RE: Bad week everywhere? Options.

[Guest guest]

I’m sad to hear that we are all having a frustrating time, but

getting the chance to hear from other docs what they are going thru is very

helpful to me. Being solo is, frankly, kind of lonely. I like

being solo, don’t get me wrong, and am more of a loner but I don’t

know if I’m just being stubborn about some things (like no antibiotics

for viral illnesses, insisting on visits instead of over the phone treatments,

asking patient to pay on their bill once in a while) or if I’m out of

touch and not practicing good compassionate medicine.

After losing much sleep over these stupid forms, especially the

diabetes shoes (which frankly are oversold around here and I don’t think

they help people nearly as much as the shoe sellers would have everyone

believe-there, I said it), I sat down and decided to come up with a solution.

I strongly believe there are always options. So here are my options

for dealing with the extensive form overload. We need to be proactive in

dealing with this and stop being run over by patients, government agencies, DME

companies and insurance companies. I would love to hear some feedback on

the pros and cons of these

Assuming a patient actually qualifies for DME (like DM shoes,

CPAP, oxygen, nebulizers, glucose monitors, bedside commodes, etc) there are

four parts that are required. I used to could just write a 1) prescription

but now they want a 2) specific exam, 3) specific paper documentation (like a

foot exam template) and 4) copious notes (up to six months worth in some cases).

They send me CMS memos saying the patient doesn’t have to pay and the companies

refuse to pay for the records either. The sending of medical

records is the straw breaking this camel’s back.

I could perform the (foot/asthma/COPD/etc)

specific exam at their regular visit and fill out the prescription, a

paper exam template form and sent form and the office notes for free.

--- Pros: the patients, DME companies, insurance companies, and the government

are happy.--- Cons: This isn’t working because I’m going broke

spending hours completing, answering forms and sending out medical records

for free.

I could perform the exam

at their regular visit and fill out the prescription, the exam template

form and charge the patient for their medical records and have them

mail them to the DME company. ---Pros, this puts the responsibility

back on the patient and not me. --- Cons: This is not working

b/c of course, no patient wants to pay for medical records, either. It

isn’t completely their fault. Some have been ok with this;

others have left me.

I could perform the exam

at their regular visit and fill out the exam template, and charge $10

for the completion of the forms (this should be billable, right) and

send the medical records for free. ---I make $10 for this

I could insist on a separate

billable visit for each and every item of DME. You need DM

shoes; that needs a separate visit. You need a renewal on your

nebulizer; you must come back in just to do the paperwork. ---Billable but

wastes my time and the patient’s time; but I get paid by the

insurance company for doing what the insurance company demands; seems fair

somehow. Patient loses another copay. Also DME companies keep

faxing the paperwork over and over until the patient comes in for a visit

I could turf

everybody to a specialist. --- Then I’m no better than an

urgent care, IMO and I make no money.

I could go back to work

for the hospital and run their clinic where they have lots of staff to

do this stuff and get paid a salary so I’m paid the same thing for

treating CHF as I am completing forms for shoes and commodes.

I do apologize for this very long post. I am burning out and am

trying to find workable solutions to turn things around. This listserv

has been very supportive and very helpful and I am grateful for it

Tonya S. Little, MD

1704 Glendale Drive SW, Suite C

NC 27893

fax

cell

tslittle@...

From: [mailto: ] On Behalf Of

Sent: Sunday, August 12, 2012

10:27 AM

To:

Subject: Re:

Bad week everywhere?

I think the fact that you have been practicing so long

in difficult NJ is a tribute Kath and I sure mean not offense just

the opposite

It was that I think that I am entitled to be told when someone is in

the hospital.This is where I could be wrong.

The nonsystem here is that I would have to install a hospital printer and go

look every day at a report that would tell me a list of names that would

be everything from Suzie Q needing 3 stiches on her hand to JOhn

admitted for MI Maybe some of you think that is great. I contend not. This

ain;t a third world country. They cannot send me something paperless to

tel l me who was admitted or in the ER and for what ,without some

other machine/ some other place to go look .Think of the errors we make when

overloaded with interruptions to adjust to some other institutions work

systems.

It is possible I should be grateful to have a machine available

this is the suck it up part, and go get the paper off it and get up

and go look at it and open the hospital data base and go see what happened to

who but

I don;t think so

A local office invovled in the PCMH pilot has this printer but the

doc still had no idea he could tell who was admitted

Nonsytems that demand more work and more nonsense flurrying

around to attend to the computer.

are nuts! However if I am trying to do care coordination I should

rightly KNOW if a patietn is admitted and discharged eh?

In some offices I know that the nurses check this thing and

print out reams of reports and put them on the docs desk

I am not sure that improves care or follow up And it don;t do much for

expenses.

I just cannot do one more fragmetned thing to get my work

done You were saying oh suck it up get the printer installed

This maybe why you stay in practice Kath some things should be sucked up

SOme things infuriate me when I have to do MORE work and disrupt my work

flow to get my work done well

Jeez i coudl do alot if no real people ever came in.I could chase faxes

and attach them to charts and copy and paste etc.

Some offices just get stuff done- but I am sure leaving other stuff by

the wayside i complain becasue it is stupid and I want to make change PCPs have

been lying down like rugs for yrs.. You want me to keep people from being

readmitied? Well tell me when they are, so

I can follow up

,

Needy patients get needy. we do our best to be helpful Yes Ihad a woman

who owed me 57.00 for a year HAs horrbile conflicts about fear of

her htn vs fear of meds and could use more of a therapist than I can be

for her. Cries fearful , angry AND then lost her job. Through

the resp co. last year I was asked who would like a free holiday dinner

and I sent her one But then she sneds nasty nasty emails when I

snet her a third personal from me letter to please for the last time see if she

could call my biller just call and answer the bills and pay 5.00? Just talk to

us is all I ever ask of patietns Sent me emails that my letters are

threatening and that if she had been told she could pay a little at a time she

would; how dare i threaten her. And you guys want to talk NCBF?? Dream on

..

She has now paid her bill 5.00 by 5.00 and lives in an

angry conflicted world- and sees a hosp clinic where she sees docs who

are paid handsomely see her for 5.00 Sigh.

Ah lets see the guy whose wife I saw through incredible stuff had a

visit to quit tobacco which he did Owed me 80 for a yr Got insuracne Came

in Was told the copay was 20 and there was an old bill of 80 as well. 1 yr

later He said- this is almost funny -- " but you siad I could

pay it when I could "

well uh yess.... He stormed out saying I hate men

Trouble is that in a rural area one person likes this tells 20 and

it is hard to fill a schedule when you actually cannot see them for

5.00 and there is bad shit all over town. about you

the job is really really hard the visits are busy with many demands

and the pay and respect and nonsystems suck right now

Even if the pay were good the systems superb and the specialist and

resepct better it is just a hard job and gets to us.

Will get off email and stop bothering you guys

HAppy sunday

On Sat, Aug 11, 2012 at 11:25 PM, Kathy Saradarian

wrote:

Oh. I thought I told you to go out in your garden or take

a vacation; not suck it up and stop whining.

I’ve recently fired a couple of patients who I just got

sick of abusing me. It was very uplifting. And then, I get mad at

the patient who sends an e-mail that she went to another doctor after I refused

to call in an ABT for her usual sinusitis and bronchitis as I tried to explain

that they are viral and don’t need antibiotics. The other doctor

told her she has bronchitis and sinusitis and gave her an antibiotic. Of

course she saw the other doctor too. I get pissed.

