal government look bad," they told me.
     "How?" I asked.  "That wasn't my impression when I read the newspaper piece."
     "You said the government doesn't know anything about billing and coding."
     "It's true, isn't it?  Whatever they know has to come from specialists they hire to analyze data and report back to them."
     "It doesn't matter if it's true or not.  The government doesn't like negative publicity."
     "Neither do I," I countered, and my tone was acerbic.  "The raid and forfeitures didn't boost my public ratings."
     "We understand how you feel," they said.  "And we realize that your blog is a way of dealing with  distress," they said. "But can't you wait to change the world until after your case comes to a conclusion?"
     "That could be five more years," I said.
     "These cases don't usually go on that long."
     "It's already been two," I reminded them.
     "But things are going to move forward now," they insisted.
     "How do you know?" I asked.
     "There was a backlog for the prosecutors, they had other cases..."
     "No problem!  They did their damage, now they can sit on it...while I resuscitate my life--"
     "Wait," they interrupted with an equanimity only lawyers are able to sustain in the middle of a crisis.  (Physicians are too busy putting in central lines, injecting heart-rousing medicines, rushing to plaster electrodes over the chest wall to jolt a person back to the onerous world of the living.  We can't pretend to be calm.  We aren't calm, we're fighting against forces that drag people down into hell.)
     I must assume my lawyers are doing the same thing, fighting against hellish forces--in their suits and ties, no Betadine, no blood stains.  Do they have the tools to save lives like mine?  Do they know what they're doing?
     "Trust us," they said.  "We've been at this a long time.  We know how to proceed."
     "Okay," I agreed.  "What do you want from me?"
     "Try to keep a low profile," they said.  "At least where the federal government is concerned."
     "You mean I shouldn't say anything about what I think they're doing?"
     "More like...don't imply that they don't know what they're doing."
     "What are they doing?"
     "They're doing their jobs. You don't realize what kind of pressure they're under.  They have terrific demands from above.  They have to meet stringent standards.  There is lots of politics in the Department of Justice, and it trickles down.  Their jobs aren't easy."
     They were telling me to consider the FBI and prosecutors as suffering human beings.  Wow, I thought.  That's like feeling sorry for an alligator.
     Nevertheless, I realized how much easier it can be to battle imagined monsters than to look upon those who seem to be harming us as real people.  It's not so black and white.  I doubt if the federal agents want to harm me.  They just need someone.
     "Are you asking me to have compassion for them?"
     "Just give us a chance.  We see the big picture.  We know what we're doing.  Things are going to be all right."
     "You're sure?"
     "We're sure."

Thursday, August 30, 2012

"The Government is Clueless about Visits"

     This is the title of a May 2012 letter to the editor about the requirement for physicians to adopt software programs (with start-up costs including staff expenses for transitioning of $150,000) and coding for office visits.  It is so much expresses the feelings of doctors I know, that I feel compelled to reprint it.
     It's from Medical Economics, and was written by Douglas Morrell, MD, from Rushville, Indiana.  He resents being forced by the new EHR (electronic health records) mandate to use a computer (or accept big cuts in payment) (by the way, who lobbied congressmen for that?--it surely wasn't doctors) while having a conversation with a patient.

          I am going to have to be keying in so much "stuff" that typing is going 
          to take up more than half of the encounter time with my patients.
          The government is clueless about what actually goes on between a
          patient and doctor during an office visit.  If you take care of an acute
          medical problem and do the rest of the "stuff," it will take more than
          45 minutes, and every encounter will essentially be a 99215 level.  
          These bills will then be flagged and denied because of the number that
          will be completed during the day;  reimbursement will fall all the while.
          The entire program is just going to implode on itself because of the cost
          and complexity.
          I am a solo practitioner on my third server to run the upgraded software. 
          The software has lots of glitches in it, and I have to do charts manually
          when the system is down  I am pretty computer-savvy and have good
          good computer people, but this has been a nightmare.  I am going to be
          64 soon, and it may be time to just hang it up.  I enjoy the patients and
          am as medically competent as I have ever been, but running a practice 
          on crashing software is really making it tough.

     Here's what this is about.  As a solo family physician we are supposed to do a whole lot of things when we see a patient for anything.  There are no purely "acute" (meaning quick, in and out) visits in a family practice office if the doctor is doing what we're all supposed to be doing--important things that keep patients from getting bad diseases and costing the country and themselves money and years of productive life.  We can't add any more to our roster of requirements, and EHR's don't make sense for many of us.
     Today I saw a new patient who "just needed a refill" on her blood pressure medicine.  Never mind that the medicine was having an adverse effect on her heart, a finding that showed up when I put my stethoscope on her chest and listened carefully.
     So I did an EKG and asked a few more questions.  Turns out she had a long list of symptoms in places all over her body:  shortness of breath, moles on her legs and back, insomnia, swelling in her legs, heartburn, a 40-pound weight loss in six weeks, vertigo, ringing in her ears.  She had just moved from another part of the state and was trying to adjust and find a new church.  Her husband had left her, which was still painful after many years.
     Her physical exam revealed more problems.  There was a surgical scar indicating a past cancer.  Her nails had telltale signs of psoriasis.  Her hair was thin and she had no eyebrows--they were painted on.  A chest x-ray was abnormal.
     My job as a family doctor is to do labs to check cholesterol and other important indicators of disease, and to make sure she's had a colonoscopy, mammogram, pelvic exam, ophthalmology check--three referrals and another visit to see me.  She needed a biopsy of her skin lesions.  She hadn't had pneumonia or shingles vaccinations, and one wasn't covered by her insurance.  She didn't want a colonoscopy, which entailed a long discussion.  She seemed confused and overwhelmed, perhaps from loneliness and the move, but maybe an organic brain problem.  There was so much to think about, and then there was the patient, who wanted to talk about her medicine, side effects of other medicines, what she could and couldn't pay for, and she wasn't sure she could trust me!  She looked me up on google and read about the FBI investigation, but then saw some positive reports by patients, and decided to check me.
     Now, I'm supposed to organize all these symptoms and findings, order tests, refer her for recommended preventive exams, persuade her that they are necessary, avoid prescribing medicines that could cause side effects, make her feel better, stay within her budget, write all this in an office note that will surely be several pages long--and not bill a 99205 code, because Medicare will audit me and find that I couldn't have spent an hour with a patient who simply came in for a refill on blood pressure medicine.  I must have invented her problems, or spent more time than necessary.
     In addition, I have to make sure I code everything exactly right, despite the labyrinthine rules and ambiguity about the process--or that could be judged to be "fraud."  And there are dozens of codes required for this visit, with modifiers and special documentation guidelines.  And I should be instituting a new and (we all know) imperfect software system, as well as electronic prescriptions, and protect the patient's privacy, and make sure my staff doesn't violate any standards of care.  Yes, this is a high-complexity visit, but will I code it that way?  Almost no doctors do this--so we lose revenue in the hope of avoiding scrutiny.
     Oh, I forgot.  The patient is angry that she had to wait an hour to be seen, because, in fact, every patient is this complex, the the doctor takes time to listen and examine, and if all the guidelines ("other stuff") are followed for good patient care.  Every patient has many issues, and needs time, and questions the medicines, immunizations, cost, guidelines, tests, and recommendations doctors make.  And now these same patients have questions about my integrity.
     ARE YOU READY TO TAKE CARE OF 35 MILLION NEW PATIENTS?  a news headline shouts at me.  These are patients who haven't had medical care, people who are likely to be added to the rosters with the new Affordable Care Act.  Patients who haven't had medical care need a great deal of attention.  Family doctors are sued most often for "failure to make a timely diagnosis," but how can we do this, if we are attacked by insurance companies when we spend the time necessary to be thorough, and if we are attacked by patients and their lawyers when we don't?
     Good luck, America.  Physicians are dropping from the rosters like flies sickened by poison--it's everywhere.  If you don't take care of us, we can't take care of you.


