Reply to Doximity Request for Nominations of Psychiatric Hospitals Offering the Best Care

Most academic hospitals are staffed by trainees. Their supervisors spend only half their time on patient care, and have half the experience of clinicians.

Furthermore, all hospitals are now subject to implacable pressure from insurance companies to discharge patients after a few days. So the sole care that takes place in hospitals is to provide some eyesight supervision for dangerous patients. They are loaded up on medications with strong sedative side effects to quiet them. That way they may be discharged safely, with a lesser risk of litigation against the hospital for malpractice. Most psychiatric medications take weeks to work, since the brain is a very slow changing organ.

Upon discharge, the sedative side effects wear off after a couple of weeks, and the patient is back to his original level of distress and dangerousness.

There is no quality psychiatric hospital care in the United States. Any result you may come up with will be quite misleading to desperate families.

David Behar, MD

After Every Adverse Communication from a Health Plan

After every adverse decision or letter from a Health Plan, a letter of complaint about the Medical Director should be sent to the licensing board. Let them spend their time being investigated, and their money hiring lawyers. As they make it tough to do our jobs, so should we return the favor. Here is an example.

State Board of Medicine
P.O. Box 2649, Harrisburg, PA 17105-2649
Phone:             (717) 783-1400      
Fax: (717) 787-7769
ST-MEDICINE@pa.gov

RE: Unprofessional Conduct; X, MD; Medical Director,
Y Health Plan,
Dear Doctor:
I enclose a copy of a letter from Dr. X. I request that it be investigated for its unprofessional conduct. The blacked out areas have a single patient name. General opinion, commentary, and criticism have First Amendment immunity. This letter’s specific demands, criticisms, etc., represent the practice of medicine, because they are about a specific patient. They are therefore under your jurisdiction.

1) Y is a quasi-governmental organization with the ability to punish doctors. Its actions require a fair hearing. That was not granted nor even offered.

2) I believe Dr. X is not a qualified psychiatrist. He is therefore criticizing doctors outside his scope of knowledge or experience, two psychiatrists. I am board-certified in psychiatry. The Mcare Act requires that any governmental medical action be based on the opinion of an expert with qualifications equal to mine. This letter violates that statute.

3) Assume nothing was wrong with the procedure of Y. This doctor is still giving specific, technical, medical advice about a patient he has never met, nor whose clinical record he has reviewed.

4) His allegation of multiple prescribers of a psychotropic drug over 45 days fails to acknowledge that Dr. Z and I work for the same clinic. We are providing coverage for each other, using the same facility, reviewing the same chart, and seeing the patient when follow up visits are due. There is therefore good continuity of care, not multiple, unrelated prescribers. Clozapine is prescribed to patients who have failed to respond to multiple neuroleptic tranquilizers, and remain dangerous to themselves and to others. Not seeing such patients regularly is substandard care. He is also receiving Seroquel, to reduce the dose of required clozapine, a desirable goal given the side effects of this medication.

Weasel clauses in the standard insert do not detract from the seriousness of the allegation of medical mismanagement being made by this quasi-governmental organization.

Sincerely Yours,

David Behar, M.D.

Less Painful Pre-Authorizations

The cancellation of a prescription by refusal to pay for it is the same as making a prescribing, an act of medical practice. Assume the prescription was cancelled by a doctor in the same specialty as the prescriber. It remains unprofessional conduct to make a medical decision on a patient whom one has never seen, and whose records have not been reviewed.

I would like to see an ethics complaint for unprofessional conduct filed after every denial. The pre-authorization itself is a joke. It implies, the prescribing doctor was not serious in writing his prescription, or only meant it a little. I disagree that the time and effort are built into the encounter fee, without causing a conflict of interest. The fee is to see the patient. It is not to do work for the insurance company. If the doctor is on the payroll of the insurance company and owes a duty of performance, he cannot be 100% committed to the medical interest of the patient.

In any case, here is some advice on trying to make it easier.

******

Insurance preauthorizations: How to make the process less painful

Practice Management. By Victoria Stagg Elliott, amednews staff. Posted April 5, 2010.
The process can be automated. Or, practices can note what issues trigger a denial, and adjust their processes to quicken and gain approval.

And while insurers normally view precertification as a nonbillable service because it's considered part of a medical visit, evidence of how much time it takes can be used as a negotiating chip with insurers.

"It's supposed to be built into the revenue for the services that doctors are providing, but it can be an administrative nightmare for practices. Every insurance company requires something just a little bit different," said Rhonda Buckholtz, vice president of business and member development at the American Academy of Professional Coders. "But we can simplify the process as best we can."

The first step is to analyze how the office handles the process. Is it possible to get some preauthorizations completed before the patient comes in? Are there insurer-provided online tools that the practice is not taking full advantage of?

For example, Elizabeth Woodcock, principal of Woodcock & Associates in Atlanta, said she worked with an endocrinology practice that entered precertification information into an insurer's online system. But, rather than submitting it electronically, staff printed it out and faxed it, which took additional time.

"Make sure you are using all the automation that the payer allows," Woodcock said.

Experts also suggest creating some kind of tool that staff can refer to with all the policies and procedures of various insurers. This does not have to be particularly high-tech. For instance, Buckholtz has set up three-ring binders at several medical practices she has worked with. The binders can be particularly handy if the person who usually handles preauthorizations is out of the office.