But when patients just start getting me mad, I know it’s past time for a

vacation.

Saradarian

[Guest guest]

I'm never sending records. End of story. Period. I will write a script, put the date I saw the patient, give Dx code and give to patient AT time of visit. (Maybe paying that co-pay will make them take better care of those shoes just like the kid who pays for his bike uses the kick stand and the kid who never pays toward that bike leaves it on the ground.) I've been told by at least a couple of places that this provision of records is being over read by the DME companies but I think in most offices it's just easier to "let the records people" push send for the whole bluming chart. They sure don't need my patients STD records to provide oxygen! Keep insisting on visits. You're right about no antibiotics for virals. If a

patient goes elsewhere to get meds then a 30 day letter goes out. "I note that you are dissatisfied with my care and have chosen to go elsewhere. This letter verifies my acknowledgement of you having chosen another primary care physician as of such and such a date. Please find enclosed a HIPPA release to forward your records at a cost of (whatever the going rate is for your area.)" Patients need to pay their bill somehow. Cash, food, barter...... Compassionete Medicine does not equal Doormat.Setting limits is respectful for your patients and yourself. Now...........if I could just follow my own advice A WHOLE LOT BETTER! Vacation will help. To: Sent: Sunday, August 12, 2012 11:37 AM Subject: RE: Bad week everywhere? Options.

I’m sad to hear that we are all having a frustrating time, but

getting the chance to hear from other docs what they are going thru is very

helpful to me. Being solo is, frankly, kind of lonely. I like

being solo, don’t get me wrong, and am more of a loner but I don’t

know if I’m just being stubborn about some things (like no antibiotics

for viral illnesses, insisting on visits instead of over the phone treatments,

asking patient to pay on their bill once in a while) or if I’m out of

touch and not practicing good compassionate medicine. After losing much sleep over these stupid forms, especially the

diabetes shoes (which frankly are oversold around here and I don’t think

they help people nearly as much as the shoe sellers would have everyone

believe-there, I said it), I sat down and decided to come up with a solution. I strongly believe there are always options. So here are my options

for dealing with the extensive form overload. We need to be proactive in

dealing with this and stop being run over by patients, government agencies, DME

companies and insurance companies. I would love to hear some feedback on

the pros and cons of these Assuming a patient actually qualifies for DME (like DM shoes,

CPAP, oxygen, nebulizers, glucose monitors, bedside commodes, etc) there are

four parts that are required. I used to could just write a 1) prescription

but now they want a 2) specific exam, 3) specific paper documentation (like a

foot exam template) and 4) copious notes (up to six months worth in some cases).

They send me CMS memos saying the patient doesn’t have to pay and the companies

refuse to pay for the records either. The sending of medical

records is the straw breaking this camel’s back.

I could perform the (foot/asthma/COPD/etc)

specific exam at their regular visit and fill out the prescription, a

paper exam template form and sent form and the office notes for free.

--- Pros: the patients, DME companies, insurance companies, and the government

are happy.--- Cons: This isn’t working because I’m going broke

spending hours completing, answering forms and sending out medical records

for free. I could perform the exam

at their regular visit and fill out the prescription, the exam template

form and charge the patient for their medical records and have them

mail them to the DME company. ---Pros, this puts the responsibility

back on the patient and not me. --- Cons: This is not working

b/c of course, no patient wants to pay for medical records, either. It

isn’t completely their fault. Some have been ok with this;

others have left me. I could perform the exam

at their regular visit and fill out the exam template, and charge $10

for the completion of the forms (this should be billable, right) and

send the medical records for free. ---I make $10 for this I could insist on a separate

billable visit for each and every item of DME. You need DM

shoes; that needs a separate visit. You need a renewal on your

nebulizer; you must come back in just to do the paperwork. ---Billable but

wastes my time and the patient’s time; but I get paid by the

insurance company for doing what the insurance company demands; seems fair

somehow. Patient loses another copay. Also DME companies keep

faxing the paperwork over and over until the patient comes in for a visit I could turf

everybody to a specialist. --- Then I’m no better than an

urgent care, IMO and I make no money. I could go back to work

for the hospital and run their clinic where they have lots of staff to

do this stuff and get paid a salary so I’m paid the same thing for

treating CHF as I am completing forms for shoes and commodes.

I do apologize for this very long post. I am burning out and am

trying to find workable solutions to turn things around. This listserv

has been very supportive and very helpful and I am grateful for it

Tonya S. Little, MD 1704 Glendale Drive SW, Suite C NC 27893 fax cell tslittle@...

From: [mailto: ] On Behalf Of

Sent: Sunday, August 12, 2012

10:27 AM

To:

Subject: Re:

Bad week everywhere?

I think the fact that you have been practicing so long

in difficult NJ is a tribute Kath and I sure mean not offense just

the opposite

It was that I think that I am entitled to be told when someone is in

the hospital.This is where I could be wrong.

The nonsystem here is that I would have to install a hospital printer and go

look every day at a report that would tell me a list of names that would

be everything from Suzie Q needing 3 stiches on her hand to JOhn

admitted for MI Maybe some of you think that is great. I contend not. This

ain;t a third world country. They cannot send me something paperless to

tel l me who was admitted or in the ER and for what ,without some

other machine/ some other place to go look .Think of the errors we make when

overloaded with interruptions to adjust to some other institutions work

systems.

It is possible I should be grateful to have a machine available

this is the suck it up part, and go get the paper off it and get up

and go look at it and open the hospital data base and go see what happened to

who but

I don;t think so

A local office invovled in the PCMH pilot has this printer but the

doc still had no idea he could tell who was admitted

Nonsytems that demand more work and more nonsense flurrying

around to attend to the computer.

are nuts! However if I am trying to do care coordination I should

rightly KNOW if a patietn is admitted and discharged eh?

In some offices I know that the nurses check this thing and

print out reams of reports and put them on the docs desk

I am not sure that improves care or follow up And it don;t do much for

expenses.

I just cannot do one more fragmetned thing to get my work

done You were saying oh suck it up get the printer installed

This maybe why you stay in practice Kath some things should be sucked up

SOme things infuriate me when I have to do MORE work and disrupt my work

flow to get my work done well

Jeez i coudl do alot if no real people ever came in.I could chase faxes

and attach them to charts and copy and paste etc.

Some offices just get stuff done- but I am sure leaving other stuff by

the wayside i complain becasue it is stupid and I want to make change PCPs have

been lying down like rugs for yrs.. You want me to keep people from being

readmitied? Well tell me when they are, so

I can follow up

,

Needy patients get needy. we do our best to be helpful Yes Ihad a woman

who owed me 57.00 for a year HAs horrbile conflicts about fear of

her htn vs fear of meds and could use more of a therapist than I can be

for her. Cries fearful , angry AND then lost her job. Through

the resp co. last year I was asked who would like a free holiday dinner

and I sent her one But then she sneds nasty nasty emails when I

snet her a third personal from me letter to please for the last time see if she

could call my biller just call and answer the bills and pay 5.00? Just talk to

us is all I ever ask of patietns Sent me emails that my letters are

threatening and that if she had been told she could pay a little at a time she

would; how dare i threaten her. And you guys want to talk NCBF?? Dream on

..