Wednesday, August 29, 2012

What Is the Origin of Hate?

     If you are not someone who has taken refuge in the most simplistic tenets of religion--any religion--then you know that hate is part of your being.  This is not easy to accept, even for those who are not religious, as hatred is thought to be the very thing that tears social groups apart--and we need one another, that's for sure.  We need one another to survive, whether we admit it or not.  Therefore, it is a sin to hate.
     Now love, that's another story.  It's admirable to be filled with love--all the fairy tales and sacred texts have drummed this into us from the time we were old enough to see the bifurcated pictures-- princess/witch, dragon-slayer/dragon, David/Goliath--in our storybooks.  It's the perennial clash between good and evil--and we know which side we're on, don't we?
     Who's on the side of hate?  Even self-admitted serial murderers lay claim to love, many turning their lives over to one conventional love-obsessed religion or another while in prison, thereby unloading themselves.  Hate is just too hard to carry.  No one wants that baggage.  We want someone else to carry it.
     Not that I'm against love.  It's fine, with its gleaming facets flashing us in the eyes like crystals rotating in the window at midday.  But even a saint standing in bright sunlight casts a shadow, and there's the problem.  Can a person exist without a shadow?  Do we organize ourselves into groups in the hope of doing just that, dividing the burden of being human unevenly, so that some may carry only light, and be celebrated, while others are the bearers of darkness, despised, but magnetic--they're the ones we clamor to watch in Hollywood movies.  Their evil deeds so mesmerize us that we turn those movies into box office hits, and mediocre books about those serial killers I mentioned are always bestsellers.
     What do you do when you have the feeling, hatred?  Do you squash it back down where it came from, and wash your hands, and smile?  Do you pretend it was an error of metabolism, and ask your system to reconstitute it into something more agreeable?  Do you make the sign of the cross, and tell the devil to get back?  Do you fantasize about buying a gun, or strangling someone to death?  Or do you never even feel such feelings--being so divinely constructed as never to hate, or sweat, or pass gas, or eliminate odious material of any kind?
     Hate has its way whether you acknowledge it or not.  If you feel it, you can understand its origin-- which is a kernel of inadequacy that grows, especially if unseen, into envy...then greed...then a desire to do harm.  If the envy, greed and desire to do harm are also squashed below the surface of one's bright, shining self, they work their way up like the black roots of an enormous tree, breaking through the floorboards of houses, destroying people's lives, dividing us more than if we had admitted the wretched feelings to begin with.
     Better to feel your hate, envy, greed, and ill-will, and to recognize them as stories about you, not others.  This could take decades--but then you get to hold onto your shadow, and it doesn't run rampant in the world, and you have a dimensional self.  A person with dimension is real, and interesting.
     I am writing about the topic of hate on my blog because it occurred to me today that a recent comment--posted anonymously on the site--may have been written by someone who used to work for me.
     The comment was written in a style I thought I recognized, with a voice that seemed to take distinct pleasure in the chaos it had helped to wreak, "reporting" me falsely, snuggling up to authorities with the congenial demeanor of one who could do no wrong, flattering and maneuvering others to join a clan of  informants who lied for gain, and used the government's desire to profit from its own gullibility, as a weapon against me, an expression of hatred.

               So far, you've mentioned financial losses.  Is there any chance you could
               go to prison?

     There is the comment--not innocent, not by a long shot.  It is the gloating of an ex-employee, a voice I recognize for its unnatural tactfulness--a quality I had valued in the employee before I understood what it hid.  This was someone whose salary and benefits far exceeded what one might expect based on qualifications alone, someone who began to feel very important, and who took liberties that revealed a lack of conscience cleverly concealed by a show of churchy sanctity.
     Why should this employee have decided to "report" me, without cause, betting that FBI agents would fall prey to a superficial show of sophistication and special knowledge--preferring these to the difficult research required to uncover true evidence, and hard facts.
     Well, why not report me?  If a whistleblower fee is a possibility, it could pad one's nest for many years.  And if there exists in the annals of law a penalty for false reporting, I doubt if it's ever used in cases of healthcare fraud--Medicare actively solicits reports from simple citizens.
     It seems worthwhile to make a claim, even a fictitious one, against someone who has resources to usurp. advertises, "Claim your share for helping fight fraud on the government," and at you will see that whistleblower attorneys "stand by, and do the right thing," helping employees keep their jobs while reporting employers and getting big rewards.  Legal protection for whistleblowers dates back to 1863 and the False Claims Act.  If a whistleblower deliberately misleads agents, reprisals usually come--if at all--from the falsely accused, after the damage is done, not from the government.
     What an expedient way for an angry or repressed employee to vent aggression--compliments of an exploitable government.  And if making a terrible accusation makes up for this same employee's feeling of having been under-appreciated, or squashes despair over the employee's having failed to succeed elsewhere in life, through hard work--why not exercise power using the government's armed agents?

Tuesday, August 28, 2012

Patients: #9, Two Ways with Grief

           Grief is an adaptive, universal, and highly personalized response
           to loss....The symptoms of grief may overlap with those of major
           major depression;  however, grief is a distinct entity.  Feelings of 
           hopelessness, helplessness, worthlessness, guilt, lack of pleasure, 
           and suicidal ideation are present in patients with depression, but 
           not in those experiencing grief....Physicians are encouraged to
           support patients by acknowledging their grief and encouraging
           the open expression of emotion.
                                           American Family Physician, August, 2012
     Mr. H. and Mr. Y. both lost their wives after sixty-one years of marriage.  As happens with physicians who follow patients through the various stages of life, I had become enmeshed with these couples--men and women who had weathered a series of marital tempests and, in the last decade of coupledom, left those inclement zones to reside in the temperate clime of contented appreciation of one another--foibles, memory lapses, untidiness, irritability, all of it.
     These two couples did not know one another.  My involvement with them was ten years apart.  I assisted them, in the meager yet indispensable ways a doctor is able to do, side by side, lending a hand on the slow, downhill  footpath strewn with pebbles and flint, to keep them from losing their bearings and falling into the briars, or forgetting the destination in a place where love is the only compass.
     When Mr. H.'s wife died, he seemed to free-fall from the edge of a cliff.  I shouted to him, "Pull your parachute!" but he couldn't find the cord.  His friends--the few who could bear witness to his grief--said, "Pick up your life!" and he replied, "I have no life."
     He didn't cook, he stopped eating, he lost muscle mass and turned pale.  But he came to see me every week in the beginning--then, after a while, every few days.  We spent each hour together doing what he wanted, which was to recall his wife, their happy moments, their time in the flower garden, the scenes at the end, when she was dying and he spoke his last words to her.  He seemed most animated at these times, almost lighthearted.  But then he went home and lay on the couch.  I know, because I visited him there in Cross Creek, when he was too tired to make the drive to my office.  The forlorn house was scattered with debris that his wife would have picked up.  Her belongings had not been moved:  the reading glasses next to her bible, her hairbrush tangled with stray gray strands, a pair of terrycloth slippers where she had unslipped them one last time, a footprint of farewell at her side of the bed.
     Mr. H. faded into his own death, caused by a broken heart, for which no one and not a single pharmaceutical agent, could provide a cure.  In his grief he heard the siren call of his wife from the other side, and he wanted to go there to meet her.  It took six months, during which I felt, at times, his utter desolation, and his desire to fall straight into the gash this wound had inflicted.  It seemed to me that there was nothing wrong with his response to loss.  Isn't it the case that certain birds, like doves, who mate for life, waste away when the other half dies?  His friends' exhortations to "get over it"--spoken out of their own terror of such grief--seemed to have no merit against his weight of his sadness and the way in which he was coping with it.
     Mr. Y. loved his wife just as much as Mr H., but after a few weeks of mourning, he came to life.  He cleared out her clothes, musing over how many pairs of brand-new shoes remained stacked in boxes in her closets.  He presided over a beautiful memorial service, scattering her ashes, and enjoyed the company of the fifty-odd attendees.  He accepted their friends' invitations to take fishing trips with them, or accompany them to dinner, golf, and concerts.  He enjoyed the casseroles and potpies they left on his doorstep.  He joined a gym, gained muscle mass, lost the slouching shoulders and protruding belly of the past, and looked quite the dapper fellow in the new clothes he bought--styles I had never seen him don when his wife was alive.
     What happened?  Mr. Y. felt somewhat guilty, at first.  He, too, visited me every week for many months, perhaps seeking affirmation.  He kept repeating what I had told him, in his sadness, after cancer finally cozened his wife from the comfortable dyad within which they had enjoyed private jokes, played rummy, shopped for shoes, and sang in the church choir.  When I visited him at home, immediately after his loss, I saw on the kitchen table the scorecard for their ongoing card game.  "She still owes me nine dollars!" he said.
      My advice was simple. "There is the Mr. Y. before you married, there is the Mr. Y. who lived with Mrs. Y. for sixty-one years, and now there is the Mr. Y. after her death. You have been presented with the third phase of your life.  It's your choice whether to take it on, or die," I had explained.
     "I choose to live," he said, "even if my life is completely different."  He acquired a new persona, perhaps an alter-ego that had been dormant all those years.  It germinated and bloomed.  He wined and dined a pretty girlfriend, joined a social club, took two road trips to mingle with distant friends and eat lobster in Maine, and allowed his personality to expand into realms he hadn't known were his to explore.
     He even scheduled a sky-diving expedition.  "It's a gift to myself for my eightieth birthday," he pronounced one day.  When I alluded to his history of angina, he dismissed me with a wave of his hand.  "Can you think of a better way to go?"  I didn't suppose I could.
      As I was reading the article quoted above, I reflected on the many patients I have lost, whose lives came to a natural end--and wondered, as I'm sure all physicians do, whether I did the right thing.  We held onto one another at the end, arm in arm, and looked across the threshold of the no-man's land we'll all, sooner or later, pass into, frightened, adventurous, bewildered, emboldened, and carrying our own particular grief.

