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A view from the other side

I enjoyed reading the article "Working With Insurers: A View From the Dark Side" by Lee Buttz, MD, MBA, in the July/August issue of FPM. I too have been a medical director for a major insurer, and at that time I would have agreed with many of his suggestions.

However, I am now back in private practice and have a perspective from the other "other side." On an average day of seeing 20 to 25 patients in our internal medicine practice, we receive five to eight denials from multiple insurers for various services. All of these denials require faxed responses, letters or phone calls. Rarely can anything be cleared up with a single response; many denials require multiple requests that quickly overwhelm our small staff. Dr. Buttz's pearls may work in an ideal world. However, in the real world of daily practice it is difficult, if not impossible, to run the insurer gauntlet.

The final result is that patients do not receive services they require and their optimal health is jeopardized. I was also once guilty of seeing through the myopic lens of the insurer. Perhaps it's time insurers came into our world to better understand our frustrating attempts to obtain legitimate care for our patients.

Steve P. Sanders, DO, MBA
Tulsa, Okla.

I applaud Dr. Buttz for his attempts at making my practice life better, but I wonder if he knows the circumstances that are closing down primary care offices. I saw 22 patients each day in my private practice, and my reimbursement should have been contractually between $55 and $72 per visit. Payment was denied several times daily, however, and not for the reasons noted by Dr. Buttz.

I recently closed my office in California because of deteriorating payment from insurance companies. Claims were often denied for unsubstantiated reasons including "not an active member" (although the patient was active), "claim filed beyond the time allotted" (although it was filed within days), "not a covered service" (although the service was indeed covered), "improper member ID" (although the patient had a proper ID) and others.

Before anyone takes the side of the insurer, remember that the addition of a full-time re-biller is not a position a primary care office can afford. It is true that the doctor could personally call the insurance company with each erroneous reason for nonpayment, but then who would practice medicine? I left a town of 8,000 people without a physician rather than watch my income go from inadequate to worse. The role insurance companies play in ruining primary care in America is an entirely different topic but one that is far more worthy of an article in FPM.

A. Alexander, MD
Anacortes, Wash.

Author's response:

I appreciate the comments written about my article on working with insurers. Both readers describe the frustration they feel with the current American health care system. Having worked both as a practicing physician as well as a medical director at an insurer, I understand the problems resulting from miscommunication and lack of information.

Clearly we as physicians all have an obligation to work to improve the system for our patients and our providers. The purpose of my article was to help educate physicians so as to develop a better understanding of how insurers approach the review process. My hope is that this understanding will allow physicians to reduce the administrative burden of insurance coverage verification while we all work for a better tomorrow.

Lee Buttz, MD, MBA
Blue Bell, Pa.

Ensuring follow-up care

While the response from Alice Gosfield, JD, to the legal question "Do we have a legal obligation to ensure that our patients receive necessary follow-up care?" [Practice Pearls, April 2008] is legally correct, it is clinically inappropriate.

The answer given was essentially, "If you do a good job of telling your patients when to return and documenting appropriately, your legal obligation is fulfilled."

The problem with the answer is that we are not supposed to be about fulfilling the strict minimum legal requirements; we are supposed to be about taking care of patients. The ethical obligation of an aspiring medical home is to reach out to patients who are due for follow-up and remind them. And if they miss a follow-up appointment, remind them again. This is an ethical duty we owe our patients that is beyond any legal obligation.

Roger K. Howe, MD, MMM
Little Rock, Ark.

Dr. Ness' E/M rule

Dr. Nancy Ness' recommendation in "A Multiple-Service Rule for E/M Services" [Opinion, June 2008] is simply genius. The implementation is so simple. The reach is so broad. Her plan would go a long way to improve patient care, continuity, comprehensiveness and convenience while lowering cost and complexity. Is anyone at the Centers for Medicare & Medicaid Services listening?

Kevin P. Mikus, MD
Matthews, N.C.

Dr. Ness' suggestion for an E/M rule change makes sense. I am a bit surprised that those looking into containing Medicare costs have not stumbled upon this before. Certainly this was the type of calculus that was used in the days before Medicare and the multiplicity of health insurance plans. I hope this plan gets shared with the appropriate policy-makers.

I recognize it may create "turf" problems in some areas, but if implemented this would improve the remuneration of family physicians who are certainly capable of managing the type of problems presented in the article's example.

H. Thomas Wiegert, MD
Mercer Island, Wash.

Kudos

The June how-to issue of FPM was one of the most practical reads I have had in years. The step-by-step description of electronic searching and how to fix a flawed system were easily adaptable to my office.

Joe Baum, MD
Floyd, Va.