She has now paid her bill 5.00 by 5.00 and lives in an

angry conflicted world- and sees a hosp clinic where she sees docs who

are paid handsomely see her for 5.00 Sigh.

Ah lets see the guy whose wife I saw through incredible stuff had a

visit to quit tobacco which he did Owed me 80 for a yr Got insuracne Came

in Was told the copay was 20 and there was an old bill of 80 as well. 1 yr

later He said- this is almost funny --"but you siad I could

pay it when I could"

well uh yess.... He stormed out saying I hate men

Trouble is that in a rural area one person likes this tells 20 and

it is hard to fill a schedule when you actually cannot see them for

5.00 and there is bad shit all over town. about you

the job is really really hard the visits are busy with many demands

and the pay and respect and nonsystems suck right now

Even if the pay were good the systems superb and the specialist and

resepct better it is just a hard job and gets to us.

Will get off email and stop bothering you guys

HAppy sunday

On Sat, Aug 11, 2012 at 11:25 PM, Kathy Saradarian

wrote:

Oh. I thought I told you to go out in your garden or take

a vacation; not suck it up and stop whining. I’ve recently fired a couple of patients who I just got

sick of abusing me. It was very uplifting. And then, I get mad at

the patient who sends an e-mail that she went to another doctor after I refused

to call in an ABT for her usual sinusitis and bronchitis as I tried to explain

that they are viral and don’t need antibiotics. The other doctor

told her she has bronchitis and sinusitis and gave her an antibiotic. Of

course she saw the other doctor too. I get pissed.

But when patients just start getting me mad, I know it’s past time for a

vacation. Saradarian

[Guest guest]

Myria,Like you I don’t send records.  Sometimes they want the “last progress note†but sometimes the issue is not addressed there so it’s not appropriate.  I have started charging for physical forms, vaccination records, etc as those are really not part of a wellness exam.  I recently designed a letter I called “devalued patientâ€.  In the letter I stated that it had come to my attention that they no longer value me as their doctor.  I assess that by them keeping their appointments, filling there meds, going for test that  are ordered and paying me for their care.  (this is what the letter says).  And then, depending on the patient, they are discharged with 30 days to make payment plans (if they owe money) or they will be sent to collections.  They might just be dischanrged and sent to collections at that time (all these accounts are out more than 180 days and sometimes more than a year.  Or they have 30 days to call and make a payment plan or they will be discharged and sent to collections.  These people have the option of staying on as patients. I have sent out about 20 letters.  I irks me that this is what it takes to get patients to say “I don’t’ want a new doctor, I can pay “xâ€/monthâ€.  Because this is the response I have gotten.  A couple have not bothered to contact us with the 30 days notice before collections.    Only 1 patient, so far, I sent the letter because he was a pain in the ass and he got no choice.  He had a 5:30 PM appointment (30 minute apt) and walked out at 5:50 as he had to leave for his other job.  He hadn’t bothered coming in for over a year.  He is a poorly controlled diabetic, hyperlipidemic with severe psoriatic arthritis and a CDL license who calls every month for samples even though he has good insurance and only “shapes up†when he has to pass his CDL.  He never goes for his blood work.    He was always nasty to the staff and they always complained about him.  My evening appts are a premium as only open 1 night a week.  So I said “adios amigosâ€.  He called that he didn’t want to find a new doctor, he could explain…..  I didn’t return his call.  It felt really good. And, this has made my staff happy too, these letters.  And that makes it worth it also. Kathy Saradarian, MD From: [mailto: ] On Behalf Of MyriaSent: Sunday, August 12, 2012 12:49 PMTo: Subject: Re: Bad week everywhere? Options. I'm never sending records. End of story. Period. I will write a script, put the date I saw the patient, give Dx code and give to patient AT time of visit. (Maybe paying that co-pay will make them take better care of those shoes just like the kid who pays for his bike uses the kick stand and the kid who never pays toward that bike leaves it on the ground.) I've been told by at least a couple of places that this provision of records is being over read by the DME companies but I think in most offices it's just easier to " let the records people " push send for the whole bluming chart. They sure don't need my patients STD records to provide oxygen! Keep insisting on visits. You're right about no antibiotics for virals. If a patient goes elsewhere to get meds then a 30 day letter goes out. " I note that you are dissatisfied with my care and have chosen to go elsewhere. This letter verifies my acknowledgement of you having chosen another primary care physician as of such and such a date. Please find enclosed a HIPPA release to forward your records at a cost of (whatever the going rate is for your area.) " Patients need to pay their bill somehow. Cash, food, barter...... Compassionete Medicine does not equal Doormat.Setting limits is respectful for your patients and yourself. Now...........if I could just follow my own advice A WHOLE LOT BETTER! Vacation will help. To: Sent: Sunday, August 12, 2012 11:37 AMSubject: RE: Bad week everywhere? Options. I’m sad to hear that we are all having a frustrating time, but getting the chance to hear from other docs what they are going thru is very helpful to me. Being solo is, frankly, kind of lonely. I like being solo, don’t get me wrong, and am more of a loner but I don’t know if I’m just being stubborn about some things (like no antibiotics for viral illnesses, insisting on visits instead of over the phone treatments, asking patient to pay on their bill once in a while) or if I’m out of touch and not practicing good compassionate medicine. After losing much sleep over these stupid forms, especially the diabetes shoes (which frankly are oversold around here and I don’t think they help people nearly as much as the shoe sellers would have everyone believe-there, I said it), I sat down and decided to come up with a solution. I strongly believe there are always options. So here are my options for dealing with the extensive form overload. We need to be proactive in dealing with this and stop being run over by patients, government agencies, DME companies and insurance companies. I would love to hear some feedback on the pros and cons of these Assuming a patient actually qualifies for DME (like DM shoes, CPAP, oxygen, nebulizers, glucose monitors, bedside commodes, etc) there are four parts that are required. I used to could just write a 1) prescription but now they want a 2) specific exam, 3) specific paper documentation (like a foot exam template) and 4) copious notes (up to six months worth in some cases). They send me CMS memos saying the patient doesn’t have to pay and the companies refuse to pay for the records either. The sending of medical records is the straw breaking this camel’s back. I could perform the (foot/asthma/COPD/etc) specific exam at their regular visit and fill out the prescription, a paper exam template form and sent form and the office notes for free. --- Pros: the patients, DME companies, insurance companies, and the government are happy.--- Cons: This isn’t working because I’m going broke spending hours completing, answering forms and sending out medical records for free.I could perform the exam at their regular visit and fill out the prescription, the exam template form and charge the patient for their medical records and have them mail them to the DME company. ---Pros, this puts the responsibility back on the patient and not me. --- Cons: This is not working b/c of course, no patient wants to pay for medical records, either. It isn’t completely their fault. Some have been ok with this; others have left me.I could perform the exam at their regular visit and fill out the exam template, and charge $10 for the completion of the forms (this should be billable, right) and send the medical records for free. ---I make $10 for thisI could insist on a separate billable visit for each and every item of DME. You need DM shoes; that needs a separate visit. You need a renewal on your nebulizer; you must come back in just to do the paperwork. ---Billable but wastes my time and the patient’s time; but I get paid by the insurance company for doing what the insurance company demands; seems fair somehow. Patient loses another copay. Also DME companies keep faxing the paperwork over and over until the patient comes in for a visitI could turf everybody to a specialist. --- Then I’m no better than an urgent care, IMO and I make no money.I could go back to work for the hospital and run their clinic where they have lots of staff to do this stuff and get paid a salary so I’m paid the same thing for treating CHF as I am completing forms for shoes and commodes. I do apologize for this very long post. I am burning out and am trying to find workable solutions to turn things around. This listserv has been very supportive and very helpful and I am grateful for it Tonya S. Little, MD1704 Glendale Drive SW, Suite C NC 27893 fax celltslittle@...From: [mailto: ] On Behalf Of Sent: Sunday, August 12, 2012 10:27 AMTo: Subject: Re: Bad week everywhere? I think the fact that you have been practicing so long in difficult NJ is a tribute Kath and I sure mean not offense just the opposite It was that I think that I am entitled to be told when someone is in the hospital.This is where I could be wrong.The nonsystem here is that I would have to install a hospital printer and go look every day at a report that would tell me a list of names that would be everything from Suzie Q needing 3 stiches on her hand to JOhn admitted for MI Maybe some of you think that is great. I contend not. This ain;t a third world country. They cannot send me something paperless to tel l me who was admitted or in the ER and for what ,without some other machine/ some other place to go look .Think of the errors we make when overloaded with interruptions to adjust to some other institutions work systems. It is possible I should be grateful to have a machine available this is the suck it up part, and go get the paper off it and get up and go look at it and open the hospital data base and go see what happened to who butI don;t think so A local office invovled in the PCMH pilot has this printer but the doc still had no idea he could tell who was admittedNonsytems that demand more work and more nonsense flurrying around to attend to the computer.are nuts! However if I am trying to do care coordination I should rightly KNOW if a patietn is admitted and discharged eh?In some offices I know that the nurses check this thing and print out reams of reports and put them on the docs deskI am not sure that improves care or follow up And it don;t do much for expenses.I just cannot do one more fragmetned thing to get my work done You were saying oh suck it up get the printer installed This maybe why you stay in practice Kath some things should be sucked upSOme things infuriate me when I have to do MORE work and disrupt my work flow to get my work done well Jeez i coudl do alot if no real people ever came in.I could chase faxes and attach them to charts and copy and paste etc.Some offices just get stuff done- but I am sure leaving other stuff by the wayside i complain becasue it is stupid and I want to make change PCPs have been lying down like rugs for yrs.. You want me to keep people from being readmitied? Well tell me when they are, so I can follow up , Needy patients get needy. we do our best to be helpful Yes Ihad a woman who owed me 57.00 for a year HAs horrbile conflicts about fear of her htn vs fear of meds and could use more of a therapist than I can be for her. Cries fearful , angry AND then lost her job. Through the resp co. last year I was asked who would like a free holiday dinner and I sent her one But then she sneds nasty nasty emails when I snet her a third personal from me letter to please for the last time see if she could call my biller just call and answer the bills and pay 5.00? Just talk to us is all I ever ask of patietns Sent me emails that my letters are threatening and that if she had been told she could pay a little at a time she would; how dare i threaten her. And you guys want to talk NCBF?? Dream on . She has now paid her bill 5.00 by 5.00 and lives in an angry conflicted world- and sees a hosp clinic where she sees docs who are paid handsomely see her for 5.00 Sigh.Ah lets see the guy whose wife I saw through incredible stuff had a visit to quit tobacco which he did Owed me 80 for a yr Got insuracne Came in Was told the copay was 20 and there was an old bill of 80 as well. 1 yr later He said- this is almost funny -- " but you siad I could pay it when I could " well uh yess.... He stormed out saying I hate men Trouble is that in a rural area one person likes this tells 20 and it is hard to fill a schedule when you actually cannot see them for 5.00 and there is bad shit all over town. about you the job is really really hard the visits are busy with many demands and the pay and respect and nonsystems suck right now Even if the pay were good the systems superb and the specialist and resepct better it is just a hard job and gets to us.Will get off email and stop bothering you guys HAppy sunday Oh. I thought I told you to go out in your garden or take a vacation; not suck it up and stop whining. I’ve recently fired a couple of patients who I just got sick of abusing me. It was very uplifting. And then, I get mad at the patient who sends an e-mail that she went to another doctor after I refused to call in an ABT for her usual sinusitis and bronchitis as I tried to explain that they are viral and don’t need antibiotics. The other doctor told her she has bronchitis and sinusitis and gave her an antibiotic. Of course she saw the other doctor too. I get pissed. But when patients just start getting me mad, I know it’s past time for a vacation. Saradarian