Monday, August 27, 2012

Medicare Stopped Paying Me--Why?

     Immediately after the raid on my clinic, Medicare stopped paying me for clinic services.  Nor did they pay for outstanding claims left over from prior months.  Half my patients at that time were covered by Medicare.   The loss of income for the clinic, compounding the bank account forfeitures, was paralyzing.
     My billing staff and I made dozens of calls to Medicare asking why they had stopped paying us.  Our outstanding claims totaled hundreds of thousands of dollars.  Our phone calls were picked up by receptionists who "took messages"--Medicare officials did not call us back for many weeks, then were vague, saying they "needed documentation" for our charges, or didn't know why we weren't getting paid.  On several occasions we reached Myrtle Gordon or Brad Smith, our representatives at First Coast Medical (the local Medicare service provider located in Jacksonville), but told us absolutely nothing.
     Medicare then placed my clinic on a 100% review.  This means that they required us to send claims for patient services via the electronic claims transmission program, and wait several weeks for a response.  The "response" was a form letter for every patient visit--in fact, for every item we billed--requesting documentation that the services were all, in fact, provided.  We were sent thousands of form letters, including many duplicates, for which I needed additional staff to sort.  Each letter requested copies of every page in the patient charts, before payment would be considered.
     It was an absurd game.  My front office staff copied all the documents and sent them, as required, by snail mail to the First Coast Services office.  Still, we received no payments.  Phone calls were not returned.  Our e-mails must have been lost in transmission, or ignored, because they disappeared into cyberspace.  Multiple phone calls, week after week, went unanswered.  I made calls, and reached authorities twice, insisting that I be given either an explanation for non-payment or be paid.   The response was "I'll look into it and get back to you."  No one ever got back to me.
     I wanted to raise this problem in my court case, but my lawyer,  Curtis Fallgatter, said it wasn't relevant.  He seemed not to appreciate the necessity of being paid for services--except when he demanded a fee of $26,000 more than the $20,000 retainer he had already received, just before filing my motion for emergency relief.  ("I need to be paid for my work," he said.)  ("He has a reputation for obscene overcharging," another Jacksonville lawyer later told me.)
     The hearing failed to reverse the terrible effects of the government's raid.  But afterward, when the court reporter had closed her stenotype machine, I insisted that Mr. Fallgatter ask why Medicare had frozen all payments to my office.  The prosecutor and FBI agents were poised like military personnel along the mahogany-stained courtroom wall to the right of the judge.
     "I have no idea," answered Robert Murphy, the lead FBI agent, whose height accentuated his hubris.
     "Has the government instructed Medicare to stop paying Colasante Clinic?" asked Mr. Fallgatter.
     "Not that I know of," the agent said.
     "Ask him to find out, and to promise to give us an answer," I whispered to Mr. Fallgatter.  "Tell him the survival of the clinic depends on it."
     "He doesn't care about that," Mr. Fallgatter whispered back.  "He might be glad to see you shut down."
     "Can you look into this dire situation?" Mr. Fallgatter asked with a degree of formality that seems cartoon-like to those of us who don't spend much time in stately courtrooms.
     "Yes, I'll do that," Mr. Murphy answered.  He seemed to be repressing a yawn.
     "When can we expect to receive an answer about this matter?" Mr. Fallgatter pressed.
     "Within the next few days," said Mr. Murphy, gathering his belongings.
     That's when I approached the two prosecutors, Bobby Stinson and Corey Smith, who stood to the left of Robert Murphy, and addressed all three.
     "Thank you for assisting me in my efforts to leave the field of medicine and pursue another line of work," I said to them with wry satisfaction.
     There isn't much suspense to this story.  Of course we never heard from Mr. Murphy about this matter again, not without several phone calls.  I was not permitted to call him--perhaps because I might give away some clues?  But Mr. Fallgatter did, at my insistence, and I was told that the government had not put any obstacles in the way of Medicare payments to us.
     "Just between you and me," Mr. Fallgatter said, "there is a lot of inter-agency communication."  He said he wouldn't be surprised if the government had indicated to Medicare that my account ought to be flagged.
     I continued to see Medicare patients for the next six months, as we were given blandishments--"We don't see anything wrong....There's no hold-up on payments."
     "Why are we on 100% review?"  I wanted to know.
     "Oh, it's routine," was one cryptic answer.  A 100% review is tantamount to a shutdown for clinics such as those in Florida, which has a high percentage of Medicare-receiving residents.  It is not "routine."
     Medicare owes my office more than a year's worth of payments.  None of the thousands of flu shots we administered were paid, for instance, nor were EKG's, chest x-rays, IV antibiotics for pneumonia and cellulitis, surgical procedures...nothing.
      Every week I wrote certified letters to Medicare administrators, demanding an explanation for their so-called "review," which seemed nothing more than a pretext for withholding money.  In these letters I invited Medicare officials to visit my office, or send coding specialists.  I would open charts for them so they could explain what was missing, why they were not paying for my work.  I didn't want to close the doors to my long-time Medicare patients, whom I knew so well, but I couldn't afford to keep treating them for nothing.
     Finally I received a certified letter back, then another!
     "Stop writing us letters," they said.  "We will no longer accept any of your letters.  We will never be making a visit to your office."  The letters were signed by Brad Smith.
     After that, I had to explain to my Medicare patients that I could not take care of them any longer.  "Why?" they asked.  They pleaded with me.  Many wanted to pay cash--but that's illegal, since my clinic still qualified as a "Medicare provider."
     Many of these patients were irate, and said they were going to call Medicare to complain.  If they ever got through, I sure would like to know how.

