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Fam Pract Manag. 2001;8(2):57

Getting squeezed

January 8

Call me an oddball, but I enjoy posting my payments, adjustments, write-offs and credits. Among other things, it gives me the chance to learn what various insurance companies are paying me for my services.

Today, I received an interesting explanation of benefits (EOB). A Medicare patient’s secondary insurance was, I thought, picking up the difference between the allowed amount and what Medicare paid. I had billed $85 for a 99214. Medicare allowed $64.69, adjusted $20.31 and paid me $51.27. The remaining $13.42 was owed to me by my patient’s second insurer, but the check from them was for only $2.07. A careful perusal of their EOB disclosed that they allowed $53.34 for the visit, even though they weren’t the primary insurer. Most EOBs provide customer service numbers, and I didn’t hesitate to use this one.

I tried to explain to the rep that I had already accepted the Medicare discount of my services and I wasn’t going to take another adjustment. Besides, I asked, why are you rating services when you are not the primary insurer? “Oh, we do that,” she said, “and we pay based on the lower allowed amount. It’s in your participating provider contract.” I said it probably was and hung up.

My patient, Gordy, couldn’t understand why Medicare just hadn’t simply paid me the full $85 that I had billed. “Gordy,” I said, “you don’t even want to begin to know how this system works. If I take any more from you than $2.07, they’ll put me in jail and you’ll have to find a new doctor.”

“Hey doc,” he said, “how’s about I make it up to you and take you to lunch?”

Teresa, FNP

January 11

In her first week at the office, Teresa, my FNP, had a Department of Motor Vehicles physical scheduled with a crusty truck driver named Jimmy. Jimmy, however, was unaware that he was to be examined by a woman and was visibly upset when he saw Teresa calling in patients and I was nowhere in sight. “Hey, Isabel,” he called to my office manager, “Where’s Dr. Brown?” Isabel explained that I was off for the afternoon and Teresa would be seeing him. “Hell, no,” Jimmy said. “I ain’t gonna be examined by no woman. No way.”

Taking Teresa aside, Isabel explained, “We’ve got a little problem.” When Jimmy’s turn came, Teresa strode out into the waiting room and introduced herself. “Hello, Jimmy. I’m Teresa, Dr. Brown’s new nurse practitioner. Are you here for a driver’s physical? My husband has to take those too. They are such a bother, aren’t they?” she asked.

“Well, as a matter of fact, they are,” Jimmy concurred.

“Yes, I know how you feel. Well, why don’t you come in and we’ll try to make this as quick and painless as possible.” And she led him into the exam room without a peep of complaint.

A short while later, Jimmy emerged, paid his bill and left with his papers and green card in tow.

When Isabel relayed this story to me, I was impressed to hear how well Teresa had read him and handled the situation. “Good thing those physicals don’t call for a prostate exam,” I said. “Wonder if she passed on the hernia check?”

“Wouldn’t you like to know,” Isabel said.

Risk managers

January 16

When I was a medical student in the late ’60s and early ’70s, only one physician in four was sued in the course of his or her career; today it seems one in four is threatened with litigation nearly every year. Hence, the emergence of risk management as a profession and a perk that comes with paying your malpractice premiums.

I actually enjoy talking to my risk manager. Alene, whose territory includes most of Northern California, is bright, sensitive and perceptive. I don’t only call her when the little man inside me tells me to, but for broader practice issues as well. For example, when I recently began collaborating with Teresa, my FNP, Alene provided helpful comments about how to structure that relationship. She detailed my liabilities and described ways to use protocols to minimize them and yet develop Teresa’s scope of practice. Later, when discussing risks related to my medical admit responsibilities, she reminded me that patient safety always comes first. If I kept that in mind while attempting to do what was best for the patient, I could not be faulted, she said.

We spoke for an hour and a half, and then she sent me a 20-page fax and mailed me more information besides! I had a feeling Alene enjoyed getting calls that didn’t start out with a panicked doctor saying he had just been subpoenaed and what should he do now. “We’re both into prevention,” I pointed out during our last phone conversation.

“Yes,” she said, “I prefer to think of it as being proactive rather than reactive. But those aren’t usually the kind of calls I get.”

“I’ll bet that, if you did, you’d be more like the Maytag repair man, waiting around for your phone to ring.”

“That would be nice,” she said.

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