[Guest guest]

What we are all talking about here is setting boundaries, both for the patients, the insurance companies and ourselves. Patients need these boundaries, or they will continue to be inappropriate. We are at more risk of this, because we aren't like other doctors, and we do spend more time. Our difference, makes them ask more of us, often inappropriately. Damn straight that the place down the corner seeing 40/d/doctor ain't doing any phone refills, or filling out forms for free! And neither should WE!. Stand your ground, and stand up for you and your offices boundaries. I think the letters you talk of here are fabulous, but I think you waited too long ( like I usually do), giving too many changes before sending. Ideally he should have been told if he couldn't make his health a priority, he would be discharged, maybe one of the many times he called for refills without being seen.

I am in process of an expectations letter to go out to patietns when I go to NCBF. Expectations of them, and me, this is what I will and won't do. You don't like it go down the street and see if you get away with it there. These behaviors put them and US at risk, both in malpractice, but also as standard of care violations, which any patient, family member or staff can report to your local quality assurance board.

Cote

To: Sent: Sunday, August 12, 2012 12:21:11 PMSubject: RE: Bad week everywhere? Options.

Myria,

Like you I don’t send records. Sometimes they want the “last progress note†but sometimes the issue is not addressed there so it’s not appropriate. I have started charging for physical forms, vaccination records, etc as those are really not part of a wellness exam.

I recently designed a letter I called “devalued patientâ€. In the letter I stated that it had come to my attention that they no longer value me as their doctor. I assess that by them keeping their appointments, filling there meds, going for test that are ordered and paying me for their care. (this is what the letter says). And then, depending on the patient, they are discharged with 30 days to make payment plans (if they owe money) or they will be sent to collections. They might just be dischanrged and sent to collections at that time (all these accounts are out more than 180 days and sometimes more than a year. Or they have 30 days to call and make a payment plan or they will be discharged and sent to collections. These people have the option of staying on as patients.

I have sent out about 20 letters. I irks me that this is what it takes to get patients to say “I don’t’ want a new doctor, I can pay “xâ€/monthâ€. Because this is the response I have gotten. A couple have not bothered to contact us with the 30 days notice before collections. Only 1 patient, so far, I sent the letter because he was a pain in the ass and he got no choice. He had a 5:30 PM appointment (30 minute apt) and walked out at 5:50 as he had to leave for his other job. He hadn’t bothered coming in for over a year. He is a poorly controlled diabetic, hyperlipidemic with severe psoriatic arthritis and a CDL license who calls every month for samples even though he has good insurance and only “shapes up†when he has to pass his CDL. He never goes for his blood work. He was always nasty to the staff and they always complained about him. My evening appts are a premium as only open 1 night a week. So I said “adios amigosâ€. He called that he didn’t want to find a new doctor, he could explain….. I didn’t return his call. It felt really good.

And, this has made my staff happy too, these letters. And that makes it worth it also.

Kathy Saradarian, MD

From: [mailto: ] On Behalf Of MyriaSent: Sunday, August 12, 2012 12:49 PMTo: Subject: Re: Bad week everywhere? Options.