Saturday, August 25, 2012

This Blog Is My Defense

     Thank you to all the readers of this blog!
     I have had no capacity for defense, except this blog.  My lawyers--and their many colleagues, whom I have petitioned for help--have told me repeatedly that they are unable to communicate with the government, not even to find out why its agents raided my office, nor why they drained my bank accounts, nor what it is they think might be "criminal" about the management of my medical office.
     I continue to practice as I have always practiced medicine.  I bill insurance companies in the same way I have done for 13 years.  I purchase supplies for use in my office if they will get patients well, and  are affordable.  If the government "knows" enough to have punished me already for "criminal" acts (and it must, right?--or a judge wouldn't have been prompted by the FBI to take extreme action against me)--if the government knows I'm perpetrating criminal acts, why does it allow me to continue?  Why doesn't the prosecutor show his hand?  
     Those of you who are reading my blog are acting as benevolent witnesses to whatever action the government takes in my so-called case.  I can think of no stronger support:  silence begets corruption;  visibility forces honesty.  I will not back down in an ignominy compelled by our government--which has granted itself monumental powers (where were all of us when that happened?  hypnotized?)--because I have nothing to hide.  If I had committed some misdeed against my patients, or insurance giants, or the government--I might wish to make a payoff (more euphemistically referred to as a "settlement") to the feds, to keep a lid on my secrets.  They could then tally this up with the rest of their plea-bargaining booty, boasting about the spoils taken from doctors committing "fraud."  But I would consider this a form of extortion.  I want the prosecutor to come forward with his case, and I want to prove my innocence, and the government's wrongdoing.
     I am outraged.  I want my life back.  My entire world and my profession have been dominated by this "case."  I am unable to pursue my aspiration to develop an autism farm, or to run my clinic with enthusiasm.  My opinion and point of view, outside this blog, have been attenuated by the fact of the government's attack, which hovers like a dark cloud over my head.  Even my own son, yesterday, said to me, when I offered him advice about a touchy personal problem:  "Why should I listen to you?  You're under investigation by the government.  Your judgment is questionable."  He knows better, and was being impudent, but it was his trump card, a convenient escape.
     How many of my patients harbor doubts about my qualifications?  How many people question my integrity--in the unspoken, niggling ways suspicions creep into one's human interactions?  What about the patients for whom the success  of my medical care depends on their complete confidence in my credibility?
    There can be no worse punishment for a small-town doctor than this.  But for what am I being punished?  And why is our government unimpeachable?  How can its agents sit smugly in their cocooned offices--except when they're "fighting crime"-- confident of their jobs, protected by statutes that allow them to hold my assets indefinitely, and to ruin my professional life?
     Yes, I can continue to practice medicine.  But I am not the same person.
     Thank you, readers, for helping me to feel as though I have an audience to witness my despair.  I remember reading (in Victor Frankl?) that when a prisoner is being tortured in solitary confinement, with unconscionable cruelty--if that victim, in his misery, believes that at least one human being knows and cares about what is happening to him, the suffering becomes bearable--and he is likely to survive.  The 10,000 readers who have logged onto my posts give me a measure of hope.
     This blog is my life vest.  It is my mouthpiece. The government is being mirrored here, and I have a lens to reflect its deeds--and we are all watching, and waiting.  My readers are my jurors.  This blog is my only defense. 

Codes the Government Misunderstood

     Every now and then I discover a medical code that has sneaked into the compendium under the radar.  Medical codes are slippery things.  Insurance companies are constantly adding and subtracting payable codes without much fanfare.  Medicare is the worst culprit, and Medicaid is close behind.  The government loves complexity, and the rest of us get entangled in it.
     There are many new codes, but they tend to be specific to certain insurance carriers.  For example, W9881 used to be the code for a well-child exam--but only for Medicaid patients.  Q0091 used to be a code for obtaining a Pap specimen during a gynecology exam--and at first could only be used for Medicare patients, then became acceptable for Blue Cross, and of late may no longer be okay to bill to Blue Cross.  Keeping up with coding rules is like tracking  a whirlwind.  The incessant circulation of new and retired codes accounts for Medicare's coding "guidelines" totaling more than 200,000 pages--and it's why Medicaid has a completely dissimilar 200,000 pages of coding rules.  Blue Cross, Aetna, Tricare, CMS, Champus, and dozens of other insurance carriers have their unique sets of criteria for billing.  It's a source of endless frustration for medical providers, most of whom relegate the task of billing to outside companies, thereby sacrificing revenues in exchange for simplicity.  Billing companies do not go to the trouble of chasing down insurance company denials.
     Last year I discovered two codes that corresponded to services we had provided patients--but not billed.  It makes sense, when this happens, for me to back-code for the work I've done once I confirm that it's considered a compartmentalized service, separately payable.
     Doctors should make it a policy to hunt down new codes because otherwise we miss out on legitimate revenues.  I keep abreast of codes by reading practice management journals which have columns dedicated to coding.  There are newsletters about coding, too, but most of them have not been worth the subscription cost, as they reiterate what I already know.  The coders who write them don't report new G-, W-, Q-, A-, and L-codes that are added by specific insurance companies, or undrape codes for niche services.  These expensive publications must be compiled by non-physicians, because they give me the impression of people who are observing the world of  medicine from outer space.
      Three codes I discovered last year were 99441, 99442, and 99443.  They represent charges for telephone sessions with patients.  Every day dozens of patients phone to go over lab test results, discuss side effects of medicine, ask if certain symptoms warrant a visit, or get advice about how to manage early signs of illness without a full-fledged exam.  It makes sense for insurance companies to pay for telephone "visits" because they cost much less than appointments, and save trips to the emergency room.  Blue Cross and other private insurance companies have calculated the overall gain for them by paying nominally for phone calls, and therefore decided to cover telephone visits about clinical situations.  Some insurance companies, similarly, have added e-mail correspondence to the list of covered services. I didn't learn about this additional source of revenue until many months after the telephone codes had been approved for coverage.
     Therefore, once I knew about the telephone codes I asked several front-office staff to cull charts for patients whose insurance carriers covered telephone visits.  Their charts already contained written documentation of telephone calls, because we document every communication with patients.  (An exception is calls to schedule appointments, which don't qualify as telephone "visits").  We billed the 99441-99443 codes for those dates of service all at once, as soon as we had located the notes in the charts.  It is acceptable to "back-code" for services like this as far back as three years.  We billed for documented phonecalls for the prior fourteen months--back to the time when the codes were approved for payment by some insurance carriers.  There were enough to make the data collection worthwhile.
     Medicare and Medicaid don't pay for telephone visits, instead instructing providers to roll phone time into the next office visit.  A concession to family doctors, in the mid-1990's, allows us to bill for the time we spend with patients (if more than 50% of a doctor's time is spent counseling a patient, then coding should represent this time, rather than the exam and analysis required to treat the patient).  Auditors don't acknowledge this when they review our charts, considering it an anomaly, even though I am careful to document, "More than 50% of this visit consisted of counseling about...."  Such is the hypocrisy of the insurance reimbursement system.
     Blue Cross and a few other companies do pay for telephone visits, so the back-coding we did last year was above-board, resulting in small but measurable payments in due course.
     I also billed retroactively for G0396, a code that designates alcohol or substance abuse assessment.  My staff identified documentation that proved we had performed this assessment on patients, once I learned that a separate billing code covered it, and we transmitted the charges correctly.
     Medicaid does not cover the G0396, but it does cover contraceptive counseling--so I may be able to bill for the provision of this service, if the documentation in our patients' charts justifies it, and if there aren't restrictions on its use.
     Last month two FBI agents questioned one of my past employees, now an eighteen-year-old college student.  She worked part-time at my clinic during her last two years of high school, and she was one of the employees who pulled charts for the retroactive billing.
     The agents met her as she was leaving a class at Florida State University, and said:  "We need to talk to you about Dr. Colasante."  When they asked if she had been asked to do "special projects" they were referring to her assistance one week identifying documentation in the charts of telephone calls and substance abuse assessments.  There was no wrongdoing associated with this task, and it was a legitimate project.  Did we bill when we hadn't provided a service?  Of course not.
     Most doctors don't have time or the inclination to search out codes that might improve reimbursement for the work they already do.  It is odd a doctor's time should be fragmented by insurance companies into separate categories:  smoking cessation counseling, diabetes counseling, substance abuse, telephone visits, emergency services, after-hours appointments, and stabilization of critically ill patients are all supposed to be coded and paid as separate items, even though they are part of the "visit."   Unless physicians keep up-to-date with these codes, they will be under-paid for the work they do.  I keep abreast of codes as they enter and leave the various insurance formularies, and I use them in every case if a patient's visit warrants it, and I have enough documentation in the chart.
     I hope the FBI agents review all my charts, because they'll see that every charge correlates with a service for that patient on the correct date of service.  Maybe retroactive billing for legitimate services is their idea of money laundering.


