Guest guest Posted December 17, 2008 Report Share Posted December 17, 2008 Well then just draw the line where you feel you want to - one of the joys of being your own show.I agree the burden of free work in the name of being 'PCP' can really make you feel put upon and it seems magnified when you are feeling overworked already. If you're like me, part of hassle also is not being clear where you draw the line - if the line floats a lot, it generates extra aggravation, just thinking about what you should do in which case.Some time last year, after I started getting salvos from the 2 biggest insurances containing volleys of prior authorizations, I changed my unwritten policy- unless the patient can't drive/can't get in, I tell them they have to come in for a visit -because their insurance is requiring this paperwork so the insurance can maximize their profits on OUR backs - and I am not going to help them do this by donating my time for free. I jave the patient come in so I can charge their insurance a visit and fill out the paperwork. I think there is a spectrum of what people do - sounds like Pam Wible has all her patients and pharmacies trained so that she NEVER does 'free' refills.I try to get them in the office, but will usually do refills for chronic medications in between if needed unless it gets to be burdensome (my EMR makes refills really simple, maybe 45 seconds including looking at the chart to see last visit. You could certainly institute a 'form' fee for say $20, not completed at visit. It is definitely OK to draw those lines.To: From: mintek@...Date: Wed, 17 Dec 2008 00:12:01 -0500Subject: drawing the line With the loss (imminent ? ... or fait accompli ?) loss of Larry Lyon, this list-serve needs a grouchy voice, and every once in a while I feel one of those rising out of my waddle ... Today, a series of 4 or 5 phone messages culminated in another prescription (for Allegra, no less) issued to another pharmacy, in a city just across the area-code border-line from me ... I am lucky to have a cheap long-distance phone rate, but the time/hassle of making decisions, reviewing charts, and documenting actions for prescriptions is un-compensated work. I tell all patients to bring the brown paper bag full of their pill- bottles to every visit, and scan the labels for the "no more refills coming" warnings ... Some patients just don't learn, and those are usually the patients on 8 prescription drugs. We deal with the Lipitor and the Lisinopril and the Lantus, but they forgot about the Paxil running-low at home ... that phone call comes back about 3 weeks later, which is close to the limits of my memory about that last visit, but then about 6 weeks out comes the phone call about Allegra. How much free work can a doctor do for a patient, between visits, before that doctor starts to feel abused and resentful ? ... Any patient can walk on over to the all-night grocery store and buy a bottle of Claritin or Zyrtec, without bothering the doctor's office, but to cash in on his insurance deal, a patient gets the pharmacist to FAX the first salvo to the doctor's office ... Way too often, this will lead to a requirement to get "prior authorization" from the patient's new health insurance company, to prove that the only antihistamine that will let that patient live in harmony with those 3 pet cats is the one that takes a prescription ... I am getting close to the point of declaring that every prescription, every note for a boss, every handicapper parking form, etc. has to be composed / filled-out / phoned-in during a face-to-face visit , for which there will be a charge ... Send e-mail faster without improving your typing skills. Get your Hotmail® account. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 17, 2008 Report Share Posted December 17, 2008 Well then just draw the line where you feel you want to - one of the joys of being your own show.I agree the burden of free work in the name of being 'PCP' can really make you feel put upon and it seems magnified when you are feeling overworked already. If you're like me, part of hassle also is not being clear where you draw the line - if the line floats a lot, it generates extra aggravation, just thinking about what you should do in which case.Some time last year, after I started getting salvos from the 2 biggest insurances containing volleys of prior authorizations, I changed my unwritten policy- unless the patient can't drive/can't get in, I tell them they have to come in for a visit -because their insurance is requiring this paperwork so the insurance can maximize their profits on OUR backs - and I am not going to help them do this by donating my time for free. I jave the patient come in so I can charge their insurance a visit and fill out the paperwork. I think there is a spectrum of what people do - sounds like Pam Wible has all her patients and pharmacies trained so that she NEVER does 'free' refills.I try to get them in the office, but will usually do refills for chronic medications in between if needed unless it gets to be burdensome (my EMR makes refills really simple, maybe 45 seconds including looking at the chart to see last visit. You could certainly institute a 'form' fee for say $20, not completed at visit. It is definitely OK to draw those lines.To: From: mintek@...Date: Wed, 17 Dec 2008 00:12:01 -0500Subject: drawing the line With the loss (imminent ? ... or fait accompli ?) loss of Larry Lyon, this list-serve needs a grouchy voice, and every once in a while I feel one of those rising out of my waddle ... Today, a series of 4 or 5 phone messages culminated in another prescription (for Allegra, no less) issued to another pharmacy, in a city just across the area-code border-line from me ... I am lucky to have a cheap long-distance phone rate, but the time/hassle of making decisions, reviewing charts, and documenting actions for prescriptions is un-compensated work. I tell all patients to bring the brown paper bag full of their pill- bottles to every visit, and scan the labels for the "no more refills coming" warnings ... Some patients just don't learn, and those are usually the patients on 8 prescription drugs. We deal with the Lipitor and the Lisinopril and the Lantus, but they forgot about the Paxil running-low at home ... that phone call comes back about 3 weeks later, which is close to the limits of my memory about that last visit, but then about 6 weeks out comes the phone call about Allegra. How much free work can a doctor do for a patient, between visits, before that doctor starts to feel abused and resentful ? ... Any patient can walk on over to the all-night grocery store and buy a bottle of Claritin or Zyrtec, without bothering the doctor's office, but to cash in on his insurance deal, a patient gets the pharmacist to FAX the first salvo to the doctor's office ... Way too often, this will lead to a requirement to get "prior authorization" from the patient's new health insurance company, to prove that the only antihistamine that will let that patient live in harmony with those 3 pet cats is the one that takes a prescription ... I am getting close to the point of declaring that every prescription, every note for a boss, every handicapper parking form, etc. has to be composed / filled-out / phoned-in during a face-to-face visit , for which there will be a charge ... Send e-mail faster without improving your typing skills. Get your Hotmail® account. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 17, 2008 Report Share Posted December 17, 2008 Great post. Or...we go to some version of a blended capitation and per visit revenue model so that you are compensated for at least some of this non face-to-face work as a certain level of it (more on limits below) is part of great primary care. I'm a broken record on this, but a cash-only retainer/per visit model works. As would a reasonable blended reimbursement model from insurance companies - problem is those don't really exist. What absolutely doesn't work is a fee for service model because it's impossible to completely link all services provided by primary care docs to a reasonable fee. It works in the OR - it doesn't work in a primary care practice. Now I'm going to put my MBA/business hat on and encourage you to look at every patient from the perspective of whether they are good for your practice. In business-speak, this is the concept that some customers aren't worth having. One angle is whether you make money because they are in the practice. I know this is not the only perspective we ethically should use, but it is one factor. The patient who in effect abuses you by forcing all of this extra work because of their irresponsible behavior is a financial drag on the practice due to all of the uncompensated time. In addition, I believe practices have an obligation to consider how such patient behavior impacts other patients. Are you forced to spend less time with other patients because of this unnecessary run-around? Would you be able to call a diabetic struggling to control their blood sugar if you weren't wasting time playing phone-tag with pharmacies? Are you as happy as you could be professionally if this crap didn't distract you from your mission? Does being less happy in any way affect how much energy you bring to your healing work or for how long you'll practice? If the answer to any of these is yes, you owe it to your other patients and yourself to tell these people they need to change their behavior or get another doctor. Being a martyr for every patient is engrained in us from the first day of medical school - it's an illusion that it is a requirement for being a great doc. In fact, it's an ethical trap as it limits the good work we can do for all patients. My four cents... Chad > > With the loss (imminent ? ... or fait accompli ?) loss of Larry Lyon, > this list-serve needs a grouchy voice, and every once in a while I > feel one of those rising out of my waddle ... Today, a series of 4 or > 5 phone messages culminated in another prescription (for Allegra, no > less) issued to another pharmacy, in a city just across the area-code > border-line from me ... I am lucky to have a cheap long-distance phone > rate, but the time/hassle of making decisions, reviewing charts, and > documenting actions for prescriptions is un-compensated work. > I tell all patients to bring the brown paper bag full of their pill- > bottles to every visit, and scan the labels for the " no more refills > coming " warnings ... Some patients just don't learn, and those are > usually the patients on 8 prescription drugs. We deal with the Lipitor > and the Lisinopril and the Lantus, but they forgot about the Paxil > running-low at home ... that phone call comes back about 3 weeks > later, which is close to the limits of my memory about that last > visit, but then about 6 weeks out comes the phone call about Allegra. > How much free work can a doctor do for a patient, between visits, > before that doctor starts to feel abused and resentful ? ... Any > patient can walk on over to the all-night grocery store and buy a > bottle of Claritin or Zyrtec, without