I'm never sending records. End of story. Period. I will write a script, put the date I saw the patient, give Dx code and give to patient AT time of visit. (Maybe paying that co-pay will make them take better care of those shoes just like the kid who pays for his bike uses the kick stand and the kid who never pays toward that bike leaves it on the ground.) I've been told by at least a couple of places that this provision of records is being over read by the DME companies but I think in most offices it's just easier to "let the records people" push send for the whole bluming chart. They sure don't need my patients STD records to provide oxygen!

Keep insisting on visits. You're right about no antibiotics for virals. If a patient goes elsewhere to get meds then a 30 day letter goes out. "I note that you are dissatisfied with my care and have chosen to go elsewhere. This letter verifies my acknowledgement of you having chosen another primary care physician as of such and such a date. Please find enclosed a HIPPA release to forward your records at a cost of (whatever the going rate is for your area.)" Patients need to pay their bill somehow. Cash, food, barter......

Compassionete Medicine does not equal Doormat.

Setting limits is respectful for your patients and yourself.

Now...........if I could just follow my own advice A WHOLE LOT BETTER!

Vacation will help.

To: Sent: Sunday, August 12, 2012 11:37 AMSubject: RE: Bad week everywhere? Options.

I’m sad to hear that we are all having a frustrating time, but getting the chance to hear from other docs what they are going thru is very helpful to me. Being solo is, frankly, kind of lonely. I like being solo, don’t get me wrong, and am more of a loner but I don’t know if I’m just being stubborn about some things (like no antibiotics for viral illnesses, insisting on visits instead of over the phone treatments, asking patient to pay on their bill once in a while) or if I’m out of touch and not practicing good compassionate medicine.

After losing much sleep over these stupid forms, especially the diabetes shoes (which frankly are oversold around here and I don’t think they help people nearly as much as the shoe sellers would have everyone believe-there, I said it), I sat down and decided to come up with a solution.

I strongly believe there are always options. So here are my options for dealing with the extensive form overload. We need to be proactive in dealing with this and stop being run over by patients, government agencies, DME companies and insurance companies. I would love to hear some feedback on the pros and cons of these

Assuming a patient actually qualifies for DME (like DM shoes, CPAP, oxygen, nebulizers, glucose monitors, bedside commodes, etc) there are four parts that are required. I used to could just write a 1) prescription but now they want a 2) specific exam, 3) specific paper documentation (like a foot exam template) and 4) copious notes (up to six months worth in some cases). They send me CMS memos saying the patient doesn’t have to pay and the companies refuse to pay for the records either. The sending of medical records is the straw breaking this camel’s back.

I could perform the (foot/asthma/COPD/etc) specific exam at their regular visit and fill out the prescription, a paper exam template form and sent form and the office notes for free. --- Pros: the patients, DME companies, insurance companies, and the government are happy.--- Cons: This isn’t working because I’m going broke spending hours completing, answering forms and sending out medical records for free. I could perform the exam at their regular visit and fill out the prescription, the exam template form and charge the patient for their medical records and have them mail them to the DME company. ---Pros, this puts the responsibility back on the patient and not me. --- Cons: This is not working b/c of course, no patient wants to pay for medical records, either. It isn’t completely their fault. Some have been ok with this; others have left me. I could perform the exam at their regular visit and fill out the exam template, and charge $10 for the completion of the forms (this should be billable, right) and send the medical records for free. ---I make $10 for this I could insist on a separate billable visit for each and every item of DME. You need DM shoes; that needs a separate visit. You need a renewal on your nebulizer; you must come back in just to do the paperwork. ---Billable but wastes my time and the patient’s time; but I get paid by the insurance company for doing what the insurance company demands; seems fair somehow. Patient loses another copay. Also DME companies keep faxing the paperwork over and over until the patient comes in for a visit I could turf everybody to a specialist. --- Then I’m no better than an urgent care, IMO and I make no money. I could go back to work for the hospital and run their clinic where they have lots of staff to do this stuff and get paid a salary so I’m paid the same thing for treating CHF as I am completing forms for shoes and commodes.

I do apologize for this very long post. I am burning out and am trying to find workable solutions to turn things around. This listserv has been very supportive and very helpful and I am grateful for it

Tonya S. Little, MD

1704 Glendale Drive SW, Suite C

NC 27893

fax

cell

tslittle@...

From: [mailto: ] On Behalf Of Sent: Sunday, August 12, 2012 10:27 AMTo: Subject: Re: Bad week everywhere?

I think the fact that you have been practicing so long in difficult NJ is a tribute Kath and I sure mean not offense just the opposite It was that I think that I am entitled to be told when someone is in the hospital.This is where I could be wrong.The nonsystem here is that I would have to install a hospital printer and go look every day at a report that would tell me a list of names that would be everything from Suzie Q needing 3 stiches on her hand to JOhn admitted for MI Maybe some of you think that is great. I contend not. This ain;t a third world country. They cannot send me something paperless to tel l me who was admitted or in the ER and for what ,without some other machine/ some other place to go look .Think of the errors we make when overloaded with interruptions to adjust to some other institutions work systems. It is possible I should be grateful to have a machine available this is the suck it up part, and go get the paper off it and get up and go look at it and open the hospital data base and go see what happened to who butI don;t think so A local office invovled in the PCMH pilot has this printer but the doc still had no idea he could tell who was admittedNonsytems that demand more work and more nonsense flurrying around to attend to the computer.are nuts! However if I am trying to do care coordination I should rightly KNOW if a patietn is admitted and discharged eh?In some offices I know that the nurses check this thing and print out reams of reports and put them on the docs deskI am not sure that improves care or follow up And it don;t do much for expenses.I just cannot do one more fragmetned thing to get my work done You were saying oh suck it up get the printer installed This maybe why you stay in practice Kath some things should be sucked upSOme things infuriate me when I have to do MORE work and disrupt my work flow to get my work done well Jeez i coudl do alot if no real people ever came in.I could chase faxes and attach them to charts and copy and paste etc.Some offices just get stuff done- but I am sure leaving other stuff by the wayside i complain becasue it is stupid and I want to make change PCPs have been lying down like rugs for yrs.. You want me to keep people from being readmitied? Well tell me when they are, so I can follow up , Needy patients get needy. we do our best to be helpful Yes Ihad a woman who owed me 57.00 for a year HAs horrbile conflicts about fear of her htn vs fear of meds and could use more of a therapist than I can be for her. Cries fearful , angry AND then lost her job. Through the resp co. last year I was asked who would like a free holiday dinner and I sent her one But then she sneds nasty nasty emails when I snet her a third personal from me letter to please for the last time see if she could call my biller just call and answer the bills and pay 5.00? Just talk to us is all I ever ask of patietns Sent me emails that my letters are threatening and that if she had been told she could pay a little at a time she would; how dare i threaten her. And you guys want to talk NCBF?? Dream on . She has now paid her bill 5.00 by 5.00 and lives in an angry conflicted world- and sees a hosp clinic where she sees docs who are paid handsomely see her for 5.00 Sigh.Ah lets see the guy whose wife I saw through incredible stuff had a visit to quit tobacco which he did Owed me 80 for a yr Got insuracne Came in Was told the copay was 20 and there was an old bill of 80 as well. 1 yr later He said- this is almost funny --"but you siad I could pay it when I could"well uh yess.... He stormed out saying I hate men Trouble is that in a rural area one person likes this tells 20 and it is hard to fill a schedule when you actually cannot see them for 5.00 and there is bad shit all over town. about you the job is really really hard the visits are busy with many demands and the pay and respect and nonsystems suck right now Even if the pay were good the systems superb and the specialist and resepct better it is just a hard job and gets to us.Will get off email and stop bothering you guys HAppy sunday

Oh. I thought I told you to go out in your garden or take a vacation; not suck it up and stop whining.