Friday, August 24, 2012

What is Medical Coding? And Another Example

     So many people read my recent post on coding for a typical patient visit that I thought my readers might like to know more about this benumbing process.  I do not in any way advocate the continuation of this process, at least not until there is standardization across all insurance providers about how much liberty doctors should have to decide what patients need, and how they should get paid for their work.
     What is "coding"?
     Coding is the process of translating both the conversation that takes place between doctor and patient in an exam room and the behind-the-scenes thought-processes of the doctor as he/she listens very intently to what might seem like ordinary parlance, but in fact is a prodigious set of  clues pointing to the exact source of the problem--and sometimes the cure.
     It must be obvious, then, that coding cannot possibly denote what truly happens between the doctor and patient.  Human communication is multilayered, and the communication behind the closed door of the exam room is full of innuendoes and subtexts.  When patients talk to me about the weather, for instance, they are not talking about the weather.  When they tell me, conversationally, that an estranged family member is coming for a visit, they are not really talking about the physical appearance of a brother or sister.  (Stormy weather may mean that I'm likely to give them unpleasant news.  Calm weather may mean a loss of connection to a feeling function.  An estranged family member may suggest that a hidden aspect of the patient is about to emerge in the form of a symptom or illness--with features oddly analogous to the family member--because it can no longer tolerate being cut off from consciousness.)  Physicians listen with a sixth sense, taking in symbolic messages sent by the patient's inner guru--who acts as a guide to the underlying medical problem, which is sometimes a psychological problem, or a life problem.
     How can I describe all this in a SOAP note--which is the method for telling other doctors what I found and what I thought?   SOAP notes were designed for abbreviated conversation among healthcare providers, but insurance companies have decided to use them as the only basis for payment.  They have burdened doctors with the job of explaining to laypeople a process that has been abridged for the purpose of transmitting vital information to other doctors.  As a consequence, we have been forced to write virtual essays--two or more pages for each patient, in my office--rather than notes.  In spite of our efforts, insurance auditors are trained to find holes in the documentation so they can reduce or deny payment for medical services.  It's easy for auditors to find problems, because no one agrees about what constitutes adequate documentation for most physician services, especially office visits.
    Even if documentation requirements weren't impossible (because there is no consensus), how could I, in any case, explain to an insurance company, in the rudimentary numerical language of coding, why I spent the time I did, or what circuitous paths and cross-paths my thoughts took as I assembled information into a plan for treatment, and attempted to make inroads past the patient's resistance?
     "If it isn't documented, it didn't happen!" the malpractice lawyers--and now coding specialists--tell doctors.  Lawyers win cases because our complex decision-making isn't recorded in detail.  Doctors are not literature professors or journalists, so our documentation falls short, and insurance auditors refuse to pay for our services on the basis of short office notes.
     There are many subtleties about which we cannot write, because we barely intuit them as we make our way through the dark forest of the patient's interior world.  And writing in minute detail, even with computer templates, is a waste of time.  The current system can't be tweaked any more, it needs to be replaced.  I believe "coding" should disappear altogether.
     Here's another patient and the accompanying codes.
     Mr. J. is a 32-year-old office worker who says he has migraine headaches.  He tells me that he needs Demerol and Phenergan shots for the acute pain.  This is old-fashioned medicine, but many doctors still keep these products on hand for acute migraines with nausea.  Mr. J.  also wants a prescription for hydrocodone to use "when the headaches start."  I am not a fan of opioids for recurrent, chronic pain--there isn't support in the medical literature for such treatment, and opioids have been associated with immunosuppression, higher rates of infections, cancer, heart disease, constipation, mental cloudiness.  I don't know Mr. J.  I talk with him for more than half an hour, do a physical exam, obtain a urine drug screen because he's requesting opioids and seems agitated, perhaps by pain.  On exam I note that his right arm is weak compared with the left, and his sensation to light and sharp touch is diminished on the same side.  He denies having had a neck injury.  His mother died of an aneurysm at age 63.  Mr. J. is overweight, does not smoke, has "three or four  drinks" every evening after work, and doesn't exercise. He says he was told his cholesterol is high.  His last physical exam was five years ago.   He had a DUI last year, and he is vague about the reasons for his divorce two years ago.
     I recommend the pain machine--a combo of electrical nerve stimulation and muscle spasm reduction delivered via a device (Hako-Med) invented by a German doctor, approved for treatment by the FDA, and covered by most insurance plans.  Mr. J. agrees.  First, I perform a nerve conduction study to assess his pain and weakness--it reveals a pinched nerve in his neck.  He agrees to lab tests that might uncover underlying causes of neuropathy.  We discuss weight loss and cholesterol-lowering lifestyle interventions, and the possibility that he may have a problem with alcohol, or underlying depression.  He is somewhat amenable to my suggestions, and seems grateful that I have taken more than a cursory interest in him.  I do not recommend Demerol or hydrocodone.
     Here's what we "tell" the insurance company.

Account Service:  3499
Date:        Name:      Provider   Class      Procedure    Diagnosis      Units  Amount
6-14-12    John Jay    OC           EM          99395-25     V70.0              1          $$
6-14-12    John Jay    OC           EM          99203-25     723.1, 346.01  1          $$
6-14-12    John Jay    OC           PT           97032-GP    355.9               3          $$
6-14-12    John Jay    OC           PT           97112-GP    728.85             3          $$
6-14-12    John Jay    OC           LAB       80101           780.09             7          $$
6-14-12    John Jay    OC           LAB       80102           780.09             1          $$
6-14-12    John Jay    OC           EM         G0396          303.91             1          $$
6-14-12    John Jay    OC           LAB       36415-59      723.1               1          $$
6-14-12    John Jay    OC           EM         97535-GO    272.2, 278.00  1          $$
6-14-12    John Jay    OC           DIAG     64992-59      355.9               3          $$
6-14-12    John Jay    OC           DIAG     64995-59      355.9, 723.1    3          $$

     Maybe this system seems reasonable to some people.  After all, when you go to the grocery store you get a receipt listing everything you bought along with the price.  The problem arises when the price of bread varies from one person to the next, or when one patient has to pay the first $133 of his bill, and 20% of everything after that, except for peanut butter and chewing gum;  and the second customer has to pay the first $250, except for ice cream, peanuts, and steak;  the third has to pay the first $5,000, except for fifteen different items for which he has to pay 50%, 23% or 17% of the manufacturer's arbitrarily assigned pricing, and 43%, 16% and 8% of the price after the first $5,000 has been paid out-of-pocket...and so on, until next year, when--at a time ordained by each of hundreds of different plans, the same customers will be subjected to a completely different set of percentages owed for each item or service received.
     Patients never seem to know about pricing or "patient responsibility" in advance, nor to understand the meaning of the word "deductible" in most instances.  In fact, patients live in a world protected from coding, non-covered services, deductibles, costs, and percentage co-pays, because the manuals they receive once they are lucky enough to acquire health insurance are so colossal and incomprehensible they get tossed in a closet or filed away without ever being opened.
     It's up to the doctor's office to explain what a patient can and can't have, or how much might be owed once insurance carriers pay their part.  But the rules about what a patient must pay are complicated and differ in important ways even within the exact same insurance plan.  Phone calls by medical staff or patients to these insurance plans, for the purpose of clarification of coverage guidelines, are met with the same bafflement on the part of representatives.  Patients--who feel that "having insurance" is enough--are often baffled and angry when they owe anything, and sometimes storm out with angry words.  They vow not to have anything done in the future, so as not to be surprised when they find out their insurance doesn't cover certain services, or because it requires a deductible, or additional payments for select procedures, for inscrutable reasons.
     Such is life in the world of medical billing and coding, where patients buy--or are awarded--a product (insurance) which is supposed to pay their bills from a distance far-removed from the place where they get treated.  Maybe it used to make sense, but not any more.  Maybe it should work, but it doesn't--except for insurance companies, who seem to have the final say about whether they will pay for anything, or not.