bothering the doctor's office, > but to cash in on his insurance deal, a patient gets the pharmacist to > FAX the first salvo to the doctor's office ... Way too often, this > will lead to a requirement to get " prior authorization " from the > patient's new health insurance company, to prove that the only > antihistamine that will let that patient live in harmony with those 3 > pet cats is the one that takes a prescription ... > I am getting close to the point of declaring that every prescription, > every note for a boss, every handicapper parking form, etc. has to be > composed / filled-out / phoned-in during a face-to-face visit , for > which there will be a charge ... > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 17, 2008 Report Share Posted December 17, 2008 Great post. Or...we go to some version of a blended capitation and per visit revenue model so that you are compensated for at least some of this non face-to-face work as a certain level of it (more on limits below) is part of great primary care. I'm a broken record on this, but a cash-only retainer/per visit model works. As would a reasonable blended reimbursement model from insurance companies - problem is those don't really exist. What absolutely doesn't work is a fee for service model because it's impossible to completely link all services provided by primary care docs to a reasonable fee. It works in the OR - it doesn't work in a primary care practice. Now I'm going to put my MBA/business hat on and encourage you to look at every patient from the perspective of whether they are good for your practice. In business-speak, this is the concept that some customers aren't worth having. One angle is whether you make money because they are in the practice. I know this is not the only perspective we ethically should use, but it is one factor. The patient who in effect abuses you by forcing all of this extra work because of their irresponsible behavior is a financial drag on the practice due to all of the uncompensated time. In addition, I believe practices have an obligation to consider how such patient behavior impacts other patients. Are you forced to spend less time with other patients because of this unnecessary run-around? Would you be able to call a diabetic struggling to control their blood sugar if you weren't wasting time playing phone-tag with pharmacies? Are you as happy as you could be professionally if this crap didn't distract you from your mission? Does being less happy in any way affect how much energy you bring to your healing work or for how long you'll practice? If the answer to any of these is yes, you owe it to your other patients and yourself to tell these people they need to change their behavior or get another doctor. Being a martyr for every patient is engrained in us from the first day of medical school - it's an illusion that it is a requirement for being a great doc. In fact, it's an ethical trap as it limits the good work we can do for all patients. My four cents... Chad > > With the loss (imminent ? ... or fait accompli ?) loss of Larry Lyon, > this list-serve needs a grouchy voice, and every once in a while I > feel one of those rising out of my waddle ... Today, a series of 4 or > 5 phone messages culminated in another prescription (for Allegra, no > less) issued to another pharmacy, in a city just across the area-code > border-line from me ... I am lucky to have a cheap long-distance phone > rate, but the time/hassle of making decisions, reviewing charts, and > documenting actions for prescriptions is un-compensated work. > I tell all patients to bring the brown paper bag full of their pill- > bottles to every visit, and scan the labels for the " no more refills > coming " warnings ... Some patients just don't learn, and those are > usually the patients on 8 prescription drugs. We deal with the Lipitor > and the Lisinopril and the Lantus, but they forgot about the Paxil > running-low at home ... that phone call comes back about 3 weeks > later, which is close to the limits of my memory about that last > visit, but then about 6 weeks out comes the phone call about Allegra. > How much free work can a doctor do for a patient, between visits, > before that doctor starts to feel abused and resentful ? ... Any > patient can walk on over to the all-night grocery store and buy a > bottle of Claritin or Zyrtec, without bothering the doctor's office, > but to cash in on his insurance deal, a patient gets the pharmacist to > FAX the first salvo to the doctor's office ... Way too often, this > will lead to a requirement to get " prior authorization " from the > patient's new health insurance company, to prove that the only > antihistamine that will let that patient live in harmony with those 3 > pet cats is the one that takes a prescription ... > I am getting close to the point of declaring that every prescription, > every note for a boss, every handicapper parking form, etc. has to be > composed / filled-out / phoned-in during a face-to-face visit , for > which there will be a charge ... > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 17, 2008 Report Share Posted December 17, 2008 I'm from Battle Creek (very close to Allegan for those not from Michigan) so know the area and the economics well. Most of my family still lives in Michigan. My wife and I met at U of M and most of our college friends work for the auto industry. My in-laws rely on a GM pension. So we know how real the pain is in places like Allegan. I of course don't know Rian so didn't in any way mean to imply he was unhappy - mine was a general commentary on the unhappiness of too many physicians and the link between our perceived need to go the extra mile for every patient and the burnout rates in primary care we're seeing. I highly respect practices such as yours and towns such as Allegan and hope that wasn't lost in my post. However, I would challenge you on the cash-only practice assumption based upon the low income level of many of your patients. Cash-only or retainer practices do not need to be for the well-to-do. It's really unfortunate that these practices got labeled as " Concierge " or " Boutique " practices, words that imply fancy care for those with a lot of money. Those practices are certainly out there, but they certainly don't reflect my practice or those of others on this listserve. In fact, the early traction I'm seeing for my practice is from the working poor with no insurance whatsoever - they see joining a primary care membership practice as a cheaper alternative to the unnecessary ER visits for non-emergent issues. As factories close, people lose insurance and low overhead practices with low retainer fees are a better alternative for care than minute-clinics or the ER. The seniors in your practice are in a tough spot, because they were told throughout their lives that once they reached 65 Medicare and Social Security would take care of them - now they realize that Medicare only works if you can find a doc like Rian who will sacrifice much to provide what in effect is undercompensated and thus charity work. The problem is the system will never fill the primary care supply need with such doctors. There just aren't enough people willing to go through the cost and rigor of training to make less than most people they knew in college and nearly everyone with whom they went to med school, especially if the work environment isn't attractive. I use a cell phone analogy with people. Most financially struggling people still have a cell phone that costs more than the total cost of care at my practice. As an aside, when I worked at a FQHC serving only the poor - we had a huge problem of patients (many of whom were supposedly homeless and destitute) wandering the halls talking loudly on cell phones). If you can convince 75% of your patients that their health is more important than their Motorola, you can provide free memberships to 25% of the patients - those who really can't afford a cell phone. Best, Chad > > > > > > With the loss (imminent ? ... or fait accompli ?) loss of Larry > > Lyon, > > > this list-serve needs a grouchy voice, and every once in a while I > > > feel one of those rising out of my waddle ... Today, a series of 4 > > or > > > 5 phone messages culminated in another prescription (for Allegra, no > > > less) issued to another pharmacy, in a city just across the area- > > code > > > border-line from me ... I am lucky to have a cheap long-distance > > phone > > > rate, but the time/hassle of making decisions, reviewing charts, and > > > documenting actions for prescriptions is un-compensated work. > > > I tell all patients to bring the brown paper bag full of their pill- > > > bottles to every visit, and scan the labels for the " no more refills > > > coming " warnings ... Some patients just don't learn, and those are > > > usually the patients on 8 prescription drugs. We deal with the > > Lipitor > > > and the Lisinopril and the Lantus, but they forgot about the Paxil > > > running-low at home ... that phone call comes back about 3 weeks > > > later, which is close to the limits of my memory about that last > > > visit, but then about 6 weeks out comes the phone call about > > Allegra. > > > How much free work can a doctor do for a patient, between visits, > > > before that doctor starts to feel abused and resentful ? ... Any > > > patient can walk on over to the all-night grocery store and buy a > > > bottle of Claritin or Zyrtec, without bothering the doctor's office, > > > but to cash in on his insurance deal, a patient gets the > > pharmacist to > > > FAX the first salvo to the doctor's office ... Way too often, this > > > will lead to a requirement to get " prior authorization " from the > > > patient's new health insurance company, to prove that the only > > > antihistamine that will let that patient live in harmony with > > those 3 > > > pet cats is the one that takes a prescription ... > > > I am getting close to the point of declaring that every > > prescription, > > > every note for a boss, every handicapper parking form, etc. has to > > be > > > composed / filled-out / phoned-in during a face-to-face visit , for > > > which there will be a charge ... > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 17, 2008 Report Share Posted December 17, 2008 I'm from Battle Creek (very close to Allegan for those not from Michigan) so know the area and the economics well. Most of my family still lives in Michigan. My wife and I met at U of M and most of our college friends work for the auto industry. My in-laws rely on a GM pension. So we know how real the pain is in places like Allegan. I of course don't know Rian so didn't in any way mean to imply he was unhappy - mine was a general commentary on the unhappiness of too many physicians and the link between our perceived need to go the extra mile for every patient and the burnout rates in primary care we're seeing. I highly respect practices such as yours and towns such as Allegan and hope that wasn't lost in my post. However, I would challenge you on the cash-only practice assumption based upon the low