I’ve recently fired a couple of patients who I just got sick of abusing me. It was very uplifting. And then, I get mad at the patient who sends an e-mail that she went to another doctor after I refused to call in an ABT for her usual sinusitis and bronchitis as I tried to explain that they are viral and don’t need antibiotics. The other doctor told her she has bronchitis and sinusitis and gave her an antibiotic. Of course she saw the other doctor too. I get pissed. But when patients just start getting me mad, I know it’s past time for a vacation.

Saradarian

[Guest guest]

Send a copy of the letter to the list serve if able.

CCote

To: Sent: Sunday, August 12, 2012 12:21:11 PMSubject: RE: Bad week everywhere? Options.

Myria,

Like you I don’t send records. Sometimes they want the “last progress note†but sometimes the issue is not addressed there so it’s not appropriate. I have started charging for physical forms, vaccination records, etc as those are really not part of a wellness exam.

I recently designed a letter I called “devalued patientâ€. In the letter I stated that it had come to my attention that they no longer value me as their doctor. I assess that by them keeping their appointments, filling there meds, going for test that are ordered and paying me for their care. (this is what the letter says). And then, depending on the patient, they are discharged with 30 days to make payment plans (if they owe money) or they will be sent to collections. They might just be dischanrged and sent to collections at that time (all these accounts are out more than 180 days and sometimes more than a year. Or they have 30 days to call and make a payment plan or they will be discharged and sent to collections. These people have the option of staying on as patients.

I have sent out about 20 letters. I irks me that this is what it takes to get patients to say “I don’t’ want a new doctor, I can pay “xâ€/monthâ€. Because this is the response I have gotten. A couple have not bothered to contact us with the 30 days notice before collections. Only 1 patient, so far, I sent the letter because he was a pain in the ass and he got no choice. He had a 5:30 PM appointment (30 minute apt) and walked out at 5:50 as he had to leave for his other job. He hadn’t bothered coming in for over a year. He is a poorly controlled diabetic, hyperlipidemic with severe psoriatic arthritis and a CDL license who calls every month for samples even though he has good insurance and only “shapes up†when he has to pass his CDL. He never goes for his blood work. He was always nasty to the staff and they always complained about him. My evening appts are a premium as only open 1 night a week. So I said “adios amigosâ€. He called that he didn’t want to find a new doctor, he could explain….. I didn’t return his call. It felt really good.

And, this has made my staff happy too, these letters. And that makes it worth it also.

Kathy Saradarian, MD

From: [mailto: ] On Behalf Of MyriaSent: Sunday, August 12, 2012 12:49 PMTo: Subject: Re: Bad week everywhere? Options.

I'm never sending records. End of story. Period. I will write a script, put the date I saw the patient, give Dx code and give to patient AT time of visit. (Maybe paying that co-pay will make them take better care of those shoes just like the kid who pays for his bike uses the kick stand and the kid who never pays toward that bike leaves it on the ground.) I've been told by at least a couple of places that this provision of records is being over read by the DME companies but I think in most offices it's just easier to "let the records people" push send for the whole bluming chart. They sure don't need my patients STD records to provide oxygen!

Keep insisting on visits. You're right about no antibiotics for virals. If a patient goes elsewhere to get meds then a 30 day letter goes out. "I note that you are dissatisfied with my care and have chosen to go elsewhere. This letter verifies my acknowledgement of you having chosen another primary care physician as of such and such a date. Please find enclosed a HIPPA release to forward your records at a cost of (whatever the going rate is for your area.)" Patients need to pay their bill somehow. Cash, food, barter......

Compassionete Medicine does not equal Doormat.

Setting limits is respectful for your patients and yourself.

Now...........if I could just follow my own advice A WHOLE LOT BETTER!

Vacation will help.

To: Sent: Sunday, August 12, 2012 11:37 AMSubject: RE: Bad week everywhere? Options.

I’m sad to hear that we are all having a frustrating time, but getting the chance to hear from other docs what they are going thru is very helpful to me. Being solo is, frankly, kind of lonely. I like being solo, don’t get me wrong, and am more of a loner but I don’t know if I’m just being stubborn about some things (like no antibiotics for viral illnesses, insisting on visits instead of over the phone treatments, asking patient to pay on their bill once in a while) or if I’m out of touch and not practicing good compassionate medicine.

After losing much sleep over these stupid forms, especially the diabetes shoes (which frankly are oversold around here and I don’t think they help people nearly as much as the shoe sellers would have everyone believe-there, I said it), I sat down and decided to come up with a solution.

I strongly believe there are always options. So here are my options for dealing with the extensive form overload. We need to be proactive in dealing with this and stop being run over by patients, government agencies, DME companies and insurance companies. I would love to hear some feedback on the pros and cons of these

Assuming a patient actually qualifies for DME (like DM shoes, CPAP, oxygen, nebulizers, glucose monitors, bedside commodes, etc) there are four parts that are required. I used to could just write a 1) prescription but now they want a 2) specific exam, 3) specific paper documentation (like a foot exam template) and 4) copious notes (up to six months worth in some cases). They send me CMS memos saying the patient doesn’t have to pay and the companies refuse to pay for the records either. The sending of medical records is the straw breaking this camel’s back.

I could perform the (foot/asthma/COPD/etc) specific exam at their regular visit and fill out the prescription, a paper exam template form and sent form and the office notes for free. --- Pros: the patients, DME companies, insurance companies, and the government are happy.--- Cons: This isn’t working because I’m going broke spending hours completing, answering forms and sending out medical records for free. I could perform the exam at their regular visit and fill out the prescription, the exam template form and charge the patient for their medical records and have them mail them to the DME company. ---Pros, this puts the responsibility back on the patient and not me. --- Cons: This is not working b/c of course, no patient wants to pay for medical records, either. It isn’t completely their fault. Some have been ok with this; others have left me. I could perform the exam at their regular visit and fill out the exam template, and charge $10 for the completion of the forms (this should be billable, right) and send the medical records for free. ---I make $10 for this I could insist on a separate billable visit for each and every item of DME. You need DM shoes; that needs a separate visit. You need a renewal on your nebulizer; you must come back in just to do the paperwork. ---Billable but wastes my time and the patient’s time; but I get paid by the insurance company for doing what the insurance company demands; seems fair somehow. Patient loses another copay. Also DME companies keep faxing the paperwork over and over until the patient comes in for a visit I could turf everybody to a specialist. --- Then I’m no better than an urgent care, IMO and I make no money. I could go back to work for the hospital and run their clinic where they have lots of staff to do this stuff and get paid a salary so I’m paid the same thing for treating CHF as I am completing forms for shoes and commodes.

I do apologize for this very long post. I am burning out and am trying to find workable solutions to turn things around. This listserv has been very supportive and very helpful and I am grateful for it

Tonya S. Little, MD

1704 Glendale Drive SW, Suite C

NC 27893

fax

cell

tslittle@...