Thursday, August 23, 2012

The Gainesville Sun Prints an Article

     I wrote a letter to the editor of the local newspaper, The Gainesville Sun because the media coverage of the FBI raid at my office last year seemed, as usual, to sensationalize the event.  I had not been asked to comment for the media at that time.
     But the Sun's editorial page editor didn't publish my letter--it was too long.  I asked that it be printed as an Op-Ed piece.  Instead, another editor called me at my office and asked questions about what had happened and what I thought was going on.  I answered with frankness...then realized that this was a reporter who planned to do a story about me in the fourteen-month aftermath of the raid.
     "Are you asking me questions because you're planning to write an article about this?"  I asked, once I realized what was going on.
     "Maybe," said the reporter.
     "Why?"  I asked.
     "I think it's an interesting story."
     "But I wrote a letter to the editor," I pressed her.  "Why can't you simply publish it?"
     "A story might provide better coverage," she said.
     "But a story written by you is different from a letter written by me," I told her.  "You'll write something that slants the story in a direction that makes people read it.  That's not what I want."
     "I'll try to represent you accurately," she said.
     "Why can't you print what I wrote as an Op-Ed piece?"  I asked.  Then, I'll know you've printed what I want to get across.  I've been treated unfairly, and I think people should know this is how the federal government operates.  The American legislature has given the federal government power to ransack and raid just about any doctor."  
     "That's a story we'd like to cover," she answered vaguely.
     So I offered her a tour of the clinic, and gave her permission to take a few photos.
     The article was printed:
and I thought it slanted the story of what is happening to me in a negative way.  I never said that the federal government is investigating me for fraud.  I don't know what they're doing, and I certainly haven't committed fraud, or a crime in any sense of the word as it is is understood by any of us.
     However, the government has been extended great liberties under HIPAA, since this act was passed in 1996.  Using HIPAA as an excuse--and statutes that were put into place as part of the "war on drugs" and the "war on terrorism"--to invade doctors' offices and "recuperate" money is--I believe, a crime against doctors.  Raids on any business are bad, but raids on doctors cause a degree of anxiety that wounds our sensitivity--the very organ by which we are able to make diagnoses.  If these attacks are unfounded, the damage they do becomes a social problem.
     We need good doctors in this country.  Doctors who are under attack, and doctors who are paranoid about being audited, sued or investigated, are not good doctors.  They flee their natural habitat--which is, I believe, solo or small group practices--to take cover in megalithic groups or corporations.  Or, they join the government:  the most popular job by far, among doctors with whom I speak, is any job at the V.A. Hospital.  Or a job outside medicine altogether.  Many doctors do what used to be unheard-of:  they take early retirement.
     Most doctors in America feel great uneasiness about their positions.  This has something to do with the tectonic shifts in the politics of medicine, especially of late.  But down here in the trenches, where I live with my solo-doctor-colleagues, the anxiety we feel every day stems from the craziness surrounding coding, billing, charging, collecting, interacting with HMO's, feeling despair about unpaid claims and huge A/R's, and the hegemony of insurance and pharmaceutical companies over the whole of medicine.  Medicare has complicated the process of the third-party payor system beyond repair, because it has set the (bad) standard which all insurance companies use to "save money" by capitalizing on a system for billing that is so complicated doctors can't keep track of how to get paid for what they do and err on the side of doing nothing so as not to be targeted for audits.  In addition, no one can agree on the correct way to code anything, or on the proper amount and kind of documentation required to demonstrate that the coding is "accurate," not "fraudulent."
     The system is a mess.  The politicization of medicine isn't helping, but the system was a mess long before the Affordable Healthcare Act ("Obamacare") became such a lion of a topic.
     Do I have a solution?
     I think someone should be asking solo doctors how the practice of medicine in America could be restored to a standard of simplicity and commonsense procedures that would actually enhance the health of the citizenry rather than cause us to chase after diseases once they've taken such a lead we can't overcome them.  That's where the savings are, and that's what we solo family doctors--whose hearts and souls haven't been hammered by bureaucracy and corporate greed--know a whole lot about.
     When was the last time a politician or an advisory panel asked one of us solo docs how medicine ought to be delivered in this country?    

Wednesday, August 22, 2012

They Need a Doctor on Green Turtle Cay

     The citizens of the beautiful Abaco Islands on the far Atlantic side of the Bahamas are in need of a doctor.  I visited Green Turtle Cay and was considered this opportunity.  Managing the hardware store was a woman who surely needed someone to excise a large basal cell cancer on her forehead.  I wished for my sterile instruments and a vial of lidocaine so I could do this for her.  Perhaps the surgery could have been a trade for the machete I needed to cut open some green coconuts I found.  No need to worry about cutting the government out of taxes by bartering:  there is no income tax in the Bahamas.
      "I have to go to the mainland to get that fixed," the woman told me, "and that's not possible."  A man getting out of his truck down the road could hardly walk because of hip pain.  "No doctor," he said.  "But don't worry, I'm working on it with herbs and such."  I saw another woman's knee joint lock up like a rusty deadbolt when she made a move to get out of her chair.
     Maybe I should go to the Abacos and be a normal doctor.  "It's a cash business," one resident told me.  "No insurance, no malpractice, no hassle."  It sounds too good to be true.  Property taxes are low.  People on the little islands live like villagers and seem to require minimal policing.  And the Bahamian waters beckon like none other:  transparent to fifty feet, voluptuous, abounding with coral reefs and rainbow fish, alternating with greens and blues of luminous intensity.  I could be lulled into believing there is nothing wrong in the world, nothing at all.
      Why am I not in the Bahamas?  How did I get caught up in the quicksand of American medicine?  Why do so many American doctors want to jettison their jobs?  It can't be the patients--they're wonderful, even the difficult ones.  "Every patient is a short story," said Richard Selzer, a surgeon who left medicine to write books.  He's right:  patients are endlessly.
     My lawyers have informed me that we need to schedule a meeting.  One of them had a talk with the federal prosecutor presiding over my "case," but can't tell me about it until we meet--he needs to preserve attorney-client privilege.  I don't know what attorney-client privilege is.  Not really.
     That job in the Abacos sounds pretty good.

"Assuming your innocence..."