income level of many of your patients. Cash-only or retainer practices do not need to be for the well-to-do. It's really unfortunate that these practices got labeled as " Concierge " or " Boutique " practices, words that imply fancy care for those with a lot of money. Those practices are certainly out there, but they certainly don't reflect my practice or those of others on this listserve. In fact, the early traction I'm seeing for my practice is from the working poor with no insurance whatsoever - they see joining a primary care membership practice as a cheaper alternative to the unnecessary ER visits for non-emergent issues. As factories close, people lose insurance and low overhead practices with low retainer fees are a better alternative for care than minute-clinics or the ER. The seniors in your practice are in a tough spot, because they were told throughout their lives that once they reached 65 Medicare and Social Security would take care of them - now they realize that Medicare only works if you can find a doc like Rian who will sacrifice much to provide what in effect is undercompensated and thus charity work. The problem is the system will never fill the primary care supply need with such doctors. There just aren't enough people willing to go through the cost and rigor of training to make less than most people they knew in college and nearly everyone with whom they went to med school, especially if the work environment isn't attractive. I use a cell phone analogy with people. Most financially struggling people still have a cell phone that costs more than the total cost of care at my practice. As an aside, when I worked at a FQHC serving only the poor - we had a huge problem of patients (many of whom were supposedly homeless and destitute) wandering the halls talking loudly on cell phones). If you can convince 75% of your patients that their health is more important than their Motorola, you can provide free memberships to 25% of the patients - those who really can't afford a cell phone. Best, Chad > > > > > > With the loss (imminent ? ... or fait accompli ?) loss of Larry > > Lyon, > > > this list-serve needs a grouchy voice, and every once in a while I > > > feel one of those rising out of my waddle ... Today, a series of 4 > > or > > > 5 phone messages culminated in another prescription (for Allegra, no > > > less) issued to another pharmacy, in a city just across the area- > > code > > > border-line from me ... I am lucky to have a cheap long-distance > > phone > > > rate, but the time/hassle of making decisions, reviewing charts, and > > > documenting actions for prescriptions is un-compensated work. > > > I tell all patients to bring the brown paper bag full of their pill- > > > bottles to every visit, and scan the labels for the " no more refills > > > coming " warnings ... Some patients just don't learn, and those are > > > usually the patients on 8 prescription drugs. We deal with the > > Lipitor > > > and the Lisinopril and the Lantus, but they forgot about the Paxil > > > running-low at home ... that phone call comes back about 3 weeks > > > later, which is close to the limits of my memory about that last > > > visit, but then about 6 weeks out comes the phone call about > > Allegra. > > > How much free work can a doctor do for a patient, between visits, > > > before that doctor starts to feel abused and resentful ? ... Any > > > patient can walk on over to the all-night grocery store and buy a > > > bottle of Claritin or Zyrtec, without bothering the doctor's office, > > > but to cash in on his insurance deal, a patient gets the > > pharmacist to > > > FAX the first salvo to the doctor's office ... Way too often, this > > > will lead to a requirement to get " prior authorization " from the > > > patient's new health insurance company, to prove that the only > > > antihistamine that will let that patient live in harmony with > > those 3 > > > pet cats is the one that takes a prescription ... > > > I am getting close to the point of declaring that every > > prescription, > > > every note for a boss, every handicapper parking form, etc. has to > > be > > > composed / filled-out / phoned-in during a face-to-face visit , for > > > which there will be a charge ... > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 17, 2008 Report Share Posted December 17, 2008 I'm from Battle Creek (very close to Allegan for those not from Michigan) so know the area and the economics well. Most of my family still lives in Michigan. My wife and I met at U of M and most of our college friends work for the auto industry. My in-laws rely on a GM pension. So we know how real the pain is in places like Allegan. I of course don't know Rian so didn't in any way mean to imply he was unhappy - mine was a general commentary on the unhappiness of too many physicians and the link between our perceived need to go the extra mile for every patient and the burnout rates in primary care we're seeing. I highly respect practices such as yours and towns such as Allegan and hope that wasn't lost in my post. However, I would challenge you on the cash-only practice assumption based upon the low income level of many of your patients. Cash-only or retainer practices do not need to be for the well-to-do. It's really unfortunate that these practices got labeled as " Concierge " or " Boutique " practices, words that imply fancy care for those with a lot of money. Those practices are certainly out there, but they certainly don't reflect my practice or those of others on this listserve. In fact, the early traction I'm seeing for my practice is from the working poor with no insurance whatsoever - they see joining a primary care membership practice as a cheaper alternative to the unnecessary ER visits for non-emergent issues. As factories close, people lose insurance and low overhead practices with low retainer fees are a better alternative for care than minute-clinics or the ER. The seniors in your practice are in a tough spot, because they were told throughout their lives that once they reached 65 Medicare and Social Security would take care of them - now they realize that Medicare only works if you can find a doc like Rian who will sacrifice much to provide what in effect is undercompensated and thus charity work. The problem is the system will never fill the primary care supply need with such doctors. There just aren't enough people willing to go through the cost and rigor of training to make less than most people they knew in college and nearly everyone with whom they went to med school, especially if the work environment isn't attractive. I use a cell phone analogy with people. Most financially struggling people still have a cell phone that costs more than the total cost of care at my practice. As an aside, when I worked at a FQHC serving only the poor - we had a huge problem of patients (many of whom were supposedly homeless and destitute) wandering the halls talking loudly on cell phones). If you can convince 75% of your patients that their health is more important than their Motorola, you can provide free memberships to 25% of the patients - those who really can't afford a cell phone. Best, Chad > > > > > > With the loss (imminent ? ... or fait accompli ?) loss of Larry > > Lyon, > > > this list-serve needs a grouchy voice, and every once in a while I > > > feel one of those rising out of my waddle ... Today, a series of 4 > > or > > > 5 phone messages culminated in another prescription (for Allegra, no > > > less) issued to another pharmacy, in a city just across the area- > > code > > > border-line from me ... I am lucky to have a cheap long-distance > > phone > > > rate, but the time/hassle of making decisions, reviewing charts, and > > > documenting actions for prescriptions is un-compensated work. > > > I tell all patients to bring the brown paper bag full of their pill- > > > bottles to every visit, and scan the labels for the " no more refills > > > coming " warnings ... Some patients just don't learn, and those are > > > usually the patients on 8 prescription drugs. We deal with the > > Lipitor > > > and the Lisinopril and the Lantus, but they forgot about the Paxil > > > running-low at home ... that phone call comes back about 3 weeks > > > later, which is close to the limits of my memory about that last > > > visit, but then about 6 weeks out comes the phone call about > > Allegra. > > > How much free work can a doctor do for a patient, between visits, > > > before that doctor starts to feel abused and resentful ? ... Any > > > patient can walk on over to the all-night grocery store and buy a > > > bottle of Claritin or Zyrtec, without bothering the doctor's office, > > > but to cash in on his insurance deal, a patient gets the > > pharmacist to > > > FAX the first salvo to the doctor's office ... Way too often, this > > > will lead to a requirement to get " prior authorization " from the > > > patient's new health insurance company, to prove that the only > > > antihistamine that will let that patient live in harmony with > > those 3 > > > pet cats is the one that takes a prescription ... > > > I am getting close to the point of declaring that every > > prescription, > > > every note for a boss, every handicapper parking form, etc. has to > > be > > > composed / filled-out / phoned-in during a face-to-face visit , for > > > which there will be a charge ... > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 17, 2008 Report Share Posted December 17, 2008 Grouch here I can be the list serv crab any time you need oneHowever you a re gonna kill me-- When I get the allergra refill request it is me I get mad at. MY SYSTEMS are supposed to work . I was supposed to do the refills a t each visit .That is my job I find that this goes well when i do my work My work means I have to stay focused and not goof off.Meaning I gott be careful answeredin them when they ask me about politics or the price of gas and stay on track. I mUST ask patietns do you have a med list ( and have you done HYH and are you confident) those questions begin the template of every SOAP note then I must set them for refills which works well for the q 12 or q 6monther's The q-monthers do get lostBut it ismy job to do it when they a re thereI am very grouchy but now you all will probably kill me. Jean With the loss (imminent ? ... or fait accompli ?) loss of Larry Lyon, this list-serve needs a grouchy voice, and every once in a while I feel one of those rising out of my waddle ... Today, a series of 4 or 5 phone messages culminated in another prescription (for Allegra, no less) issued to another pharmacy, in a city just across the area-code border-line from me ... I am lucky to have a cheap long-distance phone rate, but the time/hassle of making decisions, reviewing charts, and documenting actions for prescriptions is un-compensated work. I tell all patients to bring the brown paper bag full of their pill- bottles to every visit, and scan the labels for the " no more refills coming " warnings ... Some patients just don't learn, and those are usually the patients on 8 prescription drugs. We