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Fam Pract Manag. 2003;10(6):62

A complicated case

I was going through my electronic claims reports the other day when I noticed something strange. The previous week, we had submitted four claims for a Jonathan Stephens, yet I knew the dates of service were four months earlier and we had already been paid by Blue Cross, the patient’s primary insurer. I also knew that Mr. Stephens still owed us $124, and it was over 90 days past due. Why had Dalia, my office manager, resubmitted the bills?

The file showed that Dalia had indeed rebilled the full amount – but to Medicare, not Blue Cross. I couldn’t fathom what she was up to, so I asked her. “I called Mr. Stephens about his outstanding balance, and he said Medicare was his secondary insurance so I should bill them for the rest,” she said.

This, I thought, is why I’m glad I know a little about my business. “Dalia,” I explained, “Medicare can be a secondary insurer when a person reaches the age of 65 and continues to work, but Mr. Stephens is 64 and unemployed. What it looks like we’re doing is double-dipping, and that’s fraud.” I could tell Dalia felt badly about the mistake, so I gave her the opportunity to fix it. “Call Medicare and tell them these claims were sent in error and we’ll refund their money.”

When I got back to the office after rounding this afternoon, there was a note from Dalia waiting on my desk. “Medicare said that, at the time of service, they were Mr. Stephen’s primary insurer because he had gotten early Medicare coverage due to a disability. Blue Cross was his secondary. When Medicare pays us, we should refund Blue Cross and then rebill them for the correct amount.”

So, Blue Cross had paid us in error! Who would have imagined it? Without knowing why, Dalia had done the right thing in billing Medicare. I made a note to compliment her on a job well done the next day.

Horses vs. zebras IV

I was perusing a report on a patient of mine who had checked into the emergency room for vomiting when I noted that his creatinine had risen from a baseline of 1.5 to 2.4. Earl was a 78-year-old man with diabetes and mild hypertension and was on two potentially nephrotoxic drugs, Glucophage and Zestril. The ER doctor had told him to stop the Glucophage. Two weeks later, after retesting him and finding his creatinine had risen to 3, I told him to stop the Zestril as well.

Jill, a nephrologist I consulted, said it might take two to four weeks for his creatinine to normalize. I continued to monitor him biweekly; all the while he was feeling fine and able to urinate. But after one two-week cycle, his creatinine hit 7. That was enough for another call to the nephrologist.

“I would get a magnesium, phosphorus and serum complement and an ultrasound with a color Doppler add-on to assess renal blood flow,” advised Richard, the nephrologist on call. “What other drugs is he on?”

“Allopurinol, Flomax and glyburide,” I said.

“I’ve heard of allopurinol causing an interstitial nephritis,” he said. “I’d stop that as well. If you can’t figure it out in a couple of days you should ship him down to us.”

I got the ultrasound scheduled for the next morning and worried all night about a renal artery stenosis or an atypical aortic dissection. The radiologist called me the next day. “Your patient has the biggest bladder I’ve ever seen. It’s huge. There must be three liters of residual urine in there.”

“Duh,” I thought. He was, after all, on Flomax, although he had never complained of any abdominal pain that you would associate with a grossly distended bladder.

“Earl,” I reassured, “all you need to fix your problem is a urinary catheter and a transurethral prostatic resection in a few weeks.”

Several days later, Earl’s creatinine had fallen to 2.7, and it looked like he was going to be OK. Fooled by his medication, I was relieved he hadn’t lost his kidneys from something as mundane as an obstructive uropathy but felt stupid that I hadn’t figured out his puzzling presentation sooner. This one was no zebra.

Old myths die hard

Medical students and residents seem to be getting the message that doctors are no longer rich (unless we make good investments), but the public is slow to catch on. I increasingly find myself being taken advantage of by folks who think I can afford to be. Case in point: Daryl, a patient and carpenter, who recently built me a woodshed. He quoted me a rate for time and materials and said the project would take a week. It took two, and he missed parts of some days and didn’t come at all for several others. On the final bill, his labor charges seemed to reflect far too many hours and the “materials” he charged me for included several sets of tie downs, a measuring tape and a hammer tacker – tools he kept. When I asked Daryl to show me his time sheet, he said he hadn’t kept one. “Daryl,” I said, feeling frustrated, “it’s not my job to keep tabs on your hours. It’s yours. And just because I’m a doctor doesn’t mean I can’t tell the difference between materials and tools on an invoice.” Eventually, we reached a figure that seemed fair, but neither of us was really satisfied. Are people just becoming more avaricious, or are they confusing us with investment bankers and dentists?

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