     Thank you, to the anonymous person who made the comment starting with these words.
     You assume my innocence based on my "numerous and heartfelt" blogposts--then, to be fair, since you don't know me, you suggest that I may not be innocent...
     What are "guilt" and "innocence" in a case such as mine?  Who has laid down the parameters against which doctors, especially (because we have assets?) are measured once the feds get their hands on their lives?  The government will find me guilty of something, won't it?
     The fact is that the government's methodology for determining guilt or innocence is different these days from yours, and mine, and from our founding fathers', and from that of everyone we know, and from what people--in their naivete and inexperience with the forces of government--must think is standard procedure when someone is suspected of a crime.
     I doubt if the government's agents even suspect me of a crime.  They've nabbed me and expect a ransom.  They've nabbed me because they believe a ransom is easily obtained.  They've already taken the ransom, but haven't released me, because they want more.
    The government's methodology is not not intuitive or rational.  It's rapacious, and it denies the rights of people like me to run a business, by taking away funds and supplies necessary to run that business.    HIPAA introduced into law many statutes that had been rejected by Congress when they were presented as part of the Clinton Health Act.  It seems to me they make it possible to indict just about anyone operating a private medical practice--certainly anyone who accepts Medicare or Medicaid, since these are government insurances.  Doctors are frightened about this state of affairs.  Paranoid doctors are not good doctors--they're always looking over their shoulders, expecting attack.  It is unfortunate that my blog confirms that attacks are random little blitzkriegs in the medical profession, because the last thing I want is for doctors to be more fearful than they already are.  Their hypervigilance keeps them from providing good care.  Very often patients are "turfed" from one doctor to another, because they seem risky and litigious, or because they need so much expensive care to get well.  Providing too much care makes the government suspicious.  I talk about this in my "Outliers" post.
     Am I guilty?  Yes, probably--though I don't know of what.  Probably, because I see how the government's set-up allows them to find someone like me guilty of something--especially if it's related to coding or billing.  They may persist in a so-called case against me, if only to save face when they don't find something truly criminal, or to rake in funds for the government's giant maws--which take in and digest more money than any of us can imagine.
     Am I innocent?  Yes, certainly.  I have not committed a crime in any sense of the word as it is and has been defined by all of us common folk for centuries.  I know my business, and there is nothing in it that would constitute fraud or a deliberate attempt to deceive anyone.
     The whole point of this blog is to insinuate that the government's destruction of my career--and my motivation to practice medicine--is not an isolated event.  It seems to me that doctors are besieged by overwhelming threats of many kinds, especially those of governmental and corporate powers.   There are also threats from malpractice suits, censorship by innumerable regulatory agencies, contradictory advice from healthcare groups, and--oh, I almost forgot--the expectations of patients.  In addition, doctors fear that they will make medical errors as a result of too many bureaucratic distractions.  Such errors make us feel terrible (whether or not lawsuits develop) because we are human, and care about the effects of our actions.
     Too much fear and distraction, and too much guardedness, destroy what is most special about doctors.  No wonder we are tired and so many of us want to retire after ten years.  No wonder there is so much criticism of the medical profession.  The rampant criticism of medicine--which is a byproduct of its political and financial importance in this country--feels personal to doctors, and makes practicing medicine harder.   In this atmosphere, everyone suffers.


Tuesday, August 21, 2012

Sample Office Visit and Coding

     Ms. Mary Jones requests a visit with the doctor for a gynecologic exam and physical.  She is a 65-year-old who has started a new relationship, and therefore requests STD testing.  Her mother has Alzheimer's, and Ms. Jones is concerned that her memory may be waning.  "Could I be getting dementia?" she asks.  She has just retired from work as an auto mechanic in a noisy garage, smokes cigarettes, and likes to party with work friends.  She fills out a checklist of symptoms and I note that she has marked off numerous red flags:  chest pain, trouble breathing, racing thoughts, a desire to lose weight, thoughts about quitting smoking, a tender lump in her breast, an inability to catch her breath when exerting herself beyond an easy walk, and a number of life stressors.  She hasn't been to the doctor for several years.  "My last doctor never did anything," she complains.
     I spend 45 minutes during her exam, discussing her risks for cardiovascular disease, the likelihood that she has developed emphysema, the occupational risks associated with working in a noisy, fume-filled garage, her new relationship, and the fact that she's never had a mammogram or colonoscopy.  I examine her thoroughly, perform Pap, breast and pelvic exams, check for trichomonas and gonorrhea under the microscope, run a urinalysis, measure her hearing and vision, have her breathe into a spirometer to determine whether her shortness of breath is attributable to emphysema, do an EKG and chest x-ray, and refer her for mammogram and colonoscopy screenings.  I suggest an optometrist for glaucoma testing (recommended at her age) and a dentist, because she has cavities and plaque.
     We spend additional time talking about how she might lose weight, and I recommend a stress test at her next visit.  I prescribe treatment for emphysema, a diagnosis that is confirmed by her x-ray and spirometry results.  She wants to start Zumba at the local gym--I ask her to wait a week or two, until her cardiac testing is complete.  She describes multiple attempts to quit smoking in the past, says most of her friends and family smoke (but not her new partner), has not picked a quit date, and says she can't afford smoking cessation products like Zyban, nicotine patches, or Chantix.  She asks to have "blood work," which is appropriate, given her symptom list.  I send off a cholesterol panel, blood count, thyroid test, syphilis, and chemistry labs--most of these are sent to the lab and will be billed separately to her insurance by Quest.  I run a five-minute HIV test in the office and give Ms. Jones results, along with STD counseling and condoms.  Given her memory issues and family history of Alzheimer's, I do a neurobehavioral assessment and urine drug screen.  Most of the tests are run by ancillary staff, but I interpret them.
     Ms. Jones' insurance claim form looks like the following.  The section for charges is arbitrary and essentially irrelevant--insurance companies establish all fees for doctors, so we usually set our fees at twice the insurance rates for the ease of calculating amounts pending--half the amount not yet paid, or A/R.
     Here's how this patient's services look when they are translated into insurance jargon--in this case, Medicare.  One number change--a slip of a clerk's finger--could constitute "fraud." Pre-loading charges into the computer is fraught with problems, not least of which is that a diagnosis code specific to the patient's complaints must be entered for each service.  In addition, codes are not the same across insurance companies.  This claim would have to be somewhat different if the patient had Blue Cross, for instance, and therein lies an enormous problem.  Sending the claim below for the exact same patient with Blue Cross could constitute "fraud"  Physicians must speak a different language, with different vocabulary and grammar--thousands of combinations of numbers and letters as illustrated in the example below, and different "allowed" combinations for different insurance carriers.
     The systems invented to order these numbers are called ICD-9,  CPT, and HCPCS.  But the insurance companies which make the rules for which letters, numbers, modifiers, and combinations of codes are permissible to bill--are all over the map.  If the doctor's office doesn't know the rules--and no one knows them well enough--it will be underpaid.  Family physicians provide such a wide variety of services, across a range of specialties, that keeping up with the many codes is a monstrous task.      

Date of Service  1-1-11
Patient ID #        3203
Patient Name      Mary Jones
Patient DOB       12-12-45
Provider Type     NH2
Provider Class:               Procedure Code:                    Diagnosis Code:        Units:         Amount:
    E/M                            99204-25                               611.71, 786.05,          1                xxxx
                                                                                     794.2, 296.52
    IMAG                        71020-59                               786.05, 496, 305.1     1                xxxx
    DIAG                         G0101                                   V72.31                       1                xxxx
    E/M                            G0402                                   V70.0                         1                xxxx
    LAB                           G0328                                   V76.41                       1                xxxx
    DIAG                         94375                                    493.90                        1                xxxx
    DIAG                         99173                                    368.10                        1                xxxx
    DIAG                         99552                                    389.12                        1                xxxx
    DIAG                         92567                                    389.00                        1                xxxx
    DIAG                         93000-59                               786.50                        1                xxxx
    DIAG                         96116-59                               290.0                          1                xxxx
    LAB                           81003                                     V15.85, 788.1            1                xxxx
    LAB                           G0434-QW                            780.09                        1                xxxx
    IMAG                        76645                                      216.5                         1                xxxx
    DIAG                         96150                                      311                            1                xxxx
    LAB                           Q0091                                     V72.31                      1                xxxx
    HM                             99406                                      305.1                         1                xxxx
    LAB                           86703-QW                              V15.85, 786.00         1                xxxx
    LAB                           83986-QW                              616.10                       1                xxxx
    HM                             97535-GO                              278.00                        1                xxxx
    LAB                           87205-QW                             V15.85                      1                xxxx     