deal with the Lipitor and the Lisinopril and the Lantus, but they forgot about the Paxil running-low at home ... that phone call comes back about 3 weeks later, which is close to the limits of my memory about that last visit, but then about 6 weeks out comes the phone call about Allegra. How much free work can a doctor do for a patient, between visits, before that doctor starts to feel abused and resentful ? ... Any patient can walk on over to the all-night grocery store and buy a bottle of Claritin or Zyrtec, without bothering the doctor's office, but to cash in on his insurance deal, a patient gets the pharmacist to FAX the first salvo to the doctor's office ... Way too often, this will lead to a requirement to get " prior authorization " from the patient's new health insurance company, to prove that the only antihistamine that will let that patient live in harmony with those 3 pet cats is the one that takes a prescription ... I am getting close to the point of declaring that every prescription, every note for a boss, every handicapper parking form, etc. has to be composed / filled-out / phoned-in during a face-to-face visit , for which there will be a charge ... -- If you are a patient please allow up to 24 hours for a reply by email/please note the new email address.Remember that e-mail may not be entirely secure/ MD ph fax Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 17, 2008 Report Share Posted December 17, 2008 Grouch here I can be the list serv crab any time you need oneHowever you a re gonna kill me-- When I get the allergra refill request it is me I get mad at. MY SYSTEMS are supposed to work . I was supposed to do the refills a t each visit .That is my job I find that this goes well when i do my work My work means I have to stay focused and not goof off.Meaning I gott be careful answeredin them when they ask me about politics or the price of gas and stay on track. I mUST ask patietns do you have a med list ( and have you done HYH and are you confident) those questions begin the template of every SOAP note then I must set them for refills which works well for the q 12 or q 6monther's The q-monthers do get lostBut it ismy job to do it when they a re thereI am very grouchy but now you all will probably kill me. Jean With the loss (imminent ? ... or fait accompli ?) loss of Larry Lyon, this list-serve needs a grouchy voice, and every once in a while I feel one of those rising out of my waddle ... Today, a series of 4 or 5 phone messages culminated in another prescription (for Allegra, no less) issued to another pharmacy, in a city just across the area-code border-line from me ... I am lucky to have a cheap long-distance phone rate, but the time/hassle of making decisions, reviewing charts, and documenting actions for prescriptions is un-compensated work. I tell all patients to bring the brown paper bag full of their pill- bottles to every visit, and scan the labels for the " no more refills coming " warnings ... Some patients just don't learn, and those are usually the patients on 8 prescription drugs. We deal with the Lipitor and the Lisinopril and the Lantus, but they forgot about the Paxil running-low at home ... that phone call comes back about 3 weeks later, which is close to the limits of my memory about that last visit, but then about 6 weeks out comes the phone call about Allegra. How much free work can a doctor do for a patient, between visits, before that doctor starts to feel abused and resentful ? ... Any patient can walk on over to the all-night grocery store and buy a bottle of Claritin or Zyrtec, without bothering the doctor's office, but to cash in on his insurance deal, a patient gets the pharmacist to FAX the first salvo to the doctor's office ... Way too often, this will lead to a requirement to get " prior authorization " from the patient's new health insurance company, to prove that the only antihistamine that will let that patient live in harmony with those 3 pet cats is the one that takes a prescription ... I am getting close to the point of declaring that every prescription, every note for a boss, every handicapper parking form, etc. has to be composed / filled-out / phoned-in during a face-to-face visit , for which there will be a charge ... -- If you are a patient please allow up to 24 hours for a reply by email/please note the new email address.Remember that e-mail may not be entirely secure/ MD ph fax Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 17, 2008 Report Share Posted December 17, 2008 Grouch here I can be the list serv crab any time you need oneHowever you a re gonna kill me-- When I get the allergra refill request it is me I get mad at. MY SYSTEMS are supposed to work . I was supposed to do the refills a t each visit .That is my job I find that this goes well when i do my work My work means I have to stay focused and not goof off.Meaning I gott be careful answeredin them when they ask me about politics or the price of gas and stay on track. I mUST ask patietns do you have a med list ( and have you done HYH and are you confident) those questions begin the template of every SOAP note then I must set them for refills which works well for the q 12 or q 6monther's The q-monthers do get lostBut it ismy job to do it when they a re thereI am very grouchy but now you all will probably kill me. Jean With the loss (imminent ? ... or fait accompli ?) loss of Larry Lyon, this list-serve needs a grouchy voice, and every once in a while I feel one of those rising out of my waddle ... Today, a series of 4 or 5 phone messages culminated in another prescription (for Allegra, no less) issued to another pharmacy, in a city just across the area-code border-line from me ... I am lucky to have a cheap long-distance phone rate, but the time/hassle of making decisions, reviewing charts, and documenting actions for prescriptions is un-compensated work. I tell all patients to bring the brown paper bag full of their pill- bottles to every visit, and scan the labels for the " no more refills coming " warnings ... Some patients just don't learn, and those are usually the patients on 8 prescription drugs. We deal with the Lipitor and the Lisinopril and the Lantus, but they forgot about the Paxil running-low at home ... that phone call comes back about 3 weeks later, which is close to the limits of my memory about that last visit, but then about 6 weeks out comes the phone call about Allegra. How much free work can a doctor do for a patient, between visits, before that doctor starts to feel abused and resentful ? ... Any patient can walk on over to the all-night grocery store and buy a bottle of Claritin or Zyrtec, without bothering the doctor's office, but to cash in on his insurance deal, a patient gets the pharmacist to FAX the first salvo to the doctor's office ... Way too often, this will lead to a requirement to get " prior authorization " from the patient's new health insurance company, to prove that the only antihistamine that will let that patient live in harmony with those 3 pet cats is the one that takes a prescription ... I am getting close to the point of declaring that every prescription, every note for a boss, every handicapper parking form, etc. has to be composed / filled-out / phoned-in during a face-to-face visit , for which there will be a charge ... -- If you are a patient please allow up to 24 hours for a reply by email/please note the new email address.Remember that e-mail may not be entirely secure/ MD ph fax Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 17, 2008 Report Share Posted December 17, 2008 Also willing to be a grouch. But first I must say, who cares about an antihistamine, they can be refilled x 1 yr, at last visit. If new insurance, I sign without looking at chart, and then if it requires a prior auth, I loose my mind. Here in Washingon, Regence is about 50% of claims, (unless you take Medicaid, then it trumps). They have a prior auth for everything. The one I hate the most is for SSRI/SNRI's. They require 2 generics be failed before any brand. Okay, I see it, but when I get the new patient, with vegetative depression, on and off meds, mult times in last several yrs, no records, why am I the one stuck with trying to chase down everything they have ever tried. Also this means I can't just get them up to speed in 2 wk on a sample, get over the hump, and come back. With Effexor this now means fill for 37.5, take for 1 wk, then take 2 then come back. Some of these people can't get out of bed in the morning, let alone follow these instructions. With the loss of the sample, also went the loss of what used to be a Rx for"starter pack". Also the person stable on Lexapro for 2 yr, changes to regence, no longer covered, has to try TWO other medications. nbsp; They no longer allow the reason'Stable on this med". Where is the patients best interest in this? I digress. A few wks ago, several on list talked about charging patients for prior authorizations. I want to know how this is going for those that did it, are patients accepting, is insurance complaining or threatening? I want to implement this. I have a cardiac patient with an EFof 25%, whose cardiologist, sleep medicine doctor (bipap), and me, all say, has failed all sleepers has to have Ambien CR, they won't cover. Hours of time into this, unreimbursed. My biller thinks billing the patient the fee, punishes the wrong person. Looked up a code for Consult with another healthcare provider about care coordinatioin including, pharmacists, in long list, must be billed on separate day than the appt. We have tried it, if no pay will turn around and bill to patient as non-covered service to patients, $35. What are others doing, other than just dropping insurance? Cote MD COTE Medical, Laser, and Spa -------------- Original message -------------- Grouch here I can be the list serv crab any time you need oneHowever you a re gonna kill me-- When I get the allergra refill request it is me I get mad at. MY SYSTEMS are supposed to work . I was supposed to do the refills a t each visit .That is my job I find that this goes well when i do my work My work means I have to stay focused and not goof off.Meaning I gott be careful answeredin them when they ask me about politics or the price of gas and stay on track. I mUST ask patietns do you have a med list ( and have you done HYH and are you confident) those questions begin the template of every SOAP note then I must set them for refills which works well for the q 12 or q 6monther's The q-monthers do get lostBut it ismy job to do it when they a re thereI am very grouchy but now you all will probably kill me.:)Jean On Wed, Dec 17, 2008 at 12:12 AM, a Mintek <mintekcharter (DOT) net> wrote: With the loss (imminent ? ... or fait accompli ?) loss of Larry Lyon, this list-serve needs a grouchy voice, and every once in a while I feel one of those rising out of my waddle ... Today, a series of 4 or 5 phone messages culminated in another prescription (for Allegra, no less) issued to another pharmacy, in a city just across the area-code border-line from me ... I am lucky to have a cheap long-distance