From: [mailto: ] On Behalf Of Sent: Sunday, August 12, 2012 10:27 AMTo: Subject: Re: Bad week everywhere?

I think the fact that you have been practicing so long in difficult NJ is a tribute Kath and I sure mean not offense just the opposite It was that I think that I am entitled to be told when someone is in the hospital.This is where I could be wrong.The nonsystem here is that I would have to install a hospital printer and go look every day at a report that would tell me a list of names that would be everything from Suzie Q needing 3 stiches on her hand to JOhn admitted for MI Maybe some of you think that is great. I contend not. This ain;t a third world country. They cannot send me something paperless to tel l me who was admitted or in the ER and for what ,without some other machine/ some other place to go look .Think of the errors we make when overloaded with interruptions to adjust to some other institutions work systems. It is possible I should be grateful to have a machine available this is the suck it up part, and go get the paper off it and get up and go look at it and open the hospital data base and go see what happened to who butI don;t think so A local office invovled in the PCMH pilot has this printer but the doc still had no idea he could tell who was admittedNonsytems that demand more work and more nonsense flurrying around to attend to the computer.are nuts! However if I am trying to do care coordination I should rightly KNOW if a patietn is admitted and discharged eh?In some offices I know that the nurses check this thing and print out reams of reports and put them on the docs deskI am not sure that improves care or follow up And it don;t do much for expenses.I just cannot do one more fragmetned thing to get my work done You were saying oh suck it up get the printer installed This maybe why you stay in practice Kath some things should be sucked upSOme things infuriate me when I have to do MORE work and disrupt my work flow to get my work done well Jeez i coudl do alot if no real people ever came in.I could chase faxes and attach them to charts and copy and paste etc.Some offices just get stuff done- but I am sure leaving other stuff by the wayside i complain becasue it is stupid and I want to make change PCPs have been lying down like rugs for yrs.. You want me to keep people from being readmitied? Well tell me when they are, so I can follow up , Needy patients get needy. we do our best to be helpful Yes Ihad a woman who owed me 57.00 for a year HAs horrbile conflicts about fear of her htn vs fear of meds and could use more of a therapist than I can be for her. Cries fearful , angry AND then lost her job. Through the resp co. last year I was asked who would like a free holiday dinner and I sent her one But then she sneds nasty nasty emails when I snet her a third personal from me letter to please for the last time see if she could call my biller just call and answer the bills and pay 5.00? Just talk to us is all I ever ask of patietns Sent me emails that my letters are threatening and that if she had been told she could pay a little at a time she would; how dare i threaten her. And you guys want to talk NCBF?? Dream on . She has now paid her bill 5.00 by 5.00 and lives in an angry conflicted world- and sees a hosp clinic where she sees docs who are paid handsomely see her for 5.00 Sigh.Ah lets see the guy whose wife I saw through incredible stuff had a visit to quit tobacco which he did Owed me 80 for a yr Got insuracne Came in Was told the copay was 20 and there was an old bill of 80 as well. 1 yr later He said- this is almost funny --"but you siad I could pay it when I could"well uh yess.... He stormed out saying I hate men Trouble is that in a rural area one person likes this tells 20 and it is hard to fill a schedule when you actually cannot see them for 5.00 and there is bad shit all over town. about you the job is really really hard the visits are busy with many demands and the pay and respect and nonsystems suck right now Even if the pay were good the systems superb and the specialist and resepct better it is just a hard job and gets to us.Will get off email and stop bothering you guys HAppy sunday

Oh. I thought I told you to go out in your garden or take a vacation; not suck it up and stop whining.

I’ve recently fired a couple of patients who I just got sick of abusing me. It was very uplifting. And then, I get mad at the patient who sends an e-mail that she went to another doctor after I refused to call in an ABT for her usual sinusitis and bronchitis as I tried to explain that they are viral and don’t need antibiotics. The other doctor told her she has bronchitis and sinusitis and gave her an antibiotic. Of course she saw the other doctor too. I get pissed. But when patients just start getting me mad, I know it’s past time for a vacation.

Saradarian

[Guest guest]

Agree sometimes we cannot tell if we are insane  and out of the loop agree this community  helpsAs to viruses and antibiotics   I used to find it frustrating and now I find it fairly satisfying becasue I get to listen and  see what they might need  or be worried about and then be useful

 I really just had to  realize that  patietn  do not  get what  we get, no assumptions can be made that they " get " viruses.The chief job of the patietn is to make sense of their illness They saw the guy next door get antibx for " the same "

and the patietns understanding what we say about what they have and what to expect is crucial. Have met a million patietns who tell me they " were not told anythign " / the doctor did not know...  when they say on further asking,  that  they were told it was a virus.  It means nothing to them . I have watched  patients who just saw the residnet have no idea/ cannot repeat  back what was said. What was  said was not clear- like " you have X what you can expect is/ what you can do is " Instead we go on and on about having a virus and what they do not need and it does not  fit into their  picture of what they see happening /their experience of the  illness. Becasue some people do get antibx  .....I think the deal is to listen first  to   ask what they most need us for/ are most worried about then examine/ then sit and be clear about what they have in a way that suits your population Long paragraph  sorry

 as to the rest I think i t is  a  balance between being paid without obsessing over it or  nickel and diming the pateitn  vs getting people what you know they need in a way that does not  disrupt he office,  If you make alot of rules you might break them:) there ARE endless interruptions!

if it is the yearly nebulizer form you know they need and it is just asynchronous with the visit ,  do the form

If it is something new like shoes  then  hold the form til they come in If they call  say sure when can  come in?For ongoing stuff-   code  the visit higher when they do come in- document  the forms you didetc cover all the stuff

 I ignore alot of stuff. I  just ignore it .If the pateitn wants something they callIf I get this endless crap about hedis or  an email from some agency  to tell me order up aquatic therapy or  sign this form  for going to the gym sometimes I do it mostly it sits on my desk til they come in

If the  Resp co or shoe co calls tell them to give the   form to  the patietn and you will do it when they come in. Throw in happy . As in Yes sure  I am  happy to do it!  have them give me a call!When they ask you to do it without seeing them act bewildered. How can I do that?? Aren't there criteria for those shoes? Just have them call I can get them right in  you say:) Thisis the yes thing

 Not that I do not get crabby

the onslaught of stuff is endless I am also  amazed how much smarter I am  like after 5 pm on fridays when there is noone else.

When I am the one who sees the 16 yr old immediately after her ER visit for  emotional crisis becasue pshcy cannot but though mom signs a release at every visit I cannot be told what her 3 meds a re when  she comes in  for  a phsycial.

or last week when I snet a very nice  note to pre admisison testing and the orthopod and the hospitalist but when the pateitn got there for her planned admit,  noone knew anything -  AND when she left the hospital another doc threw her for somedamn reason on famvir. I find this old lady  disharcged in the NH on daily not every other day meds her INR a mess and she is on famvir

 go figureJean

 

I’m sad to hear that we are all having a frustrating time, but

getting the chance to hear from other docs what they are going thru is very

helpful to me.   Being solo is, frankly, kind of lonely.  I like

being solo, don’t get me wrong, and am more of a loner but I don’t

know if I’m just being stubborn about some things (like no antibiotics

for viral illnesses, insisting on visits instead of over the phone treatments,

asking patient to pay on their bill once in a while) or if I’m out of

touch and not practicing good compassionate medicine. 

