Wednesday, August 6, 2008

The Right Thing

I did a precertification for a patient. The precert was for breast reduction surgery. My office had reminded the patient prior to her initial visit that my office was not in her insurance network. We asked her to check her policy to see if she had out-of-network benefits as we didn't want her to get "stuck" with the bill, as it were. My office balance bills, but tries to be up front about costs.

I did the initial visit, reviewed why she felt she needed a breast reduction, did the exam, took measurements and photos, and then after she left sent a letter with documentation (photos, etc) for the precertification.

She received the letter (copied to my office) below which states that she meets her insurance requirements for the surgery. It then clearly states "If Dr Ramona Bates performs the surgery it will not be eligible for reimbursement."

She called to schedule the surgery for early September. I called her back and reminded her that if I did the surgery her insurance would not cover it (not the surgeon, not the surgery center, not the anesthesia, none of it).

"Would you still like me to do your surgery or would you like me to try to find someone in your network?"

"Well, I would really like to have my surgery in September. Do you think you could get me in to see someone soon enough that I could have it done then?"

"I'll try, but I can't guarantee that you might not have to consider a different time for the surgery."

So I called Dr PS1. He is in her network, but can't see her for the initial office visit until September and probably can't get the surgery scheduled until November or December.

Tried Dr PS2. This one, like my office doesn't participate in her insurance network.

Tried Dr PS3 and hit the jackpot for her! They can see her in a week and most likely get her scheduled (since the precert is already done) in early September.

I then called her back and told her the news. "Thank you Dr Bates. I don't know how I can ever really thank you."



StitchinByTheLake said...

I want to say thank you just for being the kind of doctor who cares about her patient, cares enough to go an extra mile. I know insurance companies make it particularly difficult for medical folks these days and even know a couple of docs who have gotten out because of it. That's sad and hurts my heart. It's kind of like that joke that's been going around about Noah - if it were today he were trying to build an Ark he couldn't do it for all the paperwork required. Bless you for doing the right thing. Blessings, marlene

purplesque said...

Its wonderful that you made that much effort for this patient. I wish it wasn't this way, though..that I didn't have to fight with third party payers for every extra day in the hospital, every extra dose of meds my patients need. That we could just practise medicine in peace.

Sorry, crummy work day.

rlbates said...

No apology necessay, Purplesque. I too wish we didn't need to go through all this.

DrB said...

Not that I know Dr PS3, and maybe I am thinking with the NYC mentality (trust me, I would have done the same thing as you in the end, by the way--going through it all for the patient just to get her in to see someone you trust and that will accommodate her), but there is a little part of me that cannot help but be anxious. If there is any complication, that patient will come after you and say that you referred her to that Dr.

(sorry to put a damper on things.)

rlbates said...

DrB, not worried about that as I documented that she was clearly given the choice. She has to meet PS3 and will always be welcome back if she doen't connect with them. She has the choice of paying more out-of-pocket if that means she gets the surgeon of her choice.