phone rate, but the time/hassle of making decisions, reviewing charts, and documenting actions for prescriptions is un-compensated work.I tell all patients to bring the brown paper bag full of their pill- bottles to every visit, and scan the labels for the "no more refills coming" warnings ... Some patients just don't learn, and those are usually the patients on 8 prescription drugs. We deal with the Lipitor and the Lisinopril and the Lantus, but they forgot about the Paxil running-low at home ... that phone call comes back about 3 weeks later, which is close to the limits of my memory about that last visit, but then about 6 weeks out comes the phone call about Allegra.How much free work can a doctor do for a patient, between visits, before that doctor starts to feel abused and resentful ? ... Any patient can walk on over to the all-night grocery store and buy a bottle of Claritin or Zyrtec, without bothering the doctor's office, but to cash in on his insurance deal, a patient gets the pharmacist to FAX the first salvo to the doctor's office ... Way too often, this will lead to a requirement to get "prior authorization" from the patient's new health insurance company, to prove that the only antihistamine that will let that patient live in harmony with those 3 pet cats is the one that takes a prescription ...I am getting close to the point of declaring that every prescription, every note for a boss, every handicapper parking form, etc. has to be BR>composed / filled-out / phoned-in during a face-to-face visit , for which there will be a charge ... -- If you are a patient please allow up to 24 hours for a reply by email/please note the new email address.Remember that e-mail may not be entirely secure/ MD ph fax Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 17, 2008 Report Share Posted December 17, 2008 Also willing to be a grouch. But first I must say, who cares about an antihistamine, they can be refilled x 1 yr, at last visit. If new insurance, I sign without looking at chart, and then if it requires a prior auth, I loose my mind. Here in Washingon, Regence is about 50% of claims, (unless you take Medicaid, then it trumps). They have a prior auth for everything. The one I hate the most is for SSRI/SNRI's. They require 2 generics be failed before any brand. Okay, I see it, but when I get the new patient, with vegetative depression, on and off meds, mult times in last several yrs, no records, why am I the one stuck with trying to chase down everything they have ever tried. Also this means I can't just get them up to speed in 2 wk on a sample, get over the hump, and come back. With Effexor this now means fill for 37.5, take for 1 wk, then take 2 then come back. Some of these people can't get out of bed in the morning, let alone follow these instructions. With the loss of the sample, also went the loss of what used to be a Rx for"starter pack". Also the person stable on Lexapro for 2 yr, changes to regence, no longer covered, has to try TWO other medications. nbsp; They no longer allow the reason'Stable on this med". Where is the patients best interest in this? I digress. A few wks ago, several on list talked about charging patients for prior authorizations. I want to know how this is going for those that did it, are patients accepting, is insurance complaining or threatening? I want to implement this. I have a cardiac patient with an EFof 25%, whose cardiologist, sleep medicine doctor (bipap), and me, all say, has failed all sleepers has to have Ambien CR, they won't cover. Hours of time into this, unreimbursed. My biller thinks billing the patient the fee, punishes the wrong person. Looked up a code for Consult with another healthcare provider about care coordinatioin including, pharmacists, in long list, must be billed on separate day than the appt. We have tried it, if no pay will turn around and bill to patient as non-covered service to patients, $35. What are others doing, other than just dropping insurance? Cote MD COTE Medical, Laser, and Spa -------------- Original message -------------- Grouch here I can be the list serv crab any time you need oneHowever you a re gonna kill me-- When I get the allergra refill request it is me I get mad at. MY SYSTEMS are supposed to work . I was supposed to do the refills a t each visit .That is my job I find that this goes well when i do my work My work means I have to stay focused and not goof off.Meaning I gott be careful answeredin them when they ask me about politics or the price of gas and stay on track. I mUST ask patietns do you have a med list ( and have you done HYH and are you confident) those questions begin the template of every SOAP note then I must set them for refills which works well for the q 12 or q 6monther's The q-monthers do get lostBut it ismy job to do it when they a re thereI am very grouchy but now you all will probably kill me.:)Jean On Wed, Dec 17, 2008 at 12:12 AM, a Mintek <mintekcharter (DOT) net> wrote: With the loss (imminent ? ... or fait accompli ?) loss of Larry Lyon, this list-serve needs a grouchy voice, and every once in a while I feel one of those rising out of my waddle ... Today, a series of 4 or 5 phone messages culminated in another prescription (for Allegra, no less) issued to another pharmacy, in a city just across the area-code border-line from me ... I am lucky to have a cheap long-distance phone rate, but the time/hassle of making decisions, reviewing charts, and documenting actions for prescriptions is un-compensated work.I tell all patients to bring the brown paper bag full of their pill- bottles to every visit, and scan the labels for the "no more refills coming" warnings ... Some patients just don't learn, and those are usually the patients on 8 prescription drugs. We deal with the Lipitor and the Lisinopril and the Lantus, but they forgot about the Paxil running-low at home ... that phone call comes back about 3 weeks later, which is close to the limits of my memory about that last visit, but then about 6 weeks out comes the phone call about Allegra.How much free work can a doctor do for a patient, between visits, before that doctor starts to feel abused and resentful ? ... Any patient can walk on over to the all-night grocery store and buy a bottle of Claritin or Zyrtec, without bothering the doctor's office, but to cash in on his insurance deal, a patient gets the pharmacist to FAX the first salvo to the doctor's office ... Way too often, this will lead to a requirement to get "prior authorization" from the patient's new health insurance company, to prove that the only antihistamine that will let that patient live in harmony with those 3 pet cats is the one that takes a prescription ...I am getting close to the point of declaring that every prescription, every note for a boss, every handicapper parking form, etc. has to be BR>composed / filled-out / phoned-in during a face-to-face visit , for which there will be a charge ... -- If you are a patient please allow up to 24 hours for a reply by email/please note the new email address.Remember that e-mail may not be entirely secure/ MD ph fax Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 17, 2008 Report Share Posted December 17, 2008 I prefer to think of you as the listserv lobster rather than crab. (And then the lyrics to " rock lobster " go through my head- " everyone had matching towels " ) I've really been enjoying this conversation and I especially like Chad's posting-I think the idea of a concierge practice can certainly be expanded beyond the meaning that we consistently give till it. My take on all of this- Encounter based care is coming to an end one way or another. Good riddance. The current economic crisis will force things to happen-either family medicine will go down the tubes or it will be seen as the best way to add value to the system. Just as democracy is the best system that we have, family medicine is also the best medical system that we have in spite of its many flaws. We definitely will provide the best value if we are allowed to do so. We just need to get reimbursed for the value that we provide. (And I believe-encounter based care won't do it-we need to get paid for value not paid by the hour and not paid by à la carte methods) I have been lucky enough to work part time for the past few years but I would be glad to start working full time as soon as the system changes. The ICD and CPT systems were the worst inventions ever produced for medicine. Even the problem oriented medical record should be scrapped and change to something that better fits what we do and the more sophisticated tools that we have. Just my four cents (I assume that is two cents with inflation. > > > With the loss (imminent ? ... or fait accompli ?) loss of Larry Lyon, > > this list-serve needs a grouchy voice, and every once in a while I > > feel one of those rising out of my waddle ... Today, a series of 4 or > > 5 phone messages culminated in another prescription (for Allegra, no > > less) issued to another pharmacy, in a city just across the area- code > > border-line from me ... I am lucky to have a cheap long-distance phone > > rate, but the time/hassle of making decisions, reviewing charts, and > > documenting actions for prescriptions is un-compensated work. > > I tell all patients to bring the brown paper bag full of their pill- > > bottles to every visit, and scan the labels for the " no more refills > > coming " warnings ... Some patients just don't learn, and those are > > usually the patients on 8 prescription drugs. We deal with the Lipitor > > and the Lisinopril and the Lantus, but they forgot about the Paxil > > running-low at home ... that phone call comes back about 3 weeks > > later, which is close to the limits of my memory about that last > > visit, but then about 6 weeks out comes the phone call about Allegra. > > How much free work can a doctor do for a patient, between visits, > > before that doctor starts to feel abused and resentful ? ... Any > > patient can walk on over to the all-night grocery store and buy a > > bottle of Claritin or Zyrtec, without bothering the doctor's office, > > but to cash in on his insurance deal, a patient gets the pharmacist to > > FAX the first salvo to the doctor's office ... Way too often, this > > will lead to a requirement to get " prior authorization " from the > > patient's new health insurance company, to prove that the only > > antihistamine that will let that patient live in harmony with those 3 > > pet cats is the one that takes a prescription ... > > I am getting close to the point of declaring that every prescription, > > every note for a boss, every handicapper parking form, etc. has to be > > composed / filled-out / phoned-in during a face-to-face visit , for > > which there will be a charge ... > > > > > > > > -- > If you are a patient please allow up to 24 hours for a reply by email/ > please note the new email address. > Remember that e-mail may not be entirely secure/ > MD > > > ph fax > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 17, 2008 Report Share Posted December 17, 2008 I prefer to think of you as the