 

After losing much sleep over these stupid forms, especially the

diabetes shoes (which frankly are oversold around here and I don’t think

they help people nearly as much as the shoe sellers would have everyone

believe-there, I said it), I sat down and decided to come up with a solution.

 

I strongly believe there are always options.  So here are my options

for dealing with the extensive form overload.  We need to be proactive in

dealing with this and stop being run over by patients, government agencies, DME

companies and insurance companies.  I would love to hear some feedback on

the pros and cons of these

  Assuming a patient actually qualifies for DME (like DM shoes,

CPAP, oxygen, nebulizers, glucose monitors, bedside commodes, etc) there are

four parts that are required.  I used to could just write a 1) prescription

but now they want a 2) specific exam, 3) specific paper documentation (like a

foot exam template) and 4) copious notes (up to six months worth in some cases). 

They send me CMS memos saying the patient doesn’t have to pay and the companies

refuse to pay for the records either.   The sending of medical

records is the straw breaking this camel’s back.

 

I could perform the (foot/asthma/COPD/etc)

specific exam at their regular visit and fill out the prescription, a

paper exam template form and sent form and the office notes for free.

--- Pros: the patients, DME companies, insurance companies, and the government

are happy.--- Cons: This isn’t working because I’m going broke

spending hours completing, answering forms and sending out medical records

for free.

I could perform the exam

at their regular visit and fill out the prescription, the exam template

form and charge the patient for their medical records and have them

mail them to the DME company.  ---Pros, this puts the responsibility

back on the patient and not me.  ---  Cons: This is not working

b/c of course, no patient wants to pay for medical records, either.  It

isn’t completely their fault.  Some have been ok with this;

others have left me.

I could perform the exam

at their regular visit and fill out the exam template, and charge $10

for the completion of the forms (this should be billable, right) and

send the medical records for free.  ---I make $10 for this

I could insist on a separate

billable visit for each and every item of DME.  You need DM

shoes; that needs a separate visit.  You need a renewal on your

nebulizer; you must come back in just to do the paperwork. ---Billable but

wastes my time and the patient’s time; but I get paid by the

insurance company for doing what the insurance company demands; seems fair

somehow.  Patient loses another copay.  Also DME companies keep

faxing the paperwork over and over until the patient comes in for a visit

I could turf

everybody to a specialist.  --- Then I’m no better than an

urgent care, IMO and I make no money.

I could go back to work

for the hospital and run their clinic where they have lots of staff to

do this stuff and get paid a salary so I’m paid the same thing for

treating CHF as I am completing forms for shoes and commodes.

 

I do apologize for this very long post.  I am burning out and am

trying to find workable solutions to turn things around.  This listserv

has been very supportive and very helpful and I am grateful for it

 

Tonya S. Little, MD

1704 Glendale Drive SW, Suite C

NC 27893

fax

cell

tslittle@...

From: [mailto: ] On Behalf Of

Sent: Sunday, August 12, 2012

10:27 AM

To:

Subject: Re:

Bad week everywhere?

 

 

I think the fact that you have been practicing so long

in difficult NJ is a tribute Kath and I sure mean not  offense  just

the opposite

It was that I  think that I am entitled to be told when someone is in

the  hospital.This is where I could be wrong.

The nonsystem here is that I would have to install a hospital printer and go

look every day at a report that would tell me  a list of names that would

be everything from Suzie  Q needing 3 stiches on her hand to  JOhn

admitted for MI Maybe some of you think that is great. I contend not. This

ain;t a third world country. They cannot send me  something paperless to

tel l me who was admitted  or in the ER  and for what ,without some

other machine/ some other place to go look .Think of the errors we make when

overloaded with interruptions to  adjust to some other institutions work

systems.

 It is possible I should be grateful to have a machine available 

this is the  suck it up part,  and go get the paper off it and get up

and go look at it and open the hospital data base and go see what happened to

who but

I don;t think so

 A local office invovled in the PCMH  pilot has this printer but the

doc  still had no idea he could tell who was admitted

Nonsytems that demand more  work  and  more nonsense flurrying

around to attend to the  computer.

are nuts!  However if I am trying to do care coordination  I should

rightly KNOW if  a patietn is admitted and discharged eh?

In some  offices I know that  the nurses check this thing  and

print out reams of reports and put them on the docs desk

I am not sure that improves care or follow up And it don;t do much for

expenses.

I just cannot do one more  fragmetned thing  to get my work

done  You were saying oh suck it up   get the printer installed

This maybe why you stay in practice Kath some things   should be sucked up

SOme things infuriate me when I have to do MORE work and disrupt  my work

flow to  get my  work done well

 Jeez i coudl do alot if no real people ever came in.I could chase faxes

and attach them to charts and copy and paste etc.

Some offices just  get stuff done- but I am sure leaving other stuff by

the wayside i complain becasue it is stupid and I want to make change PCPs have

been lying down  like rugs for yrs.. You want me to keep people from being

readmitied? Well tell me when they are, so

I can follow up

,

 Needy patients get needy. we do our best to be helpful Yes Ihad a woman

who owed me 57.00 for a year HAs horrbile conflicts  about fear of 

her htn vs fear of meds and  could use more of a therapist than I can be

for her. Cries  fearful , angry AND then  lost her job.  Through

the resp co. last year I was asked who would like a free  holiday dinner

and I sent her one  But then she sneds nasty nasty  emails when I

snet her a third personal from me letter to please for the last time see if she

could call my biller just call and answer the bills and pay 5.00? Just talk to

us is all I ever ask of patietns Sent me  emails that my letters are

threatening and that if she had been told she could pay a little at a time she

would; how dare i threaten her. And you guys want to talk NCBF??  Dream on

..

 She has now paid her bill  5.00 by  5.00  and lives in an

angry conflicted world- and sees a hosp clinic where she sees docs who 

are   paid handsomely see her for 5.00   Sigh.

Ah lets see the guy whose wife I saw through incredible stuff  had a

visit  to quit tobacco which he did Owed me 80 for a yr Got insuracne Came

in Was told the copay was 20 and there was an old bill of 80 as well. 1 yr

later   He said- this is almost funny -- " but you siad I could

pay it when I could "

well uh yess.... He stormed out saying I hate men

 

Trouble is that in a rural area   one person likes this tells 20 and

it is hard to  fill a schedule when  you actually cannot see them for

5.00  and there is bad shit  all over town. about you

 the job is really really  hard the visits are busy with many demands

and the pay and respect and nonsystems  suck   right now 

Even if the pay were good the systems superb and the  specialist and

resepct better   it is just a hard job and gets to us.

Will  get off email and stop bothering you guys

 HAppy sunday

On Sat, Aug 11, 2012 at 11:25 PM, Kathy Saradarian

wrote:

 

Oh.  I thought I told you to go out in your garden or take

a vacation; not suck it up and stop whining.

 

I’ve recently fired a couple of patients who I just got

sick of abusing me.  It was very uplifting.  And then, I get mad at

the patient who sends an e-mail that she went to another doctor after I refused

to call in an ABT for her usual sinusitis and bronchitis as I tried to explain

that they are viral and don’t need antibiotics.  The other doctor

told her she has bronchitis and sinusitis and gave her an antibiotic.  Of

course she saw the other doctor too.    I get pissed.  

But when patients just start getting me mad, I know it’s past time for a

vacation.

 

Saradarian

 

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