PRACTICE DIARY

Chapter 26

 


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Fam Pract Manag. 2001 Jun;8(6):47.

The clavicle: Part II

Almost worse than my son’s recent collar bone fracture were the billing intricacies that followed. Since Gabe is a business economics major, I suggested that he deal with it. “It will be a good experience for you, learning how this system works,” I opined.

Two months later, Gabe called to say that the envelopes he was receiving in the mail from his creditors were changing colors. “First they were white, then yellow and now they’re red,” he said. “I hope they’re not going to come after my truck.” He complained that no one seemed to know what they were doing, there were just too many bills and he was getting overwhelmed.

Bailing him out, I had him send me all the EOBs. I then separated them into piles, of which there were six: one each for radiology, anesthesiology, pathology, the orthopedic group, the emergency physician and the hospital. Next, I started calling around to all their billing services. There were errors in billing secondary insurance before primary, incorrect policy and identification numbers, and just plain delays in billing any insurance at all. It was now over five months since his accident and none of his providers had been reimbursed a cent. No wonder doctors aren’t making any money, I thought. They’re not involved with their accounts.

I was particularly amused to read a non-itemized bill from the hospital for $7,113.66 in total charges with the warning, “We have not received payment from your insurance company. The balance now becomes your responsibility. Collection action may be taken.” My business friend Charlie once received a similar dunning letter. His take: “No accounting, no specifications whatsoever. This is so sloppy that anyone in any normal business would be reprimanded. No one would ever pay such a bill.”

Is the red ink hospitals and providers are bleeding due to declining reimbursements or simply poor billing practices? I wonder.

Curbside consult

Jack, a patient I hadn’t seen for three years, cornered me in the bike shop the other day. He started in with what I thought was going to be a long diatribe about a medical problem he was having, but it turned out to be more of an “FYI” than anything else.

“I was having respiratory symptoms and tried to call you, but you were too busy to see me so I went to the ER. They gave me some antibiotics, but I didn’t get better,” Jack said.

I’m never “too busy” to see or talk to a patient, but I didn’t want to challenge Jack, so I said instead, “Well, if you’d like to see me about it, I’ll be in my office tomorrow.”

“Oh, I’m OK now,” he said. “I went to a holistic health practitioner. Do you want to know what she said?”

“Not really,” I imagined myself saying, but I knew I’d regret it immediately so said instead, “What did she say, Jack?”

“She said,” Jack continued, “that the problem was in my abdomen. I had toxins in my intestines. She prescribed some herbs and fixed me right up.”

In situations like these, what I’d like to say is, “If I have to listen to any more new age claptrap I’m going to scream,” or “Try that the next time you have pneumonia,” or “We’re in a bike shop, for Pete’s sake, give me a break.” But I smiled, remembered that I was a professional, and courteously said, “If that doesn’t work the next time, Jack, come see me.”

Organ donation

They found me at the health club just before I began a game of racquetball. “Dr. Brown,” the operator said, “the ER would like to talk to you.” I dread those calls. It was a Saturday morning and I was on medical admit.

“Sandy,” Pete, the ER doc, said, “they just brought in a near-drowning victim. She’s on a vent. Her pupils are fixed and dilated. It doesn’t look good. You’re the guy on call for unassigned patients, so come on in.”

Lauren, a 46-year-old woman visiting the coast, had swum into a cove and not answered her partner’s call. He found her floating face up in the water and started CPR while getting her back to shore. Bystanders called 911, and an ambulance was there within minutes. They started IV lines, intubated her and infused her with saline. In the ER a dopamine drip was started to support her pressure.

ABGs showed her pH to be 6.7 with a bicarb of 4. I bolused her with 4 amps of bicarb and called Jim, my pulmonologist friend in a nearby city. “I think we’ve got an organ donor here,” I told him.

“Send her down,” he advised, and we did.

Several days later he called to tell me Lauren had not only survived her near drowning but had been extubated and was talking to him. All her systems were OK, and she didn’t appear to have any major neurological impairments. He commended our crew on our resuscitative efforts and remarked how fortunate she was that the accident occurred in cold water. “By the way,” he said, almost as an aside, “I think Lauren will be needing all her organs now.”

Dr. Brown, a solo family physician living in Mendocino, Calif., is a contributing editor to Family Practice Management. These excerpts from his journal illustrate the many characters, stories and lessons family practice has to offer. No real patient names have been used. Conflicts of interest: none reported.


 

Copyright © 2001 by the American Academy of Family Physicians.
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