listserv lobster rather than crab. (And then the lyrics to " rock lobster " go through my head- " everyone had matching towels " ) I've really been enjoying this conversation and I especially like Chad's posting-I think the idea of a concierge practice can certainly be expanded beyond the meaning that we consistently give till it. My take on all of this- Encounter based care is coming to an end one way or another. Good riddance. The current economic crisis will force things to happen-either family medicine will go down the tubes or it will be seen as the best way to add value to the system. Just as democracy is the best system that we have, family medicine is also the best medical system that we have in spite of its many flaws. We definitely will provide the best value if we are allowed to do so. We just need to get reimbursed for the value that we provide. (And I believe-encounter based care won't do it-we need to get paid for value not paid by the hour and not paid by à la carte methods) I have been lucky enough to work part time for the past few years but I would be glad to start working full time as soon as the system changes. The ICD and CPT systems were the worst inventions ever produced for medicine. Even the problem oriented medical record should be scrapped and change to something that better fits what we do and the more sophisticated tools that we have. Just my four cents (I assume that is two cents with inflation. > > > With the loss (imminent ? ... or fait accompli ?) loss of Larry Lyon, > > this list-serve needs a grouchy voice, and every once in a while I > > feel one of those rising out of my waddle ... Today, a series of 4 or > > 5 phone messages culminated in another prescription (for Allegra, no > > less) issued to another pharmacy, in a city just across the area- code > > border-line from me ... I am lucky to have a cheap long-distance phone > > rate, but the time/hassle of making decisions, reviewing charts, and > > documenting actions for prescriptions is un-compensated work. > > I tell all patients to bring the brown paper bag full of their pill- > > bottles to every visit, and scan the labels for the " no more refills > > coming " warnings ... Some patients just don't learn, and those are > > usually the patients on 8 prescription drugs. We deal with the Lipitor > > and the Lisinopril and the Lantus, but they forgot about the Paxil > > running-low at home ... that phone call comes back about 3 weeks > > later, which is close to the limits of my memory about that last > > visit, but then about 6 weeks out comes the phone call about Allegra. > > How much free work can a doctor do for a patient, between visits, > > before that doctor starts to feel abused and resentful ? ... Any > > patient can walk on over to the all-night grocery store and buy a > > bottle of Claritin or Zyrtec, without bothering the doctor's office, > > but to cash in on his insurance deal, a patient gets the pharmacist to > > FAX the first salvo to the doctor's office ... Way too often, this > > will lead to a requirement to get " prior authorization " from the > > patient's new health insurance company, to prove that the only > > antihistamine that will let that patient live in harmony with those 3 > > pet cats is the one that takes a prescription ... > > I am getting close to the point of declaring that every prescription, > > every note for a boss, every handicapper parking form, etc. has to be > > composed / filled-out / phoned-in during a face-to-face visit , for > > which there will be a charge ... > > > > > > > > -- > If you are a patient please allow up to 24 hours for a reply by email/ > please note the new email address. > Remember that e-mail may not be entirely secure/ > MD > > > ph fax > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 17, 2008 Report Share Posted December 17, 2008 Just back to the practicalities here.I've been having patients come in for a visit usually charging 99213, using as diagnosis code the problem, writing a stupid note - pt is here to get xxxneeds prior auth reasons time spent ( usually less than 20 minutes, has at times been one hour)bill insurance, collect copay just like any other visit,if long visit bill 99214 short bill 99213It works,I get paid, it's a incredibly stupid, waste of time, but I refuse to work for free for the PBMs/insurance companiesLynnTo: From: magnetdoctor@...Date: Wed, 17 Dec 2008 16:37:09 +0000Subject: Re: drawing the line Also willing to be a grouch. But first I must say, who cares about an antihistamine, they can be refilled x 1 yr, at last visit. If new insurance, I sign without looking at chart, and then if it requires a prior auth, I loose my mind. Here in Washingon, Regence is about 50% of claims, (unless you take Medicaid, then it trumps). They have a prior auth for everything. The one I hate the most is for SSRI/SNRI's. They require 2 generics be failed before any brand. Okay, I see it, but when I get the new patient, with vegetative depression, on and off meds, mult times in last several yrs, no records, why am I the one stuck with trying to chase down everything they have ever tried. Also this means I can't just get them up to speed in 2 wk on a sample, get over the hump, and come back. With Effexor this now means fill for 37.5, take for 1 wk, then take 2 then come back. Some of these people can't get out of bed in the morning, let alone follow these instructions. With the loss of the sample, also went the loss of what used to be a Rx for"starter pack". Also the person stable on Lexapro for 2 yr, changes to regence, no longer covered, has to try TWO other medications. nbsp; They no longer allow the reason'Stable on this med". Where is the patients best interest in this? I digress. A few wks ago, several on list talked about charging patients for prior authorizations. I want to know how this is going for those that did it, are patients accepting, is insurance complaining or threatening? I want to implement this. I have a cardiac patient with an EFof 25%, whose cardiologist, sleep medicine doctor (bipap), and me, all say, has failed all sleepers has to have Ambien CR, they won't cover. Hours of time into this, unreimbursed. My biller thinks billing the patient the fee, punishes the wrong person. Looked up a code for Consult with another healthcare provider about care coordinatioin including, pharmacists, in long list, must be billed on separate day than the appt. We have tried it, if no pay will turn around and bill to patient as non-covered service to patients, $35. What are others doing, other than just dropping insurance? Cote MD COTE Medical, Laser, and Spa -------------- Original message -------------- From: "" <jnantonuccigmail> Grouch here I can be the list serv crab any time you need oneHowever you a re gonna kill me-- When I get the allergra refill request it is me I get mad at. MY SYSTEMS are supposed to work . I was supposed to do the refills a t each visit .That is my job I find that this goes well when i do my work My work means I have to stay focused and not goof off.Meaning I gott be careful answeredin them when they ask me about politics or the price of gas and stay on track. I mUST ask patietns do you have a med list ( and have you done HYH and are you confident) those questions begin the template of every SOAP note then I must set them for refills which works well for the q 12 or q 6monther's The q-monthers do get lostBut it ismy job to do it when they a re thereI am very grouchy but now you all will probably kill me.:)Jean On Wed, Dec 17, 2008 at 12:12 AM, a Mintek <mintekcharter (DOT) net> wrote: With the loss (imminent ? ... or fait accompli ?) loss of Larry Lyon, this list-serve needs a grouchy voice, and every once in a while I feel one of those rising out of my waddle ... Today, a series of 4 or 5 phone messages culminated in another prescription (for Allegra, no less) issued to another pharmacy, in a city just across the area-code border-line from me ... I am lucky to have a cheap long-distance phone rate, but the time/hassle of making decisions, reviewing charts, and documenting actions for prescriptions is un-compensated work.I tell all patients to bring the brown paper bag full of their pill- bottles to every visit, and scan the labels for the "no more refills coming" warnings ... Some patients just don't learn, and those are usually the patients on 8 prescription drugs. We deal with the Lipitor and the Lisinopril and the Lantus, but they forgot about the Paxil running-low at home ... that phone call comes back about 3 weeks later, which is close to the limits of my memory about that last visit, but then about 6 weeks out comes the phone call about Allegra.How much free work can a doctor do for a patient, between visits, before that doctor starts to feel abused and resentful ? ... Any patient can walk on over to the all-night grocery store and buy a bottle of Claritin or Zyrtec, without bothering the doctor's office, but to cash in on his insurance deal, a patient gets the pharmacist to FAX the first salvo to the doctor's office ... Way too often, this will lead to a requirement to get "prior authorization" from the patient's new health insurance company, to prove that the only antihistamine that will let that patient live in harmony with those 3 pet cats is the one that takes a prescription ...I am getting close to the point of declaring that every prescription, every note for a boss, every handicapper parking form, etc. has to be BR>composed / filled-out / phoned-in during a face-to-face visit , for which there will be a charge ... -- If you are a patient please allow up to 24 hours for a reply by email/please note the new email address.Remember that e-mail may not be entirely secure/ MD ph fax Send e-mail faster without improving your typing skills. 