We do most of our colonoscopies in our ambulatory surgery center (ASC), which is attached to our office. We are proud of the work that we and our staff do every day and are grateful for the outstanding feedback that we consistently receive from our patients. Some insurance companies will not cover procedures in our ASC so these patients must get "scoped" at the hospital instead. For many of them, this means required blood tests a few days in advance of the procedure, which we would not have required for an ASC procedure. On the procedure day, the patient and the driver will enjoy spending hours in the hospital for parking, checking in, interviews with various medical personnel, the procedure, and the recovery period. And, since it is a hospital, delays are inevitable. Not only does this experience take hours longer than it should, but we are mystified that an insurance company would take on the expense for a hospital test that we could do more efficiently and cheaper in our ASC. Can you make sense out of this? It is typical for a physician's prescription for a patient to be denied by an insurance company. Such denials, of course, are never issued by a medical professional but are from letters kicked out automatically if the physician's preferred drug is not included in the insurance company's sacred formulary. Appealing a denial – which we will attempt – is just as smooth and stressless as calling the IRS for questions on your tax return. It is designed this way so that physicians and patients simply give up. What physician has the time or fortitude to make several phone calls to hear repeatedly, "Please listen carefully as our options have changed ..." Sometimes, my recommended drug is denied because my patient has not first tried a different medication, which I did not prescribe because it is not indicated for my patient's condition. Should I prescribe the wrong drug so that a few weeks later when it is not effective, I can then hope that the correct medicine will be approved? Can you make sense out of this? Some insurance companies will only permit me to prescribe a 30-day supply of a medication. Some of these medicines need to be taken indefinitely. Why should these patients have to make 12 stops to the pharmacy every year? Why can't I prescribe a 3 or 6 month supply? Can you make sense out of this? A patient comes to me for a screening colonoscopy. His insurance company covers this preventive service. I do the exam and find a polyp, which I remove. This changes the definition of the procedure from screening to diagnostic. Why does this matter? Because the insurance company may require that the patient pay a greater share for a "diagnostic" procedure? In other words, the patient gets penalized because his gastroenterologist removed a polyp, which is the goal of a screening colonoscopy. Can you make sense out of this? If any reader can make any sense out of these real-life medical absurdities, then the medical profession needs you STAT. You are much smarter than we are. Michael Kirsch, MD, is a gastroenterologist who blogs at MD Whistleblower. This post originally appeared on KevinMD. Source
