Re: Managed care--ultrasound (long)
From: art fougner, md (evsono@pipeline.com)
Wed Jun 21 11:58:06 2000
Jay -
if the costs were different would you still feel the same?
art
At Tue, 20 Jun 2000, 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.