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Guest guest Posted December 17, 2008 Report Share Posted December 17, 2008 We are one of the offices charging for PA for meds. $20 is our “Forms Completion Fee” and is in our list of “non-covered services” in our Financial Policy that patients sign and acknowledge. Most patients don’t complain. The ones that do are explained that “your insurance company requires this form; not all insurance companies require this so therefore we must pass along our costs to you” (read in between the lines that the patient picked the cheap insurance, so they must pay the cost for that lesser-expensive plan that requires additional work on our part). You are not punishing the patient. You need to remember that it is usually the less expensive plans that charge us with the extra work; the patient is still saving $$ by having the cheaper plan. Pratt Office Manager Oak Tree Internal Medicine P.C Roy Medical Associates, Inc. From: [mailto: ] On Behalf Of magnetdoctor@... Sent: Wednesday, December 17, 2008 8:37 AM To: Subject: Re: drawing the line Also willing to be a grouch. But first I must say, who cares about an antihistamine, they can be refilled x 1 yr, at last visit. If new insurance, I sign without looking at chart, and then if it requires a prior auth, I loose my mind. Here in Washingon, Regence is about 50% of claims, (unless you take Medicaid, then it trumps). They have a prior auth for everything. The one I hate the most is for SSRI/SNRI's. They require 2 generics be failed before any brand. Okay, I see it, but when I get the new patient, with vegetative depression, on and off meds, mult times in last several yrs, no records, why am I the one stuck with trying to chase down everything they have ever tried. Also this means I can't just get them up to speed in 2 wk on a sample, get over the hump, and come back. With Effexor this now means fill for 37.5, take for 1 wk, then take 2 then come back. Some of these people can't get out of bed in the morning, let alone follow these instructions. With the loss of the sample, also went the loss of what used to be a Rx for " starter pack " . Also the person stable on Lexapro for 2 yr, changes to regence, no longer covered, has to try TWO other medications. nbsp; They no longer allow the reason'Stable on this med " . Where is the patients best interest in this? I digress. A few wks ago, several on list talked about charging patients for prior authorizations. I want to know how this is going for those that did it, are patients accepting, is insurance complaining or threatening? I want to implement this. I have a cardiac patient with an EFof 25%, whose cardiologist, sleep medicine doctor (bipap), and me, all say, has failed all sleepers has to have Ambien CR, they won't cover. Hours of time into this, unreimbursed. My biller thinks billing the patient the fee, punishes the wrong person. Looked up a code for Consult with another healthcare provider about care coordinatioin including, pharmacists, in long list, must be billed on separate day than the appt. We have tried it, if no pay will turn around and bill to patient as non-covered service to patients, $35. What are others doing, other than just dropping insurance? Cote MD COTE Medical, Laser, and Spa -------------- Original message -------------- From: " " <jnantonuccigmail> Grouch here I can be the list serv crab any time you need one However you a re gonna kill me-- When I get the allergra refill request it is me I get mad at. MY SYSTEMS are supposed to work . I was supposed to do the refills a t each visit .That is my job I find that this goes well when i do my work My work means I have to stay focused and not goof off.Meaning I gott be careful answeredin them when they ask me about politics or the price of gas and stay on track. I mUST ask patietns do you have a med list ( and have you done HYH and are you confident) those questions begin the template of every SOAP note then I must set them for refills which works well for the q 12 or q 6monther's The q-monthers do get lost But it ismy job to do it when they a re there I am very grouchy but now you all will probably kill me. Jean On Wed, Dec 17, 2008 at 12:12 AM, a Mintek <mintekcharter (DOT) net> wrote: With the loss (imminent ? ... or fait accompli ?) loss of Larry Lyon, this list-serve needs a grouchy voice, and every once in a while I feel one of those rising out of my waddle ... Today, a series of 4 or 5 phone messages culminated in another prescription (for Allegra, no less) issued to another pharmacy, in a city just across the area-code border-line from me ... I am lucky to have a cheap long-distance phone rate, but the time/hassle of making decisions, reviewing charts, and documenting actions for prescriptions is un-compensated work. I tell all patients to bring the brown paper bag full of their pill- bottles to every visit, and scan the labels for the " no more refills coming " warnings ... Some patients just don't learn, and those are usually the patients on 8 prescription drugs. We deal with the Lipitor and the Lisinopril and the Lantus, but they forgot about the Paxil running-low at home ... that phone call comes back about 3 weeks later, which is close to the limits of my memory about that last visit, but then about 6 weeks out comes the phone call about Allegra. How much free work can a doctor do for a patient, between visits, before that doctor starts to feel abused and resentful ? ... Any patient can walk on over to the all-night grocery store and buy a bottle of Claritin or Zyrtec, without bothering the doctor's office, but to cash in on his insurance deal, a patient gets the pharmacist to FAX the first salvo to the doctor's office ... Way too often, this will lead to a requirement to get " prior authorization " from the patient's new health insurance company, to prove that the only antihistamine that will let that patient live in harmony with those 3 pet cats is the one that takes a prescription ... I am getting close to the point of declaring that every prescription, every note for a boss, every handicapper parking form, etc. has to be BR>composed / filled-out / phoned-in during a face-to-face visit , for which there will be a charge ... -- If you are a patient please allow up to 24 hours for a reply by email/ please note the new email address. Remember that e-mail may not be entirely secure/ MD ph fax Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 17, 2008 Report Share Posted December 17, 2008 This thread is pertinent http://www.emrupdate.com/forums/p/9195/67809.aspx Basically 1. Reddy makes sure all patients are refilled before they leave his office 2. He has signs up to say that they will be charged if they forgot to ask for something out of visit,. 3. He has stopped all faxbots from filling his fax inbox 4. He e-prescribes. -- Graham Chiu http://www.synapsedirect.com Synapse - the use from anywhere EMR. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 17, 2008 Report Share Posted December 17, 2008 No you are absolutely right. I, too, get talking about gas prices, dogs, new cars,,,and forget to review the med list, problem list, list of specialists, etc. You are not alone. i HAVE BEEN TRYING TO DO THAT REVIEW before THE PATIENT GOES INTO THE EXAM ROOM. Oops, cap lock... I do have an MA, and as she gets vitals, reason for visit, I am reviewing the chart, looking for missed appointments, visits to urgent care, need for scripts, and how IS your mother?Or, I am finishing the note from the previous pati4ent. Theoretically... All that being said...I am still inhumanly behiond in charting and invoicing. we love you. I have decided that to emulate your typing, all we have to do is glue on long fake nails (like I usually do, being the beauty queen of docs) and then none of us can type and we can sympathize with you and then no one can criticize bad typing!!!!! To: Sent: Wednesday, December 17, 2008 11:06:35 AMSubject: Re: drawing the line Grouch here I can be the list serv crab any time you need oneHowever you a re gonna kill me-- When I get the allergra refill request it is me I get mad at. MY SYSTEMS are supposed to work . I was supposed to do the refills a t each visit .That is my job I find that this goes well when i do my work My work means I have to stay focused and not goof off.Meaning I gott be careful answeredin them when they ask me about politics or the price of gas and stay on track. I mUST ask patietns do you have a med list ( and have you done HYH and are you confident) those questions begin the template of every SOAP note then I must set them for refills which works well for the q 12 or q 6monther's The q-monthers do get lostBut it ismy job to do it when they a re thereI am very grouchy but now you all will probably kill me.:)Jean On Wed, Dec 17, 2008 at 12:12 AM, a Mintek <mintekcharter (DOT) net> wrote: With the loss (imminent ? ... or fait accompli ?) loss of Larry Lyon, this list-serve needs a grouchy voice, and every once in a while I feel one of those rising out of my waddle ... Today, a series of 4 or 5 phone messages culminated in another prescription (for Allegra, no less) issued to another pharmacy, in a city just across the area-code border-line from me ... I am lucky to have a cheap long-distance phone rate, but the time/hassle of making decisions, reviewing charts, and documenting actions for prescriptions is un-compensated work.I tell all patients to bring the brown paper bag full of their pill- bottles to every visit, and scan the labels for the "no more refills coming" warnings ... Some patients just don't learn, and those are usually the patients on 8 prescription drugs. We deal with the Lipitor and the Lisinopril and the Lantus, but they forgot about the Paxil running-low at home ... that phone call comes back about 3 weeks later, which is close to the limits of my memory about that last visit, but then about 6 weeks out comes the phone call about Allegra.How much free work can a doctor do for a patient, between visits, before that doctor starts to feel abused and resentful ? ... Any patient can walk on over to the all-night grocery store and buy a bottle of Claritin or Zyrtec, without bothering the doctor's office, but to cash in on his insurance deal, a patient gets the pharmacist to FAX the first salvo to the doctor's office ... Way too often, this will lead to a requirement to get "prior authorization" from the patient's new health insurance company, to prove that the only antihistamine that will let that patient live in harmony with those 3 pet cats is the one that takes a prescription ...I am getting close to the point of declaring that every prescription, every note for a boss, every handicapper parking form, etc. has to be composed / filled-out / phoned-in during a face-to-face visit , for which there will be a charge ... -- If you are a patient please allow up to 24 hours for a reply by email/please note the new email address.Remember that e-mail may not be entirely secure/ MD ph fax Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 17, 2008 Report Share Posted December 17, 2008 You are a peach Blake.:)I will be sure to tell my husband that someone said i was absolutely right:)My typing drives ME bananas ! WHY won't the letters coem out right??? see?Jean No you are absolutely right. I, too, get talking about gas prices, dogs, new cars,,,and forget to review the med list, problem list, list of specialists, etc. You are not alone. i HAVE BEEN TRYING TO DO THAT REVIEW before THE PATIENT GOES INTO THE EXAM ROOM. Oops, cap lock... I do have an MA, and as she gets vitals, reason for visit, I am reviewing the chart, looking for missed appointments, visits to urgent care, need for scripts, and how IS your mother?Or, I am finishing the note from the previous pati4ent. Theoretically... All that being said...I am still inhumanly behiond in charting and invoicing. we love you. I have decided that to emulate your typing, all we have to do is glue on long fake nails (like I usually do, being the beauty queen of docs) and then none of us can type and we can sympathize with you and then no one can criticize bad typing!!!!! To: Sent: Wednesday, December 17, 2008 11:06:35 AMSubject: Re: drawing the line Grouch here I can be the list serv crab any time you need oneHowever you a re gonna kill me-- When I get the allergra refill request it is me I get mad at. MY SYSTEMS are supposed to work . I was