Dealing with denials of the initial request for precertification also can be time consuming, but experts say the situation is another opportunity to look for time savings. Are there consistent issues that trigger a denial? Are certain codes always left off? Are necessary lab tests not being noted?

Pre-Authorizations Denials End When Investigations Begin

Insurance preauthorization denials spark inquiries

By Emily Berry, amednews staff. Posted April 15, 2010.

Years of physician complaints about Delaware health plans' utilization management programs have culminated in inquiries from a U.S. senator and the state's insurance commissioner.

Sen. Jay Rockefeller (D, W.Va.) wrote to Blue Cross Blue Shield of Delaware March 25, citing news reports that said the plan, through contracted utilization manager MedSolutions, was routinely denying requests for prior authorization for cardiac stress tests, even in cases where they appeared to be obviously medically necessary.

Rockefeller, who chairs the Senate Committee on Commerce, Science and Transportation, asked the company to give his office its records, including an explanation for every denial of a cardiac diagnostic test in the last five years.

Then on March 27, state Insurance Commissioner Karen Weldin Stewart announced she had formed a task force and was investigating prior authorization denials by the Blues, Coventry Health Care and Aetna, all of which have hired MedSolutions.

In a statement released that day, she said that until her department had completed its work, the Delaware Blues had agreed to eliminate preauthorization requirements for high-tech radiology services.

Doctor Collects from Insurance in Small Claims Court

This is straight collections of debt in small bundled amounts in Small Claims. The doctor represented himself, but did his legal homework, in anticipating and finding the rebuttal for the company's arguments.

I would like to see many doctors go beyond debt for services to patients, to charging for filling out pre-authorization forms, spending time on the telephone for approval, for retrieval of medical records. These are for the benefit of the insurance company. They represent contract in law, generating a debt called quantum meruit.

From the article.

Fla. doctor beats insurer -- in small claims court

In the Courts. By Amy Lynn Sorrel, amednews staff. Posted March 1, 2010.

Physicians are not known for taking health insurer payment abuses lying down, having marched big carriers into state and federal courtrooms in a series of successful class-action lawsuits over the years.

But one Florida physician caught an insurance giant from an angle it was not expecting when he launched an attack in small claims court. The dermatologist's strategy: to win back the roughly $130,000 he contends Humana Inc. owed his practice in unpaid bills since at least 2007, even if it took filing a few small claims at a time.

The strategy worked. The doctor has recouped nearly all of the money."If doctors have a legitimate right to be paid based on services they provided, insurance companies should pay. And if they think they can get away with nonpayment, [doctors] should be aggressive in whatever manner it takes," said Steven Rosenberg, MD, president of Palm Beach Dermatology Inc. in West Palm Beach.

Letters to Humana seeking to resolve the claims on behalf of himself and other doctors in his practice brought no recourse. After his lawyer wrote to the insurer, Dr. Rosenberg said he got a promise from Humana that it would expedite the claims.

"But here we were a year and a half later, and we were still doing this process," he said. "We basically kept getting the runaround, and we got frustrated that Humana was not responding to all our efforts."

He explored hiring an attorney to take his case to civil court. But the 40% contingency fee that would have come from whatever judgment the practice collected was not appealing.

At that point, Dr. Rosenberg put his medical research skills to work. He discovered that for the same $350 he paid the attorney to write to Humana he could file a petition against the company in Palm Beach County small claims court, where parties can represent themselves.

Because damages could not exceed $5,000 per claim, Dr. Rosenberg bundled a few bills together worth that amount, filled out a simple claim form, attached a check and, in the fall of 2009, sued the insurer in small claims court for violating Florida's prompt-payment law.

"Palm Beach Dermatology Inc. has worked for the last 29 months to remedy the issue via Humana's claims appeal/special projects process and through their appointed attorney with no resolution," the one-page complaint stated.
Legal maneuvering

Dr. Rosenberg was met in court by an attorney Humana sent to defend the case. But he was familiar with his legal rights, having been a past president of the Florida Society of Dermatology & Dermatologic Surgery and a former state medical board member, so he successfully rebuffed some of the lawyer's legal maneuvers.

When the attorney tried to argue that the dermatology practice did not obtain the requisite prior authorization before treating patients, the doctor countered that state law gave patients direct access to dermatologists without a referral. And to the insurer's contention that Palm Beach Dermatology failed to first collect payment from patients before seeking reimbursement from the insurer, Dr. Rosenberg fired back that state law prohibited such practices.

Then came a settlement offer. Humana agreed to pay the first set of claims and the doctor's filing fees, totaling $5,340, according to a court judgment dated Oct. 6, 2009. Dr. Rosenberg said the case was heard within a month of filing the lawsuit and resolved the same day.

But he warned Humana's lawyer that the case was only the beginning. "I told him this was the first of 25 claims we were going to be filing."

He took the insurer to court a second time and won again in January. Shortly after he filed the second case, Dr. Rosenberg said the practice began receiving checks in the mail from Humana totaling $90,000.

The insurer sent two representatives to the office to go through the remaining outstanding claims. Since then, Humana has restituted nearly all of the $130,000 Palm Beach Dermatology was owed, Dr. Rosenberg said. "We didn't really know if it was going to work but figured it was worth a try. Obviously, Humana got the message this was going to cost them."