Re: Managed care--ultrasound (long)
From: art fougner, md (evsono@pipeline.com)
Wed Jun 21 12:00:46 2000
somehow if we managed to get the lawyer out of the equation, the costs
would be different.
art
At Wed, 21 Jun 2000, james connerth wrote:
>
>jay--you missed some data---aids in "bonding,"often lets parents get closer-will do
>more for their baby-stop smoking,drugs,etc.Just my "impression,"after 22 years.What
>does a B1 bomber cost,the lost hard drives,etc??No rational or excuse for the lousy
>changes in medicine just to make a bunch of lawyers and their bureaucratic buddies
>bucks--who cares that we spend 15% of GNP on health care--look what we've got(or
>had)-the BEST in the world.As an aside--notice that 51% of texans are
>uninsured---another dump on us--welfare to work sure works!!!Back to sono-Also,a
>recent study from UK(i believe)showed a l;arge % of "sure" LMP's are WRONG.
>
>jkulkin wrote:
>
>> Why are we so afraid to tell a patient that a service isn't medically necessary?
>> Gary, why scan everyone who presents in the first trimester even without a
>> clinical problem and certain dates? Is there some data that I've missed. Do we
>> not have the confidence to make a diagnosis without doing every test in the book
>> when there are no problems presented. Maybe this is the ultimate in defensive
>> medicine. Why does there have to be a bad guy...the doc or the HMO? Patients do
>> accept that they can't have insurance pay for everything they want but they want
>> explanations that are fair and appropriate in order to understand it. When their
>> friend had 3 sonos during a normal pregnancy and your patient wants the same, do
>> we quote ACOG guidelines or do we say "of course you can have them too but your
>> HMO won't pay for it"!
>>
>> I understand the emotional aspect of the exam room discussion pertaining to any
>> aspect of pregnancy. I also clearly understand the pressure exerted on the
>> clinician. I also know that communication skills and agendas vary from practice
>> to practice. Sorry, but this is a self perpetuating scenario. It's been going on
>> for years and it won't stop tomorrow.
>>
>> Jay
>>
>> "Garry E. Siegel" wrote:
>>
>> > At Tue, 20 Jun 2000, Len2976@aol.com wrote:
>> > >
>> > >Has anyone had difficulty lately getting HMOs to approve routine U/Ss for
>> > >anomaly screens? Until recently we did an early (hopefully 1st trimester)
>> > >dating U/S in the office--which of course is often considered part of the
>> > >global fee. We then sent the patient to the hospital or an outside facility
>> > >for a complete 2nd trimester U/S.
>> > >
>> > >Until recently just a few HMOs insisted on a diagnosis. Now many will not
>> > >approve U/S for "fetal well-being" or 2nd trimester anomaly screen. Even
>> > >when we give a "diagnosis," some of them are asking for copies of prenatal
>> > >data to document this. Is anyone else experiencing this and what are you
>> > >doing about it?
>> > >
>> > >Lenora McCall, CNM
>> >
>> > Yes, Lenora, welcome to managed care. Many of our HMOs will not cover
>> > an ultrasound without a diagnosis--such as bleeding, large-dates,
>> > small-dates, etc. In this instance, it is a reduced fee for service
>> > type of reimbursement, again if medically indicated. Others pay our
>> > practice globally for Ob care, which includes all of the ultrasounds we
>> > care to do--meaning that we get X dollars per Ob patient on the plan,
>> > regardless of the number of ultrasounds performed, and regardless of the
>> > indication. If we choose not to do ultrasound for those patients on
>> > that plan, then they pay us global minus X per patient. The carriers
>> > have figured this out, and they pay more than one scan/patient, but less
>> > than 2. As it turns out, we average about 1.6 scans/patient.
>> >
>> > So, what happens when a patient who is uncomplicated and has no
>> > diagnosis other than pregnancy, and wants that 18 week scan? Well, we
>> > have a disclaimer for *all* patients, and tell them that if there isn't
>> > a diagnosis (and we don't stretch the truth), then we're happy to order
>> > it, perform it, code it routine pregnancy (V22 or V22.2--I forget), and
>> > they can pay us for it up front. If we file it for them (we do for many
>> > carriers, but not for the HMOs who "cap" ultrasound), and if we are
>> > paid, we follow the EOB and refund them if appropriate. If we are not
>> > paid, well, guess what, the patient has already paid us.
>> >
>> > The patients need coddling through this process, as many will call their
>> > crappy HMO (sorry Jay) and the person on the phone says, "Of course
>> > ultrasound is covered." They don't explain the cap or the medically
>> > necessary part. So, as usual, the *doctor* is the bad guy, as we won't
>> > order a scan for a phony diagnosis, and the patient is unhappy or out
>> > some bucks. That said, most people get scanned, and many are covered
>> > except by this crappy HMOs.
>> >
>> > Well, another problem is that ACOG doesn't think that ultrasound at 18
>> > weeks is the standard, and thus many carriers don't pay for a scan
>> > without a diagnosis. Furthermore, a few young primigravidas leave the
>> > office upset/crying because they can't get a covered scan like everyone
>> > else in the world did. If it were up to me, we would scan everyone at
>> > 18 weeks if requested, but I'll be damned if I lose even more money
>> > scanning when not reimbursed. For those pundits who argue, my practice
>> > will scan those on crappy HMO as many times as needed for IUGR, HTN, DM,
>> > etc., without flinching, as it is that to which we foolishly agreed.
>> >
>> > Lastly, if you scan at the first visit, it *isn't* part of the global,
>> > although you are welcome not to bill it. Personally, I bill it if there
>> > is an indication (spotting, size/dates), and don't bill if no reason,
>> > but I scan virtually everyone if they present in the first trimested.
>> >
>> > Garry
>> >
>> > --
>> > Garry E. Siegel, M.D., F.A.C.O.G.
>> > Private Practice
>> > Roswell, GA
--
art fougner, md
A series of 1000 cases begins with but a single anecdote.
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