supposed to do the refills a t each visit .That is my job I find that this goes well when i do my work My work means I have to stay focused and not goof off.Meaning I gott be careful answeredin them when they ask me about politics or the price of gas and stay on track. I mUST ask patietns do you have a med list ( and have you done HYH and are you confident) those questions begin the template of every SOAP note then I must set them for refills which works well for the q 12 or q 6monther's The q-monthers do get lostBut it ismy job to do it when they a re thereI am very grouchy but now you all will probably kill me.:)Jean On Wed, Dec 17, 2008 at 12:12 AM, a Mintek <mintekcharter (DOT) net> wrote: With the loss (imminent ? ... or fait accompli ?) loss of Larry Lyon, this list-serve needs a grouchy voice, and every once in a while I feel one of those rising out of my waddle ... Today, a series of 4 or 5 phone messages culminated in another prescription (for Allegra, no less) issued to another pharmacy, in a city just across the area-code border-line from me ... I am lucky to have a cheap long-distance phone rate, but the time/hassle of making decisions, reviewing charts, and documenting actions for prescriptions is un-compensated work.I tell all patients to bring the brown paper bag full of their pill- bottles to every visit, and scan the labels for the " no more refills coming " warnings ... Some patients just don't learn, and those are usually the patients on 8 prescription drugs. We deal with the Lipitor and the Lisinopril and the Lantus, but they forgot about the Paxil running-low at home ... that phone call comes back about 3 weeks later, which is close to the limits of my memory about that last visit, but then about 6 weeks out comes the phone call about Allegra.How much free work can a doctor do for a patient, between visits, before that doctor starts to feel abused and resentful ? ... Any patient can walk on over to the all-night grocery store and buy a bottle of Claritin or Zyrtec, without bothering the doctor's office, but to cash in on his insurance deal, a patient gets the pharmacist to FAX the first salvo to the doctor's office ... Way too often, this will lead to a requirement to get " prior authorization " from the patient's new health insurance company, to prove that the only antihistamine that will let that patient live in harmony with those 3 pet cats is the one that takes a prescription ...I am getting close to the point of declaring that every prescription, every note for a boss, every handicapper parking form, etc. has to be composed / filled-out / phoned-in during a face-to-face visit , for which there will be a charge ... -- If you are a patient please allow up to 24 hours for a reply by email/please note the new email address.Remember that e-mail may not be entirely secure/ MD ph fax -- If you are a patient please allow up to 24 hours for a reply by email/please note the new email address.Remember that e-mail may not be entirely secure/ MD ph fax Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 18, 2008 Report Share Posted December 18, 2008 Jean- when I commented on your typing it was no insult. I LOVE your typing. It makes me happy. carla With the loss (imminent ? ... or fait accompli ?) loss of Larry Lyon, this list-serve needs a grouchy voice, and every once in a while I feel one of those rising out of my waddle ... Today, a series of 4 or 5 phone messages culminated in another prescription (for Allegra, no less) issued to another pharmacy, in a city just across the area-code border-line from me ... I am lucky to have a cheap long-distance phone rate, but the time/hassle of making decisions, reviewing charts, and documenting actions for prescriptions is un-compensated work.I tell all patients to bring the brown paper bag full of their pill- bottles to every visit, and scan the labels for the "no more refills coming" warnings ... Some patients just don't learn, and those are usually the patients on 8 prescription drugs. We deal with the Lipitor and the Lisinopril and the Lantus, but they forgot about the Paxil running-low at home .... that phone call comes back about 3 weeks later, which is close to the limits of my memory about that last visit, but then about 6 weeks out comes the phone call about Allegra.How much free work can a doctor do for a patient, between visits, before that doctor starts to feel abused and resentful ? ... Any patient can walk on over to the all-night grocery store and buy a bottle of Claritin or Zyrtec, without bothering the doctor's office, but to cash in on his insurance deal, a patient gets the pharmacist to FAX the first salvo to the doctor's office ... Way too often, this will lead to a requirement to get "prior authorization" from the patient's new health insurance company, to prove that the only antihistamine that will let that patient live in harmony with those 3 pet cats is the one that takes a prescription ...I am getting close to the point of declaring that every prescription, every note for a boss, every handicapper parking form, etc. has to be composed / filled-out / phoned-in during a face-to-face visit , for which there will be a charge ... -- If you are a patient please allow up to 24 hours for a reply by email/please note the new email address.Remember that e-mail may not be entirely secure/ MD ph fax -- If you are a patient please allow up to 24 hours for a reply by email/please note the new email address.Remember that e-mail may not be entirely secure/ MD ph fax Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 18, 2008 Report Share Posted December 18, 2008 We decided a pragmatic solution was best until a better solution comes along. We drew the line about one year ago on prescription refills. We now charge $10 for upto 3 refills not during a visit. Same thing for simple forms. ($15 to $30) I realize it is not cost effective to try to collect small amounts and EMR makes Rx writing simple. But it has changed dynamics dramatically. We did not do it to increase our income. Gone from 10 or more requests per day down to 0 to 2. We don't feel put upon. (For other things yes, but not rx refills) Patients do need to cancel and will run sometimes run out. Patients (me too) do forget a medication when they go on vacation. So we call it in and receive a nominal fee. Patients are taking responsibility Patients become aware of fax hassle factor by clearinghouses. We hardly get any anymore. Those we get are faxed back with message to have patient call office. Most never call because they realize a mistake has occurred and they have enough meds till next visit. Patients make sure they check refills prior to visits My staff makes better effort at tracking Rx's and reminding patients to bring in bag of meds to avoid that nasty fee One patient left practice for this fee. We have not wanted to charge an annual fee yet, since we have been in practice 25 years and this would be an even more dramatic change for our patients. But I see it coming soon, unless real case management / medical home / per capita becomes the norm. Suspect 50% to 66% of patients would elect not to continue with us if there was an annual $300 fee. In five years we are ready to downsize anyway and this would help the process. Mike S. 2a. Re: drawing the line Posted by: "Lynn Ho" lynnhri@... lynnhri Wed Dec 17, 2008 4:34 am (PST) Well then just draw the line where you feel you want to - one of the joys of being your own show. I agree the burden of free work in the name of being 'PCP' can really make you feel put upon and it seems magnified when you are feeling overworked already. If you're like me, part of hassle also is not being clear where you draw the line - if the line floats a lot, it generates extra aggravation, just thinking about what you should do in which case. Some time last year, after I started getting salvos from the 2 biggest insurances containing volleys of prior authorizations, I changed my unwritten policy- unless the patient can't drive/can't get in, I tell them they have to come in for a visit -because their insurance is requiring this paperwork so the insurance can maximize their profits on OUR backs - and I am not going to help them do this by donating my time for free. I jave the patient come in so I can charge their insurance a visit and fill out the paperwork. I think there is a spectrum of what people do - sounds like Pam Wible has all her patients and pharmacies trained so that she NEVER does 'free' refills. I try to get them in the office, but will usually do refills for chronic medications in between if needed unless it gets to be burdensome (my EMR makes refills really simple, maybe 45 seconds including looking at the chart to see last visit. You could certainly institute a 'form' fee for say $20, not completed at visit. It is definitely OK to draw those lines. To: From: mintekcharter (DOT) net Date: Wed, 17 Dec 2008 00:12:01 -0500 Subject: drawing the line With the loss (imminent ? ... or fait accompli ?) loss of Larry Lyon, this list-serve needs a grouchy voice, and every once in a while I feel one of those rising out of my waddle ... Today, a series of 4 or 5 phone messages culminated in another prescription (for Allegra, no less) issued to another pharmacy, in a city just across the area-code border-line from me ... I am lucky to have a cheap long-distance phone rate, but the time/hassle of making decisions, reviewing charts, and documenting actions for prescriptions is un-compensated work. I tell all patients to bring the brown paper bag full of their pill- bottles to every visit, and scan the labels for the "no more refills coming" warnings ... Some patients just don't learn, and those are usually the patients on 8 prescription drugs. We deal with the Lipitor and the Lisinopril and the Lantus, but they forgot about the Paxil running-low at home ... that phone call comes back about 3 weeks later, which is close to the limits of my memory about that last visit, but then about 6 weeks out comes the phone call about Allegra. How much free work can a doctor do for a patient, between visits, before that doctor starts to feel abused and resentful ? ... Any patient can walk on over to the all-night grocery store and buy a bottle of Claritin or Zyrtec, without bothering the doctor's office, but to cash in on his insurance deal, a patient gets the pharmacist to FAX the first salvo to the doctor's office ... Way too often, this will lead to a requirement to get "prior authorization" from the patient's new health insurance company, to prove that the only antihistamine that will let that patient live in harmony with those 3 pet cats is the one that takes a prescription ... I am getting close to the point of declaring that every prescription, every note for a boss, every handicapper parking form, etc. has to be composed / filled-out / phoned-in during a face-to-face visit , for which there will be a charge ... A Good Credit Score is 700 or Above. See yours in just 2 easy steps! Quote Link to comment Share on other sites More sharing options...
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