     The patient spent one and a half hours with providers and specialized employees--including ultrasound, x-ray, lab and nursing staff.  The office note for her visit takes up eight pages, including two hand-written reports specific to her concerns and our thought processes (called "assessment and plan" in doctor-lingo), a gynecology form with notations about her exam, and multiple pages with results from her diagnostic studies.  It takes about thirty minutes to review, interpret, and record results, as well as write a unique office note about the visit--we do much of this documentation after the patient checks out.
     This patient is making a plan to quit smoking and was relieved that her chest x-ray and EKG didn't show major problems.  She will schedule a date next week to go over her lab results, talk about the impact of life-stressors (the foreclosure, her new relationship) and sort out whether this is a good time to   make a plan to quit smoking--I advise her to reduce her use of cigarettes as much as possible, for now.  She will undergo an exercise treadmill test and echocardiogram before we make recommendations for a fitness program.  If these are negative she may be motivated to quit smoking and follow a healthier lifestyle.
     We accomplish a lot with patients like this--a typical patient visit--but the documentation, coding and billing requirements are overwhelming.  There are dozens of different insurance companies, and their coding requirements can vary significantly.  For example, there are six different ways to code and bill a flu shot, depending on the age of the patient and the insurance company covering the immunization.  This year, the codes for flu shots have changed again.  If we don't keep up with coding changes, we will miscode services, we will not get paid, and we may be accused of fraudulent billing.  In family practice, which utilizes tests and procedures across many different specialties, the number of codes, modifiers, insurance variations, and rules for billing far exceed anyone's ability to keep up with changes.
     The chances that a solo doctor will make clerical errors in the world of billing and coding, therefore, is 100%.  The chances that a solo doctor could be a target for allegations of fraud, therefore, are very high--maybe also 100%, unless the doctor chooses to offer very few services, as a way of avoiding scrutiny, or as a way of keeping the billing as simple as possible.
     Since taking care of patients properly is more important than coding and billing,  providers in my clinic give relegate their best hours to patient care  Documentation, coding and billing--which are superfluous to patient care--fill the late-evening hours.  It doesn't help that insurance companies change codes at random, do not share codes (Medicare requires use of many codes that Blue Cross doesn't recognize, for instance), and are currently in the process of overhauling the entire coding system.  All the codes doctors like me have memorized over the years will be useless.  I know physicians who are planning to retire from medicine because the prospect of adapting to 130,000 new codes for describing patient symptoms and diseases is too onerous.
     The coding above is not the same for every insurance company.  Many codes vary for the exact same services, making it difficult to program a computer program to assist with transmitting charges to insurance companies.  Providers must write in diagnosis codes for every test and procedure, and these codes must be specific for each patient.    


     An hour and a half later

Monday, August 20, 2012

Are Doctors Smart?

     The IQ comparison for sixty-five different jobs and professions is illustrated in the following chart, put together as part of a University of Wisconsin study.  The IQ for medical doctors is the highest, ranging from 107 to 133.  College professors rank next, with a range of 98 to 133.  Here it is:

     A high IQ score is unlikely to guarantee success in any profession--there are just too many other qualities that factor into a person's work success, and IQ tests don't measure them.
      Most patients assume doctors are smart from a book-learning standpoint.  I guess that's true--board-certified doctors have all been through seven to fifteen years of medical training, and we all must stay informed daily of changes in our fields.
     I make it a habit to read a medical journal article every day, usually more.  In family practice it's necessary to take standardized exams every seven years to maintain board certification.  Most physicians have to study hard for this exam because it covers areas of medical practice that are outside our daily purview.  In my case, for instance, I stopped doing obstetrics after completing residency.  I don't keep up with inpatient medicine, either, preferring instead to keep people out of the hospital rather than taking care of them in the hospital.  So I have to study for these parts of the test every seven years.
     IQ is a measurement of analytical, mathematical and spatial thinking.  Computers are good at those things, too--so if IQ tests measured everything that matters, computers could treat patients.  Some people may think they can--but not me.
     An IQ of 100 is, by definition, average.  Mentally disabled people score below 70, and geniuses are said to have scores of 145 or greater.  So doctors, by and large, are not geniuses.
     In 1983, Howard Gardner proposed the theory of multiple intelligences.  He categorized nine types of intelligence:  logical, spatial, linguistic, kinesthetic, musical, interpersonal, intrapersonal, naturalistic, and existential.  Since then he has fine-tuned his theory and made it applicable to teaching, paying special attention to students who don't look smart in the public school system.  Public schools value logical/mathematical abilities, and linguistic fluency.  Coaches in public schools value spatial and kinesthetic intelligence.  A child who has a different set of abilities won't be recognized by most teachers as smart.  But kids in school seem to know about one another's special proclivities, and they segregate themselves into close-knit groups based on their particular forms of intelligence:  the nerds, the jocks, the literary/journalist types, the band kids, honor students, preps, hipsters (skateboarders and alternative musicians), and hippies (rock climbers, bikers, wilderness hikers).   These kids turn into adults who enter professions that favor particular forms of intelligence:  engineers, lawyers, people who write computer programs, athletes, painters, musicians, teachers, psychotherapists, administrators, salesmen, literary writers, and mountain climbers, to name a few.
     Gardner's theory destroyed the idea of IQ as a static measurement of overall ability.  No one is a genius across all nine areas of agility, and everyone is likely to be intelligent in some area.  The beauty of his system is that it recognizes people as individuals with genius-abilities in domains that haven't been included in logic-oriented IQ tests.
     Are doctors smart?  That depends.  Real intelligence in doctors depends on their ability to integrate their knowledge--including self-knowledge--with a number of different interpersonal skills, and to use what they know in complex communications with people from all kinds of backgrounds, in all kinds of emotional states.
     All doctors can memorize facts and protocols from books, and develop logical treatment plans for patients with heart failure or cancer or anemia.  But these concrete abilities are like hammers and hoes in the hands of people without the skills to use them, if doctors don't have emotional intelligence or a standard of ethics.  Interpersonal skills are imperative in the medical profession.  When medical school applicants are interviewed, their ability to convey warmth and curiosity are factors that are essential to acceptance into the profession.  Doctors need a minimum of three kinds of intelligence to be smart:  a)  logical IQ;  b)  emotional IQ:  and, c)  ethical IQ.  The higher they "score" in these areas, and the more balanced across all three, the better doctors are likely to be at doctoring.
     Emotional IQ is extremely important for doctors, because they have to identify and relate to a wide range of personality types.  Patients won't forgive doctors who don't "care."  But caring is perceived by patients in a variety of ways that are based on their personalities.  Some patients need logical explanations in order to feel as though a doctor cares about them;  some need plenty of face time;  some need eye contact;  some need physical touching;  some hate to be kept waiting and need speedy treatment;  some need smiles and hugs;  some need to be on a first name basis with the doctor;  some need to have boundaries enforced;  and some need a prescription--even if they don't need one.
     Doctors who don't know how to reach patients won't be of much help treating them--whatever degree of book-learning and logic they bring to their work.  And doctors who don't share the ethics of the community in which they work will have a hard time recruiting patients, too.  Ethics is extremely important in medicine.  I have on occasion consulted a medical ethicist about complex patient situations--for example, how to proceed with an HIV-positive patient who refuses to tell partners about his/her status, or what my obligation is when a patient is selling drugs on the street, or whether a parent has a right to withhold potentially life-saving but painful treatment from a child.  Many such ethics problems confront doctors every day, and we have to live with ambiguity as we urge patients along paths of self-care that aren't always certain.
     But the personal ethics of a doctor is different, and of paramount importance in medicine.  Will the doctor always act in the best interests of the patient?  Is the doctor fair and honest?  How honest should a doctor be with patients?  Does the doctor care more about money than people?  Is the doctor too lazy to research important new aspects of a patient's disease?  Does the doctor really care about people?  When the doctor and patient disagree about what treatment is needed, what does the doctor end up doing?  Should insurance restrictions--which are based on maximizing profits--come before the doctor's judgment about what's best for a patient?  If the doctor and the insurance company disagree, what should the doctor do?  Does the government have a right to tell doctors how to practice medicine?  Should anyone be able to interfere in the doctor-patient relationship?
     Doctors who take the ethics of their profession seriously, and who are sensitive enough to relate to people even when sickness causes them to regress, and who can stay abreast of an art that is constantly being impacted by changes in science--must be smart, very smart, to do their jobs well.