Alive and Shivvering...

 In other words, January in Minnesota.  

This "winter" has been a weird one.  We had a small bit of snow back in October, it arrived and melted quickly.  Since then we've set rainfall records for some days, but snow has been far from common.  As has cold.  We've been running in the 40s for most of December, and even early January was pretty temperate.  Last week I could get up from my desk, get the dogs outside, and come back in and all without adding another layer of clothing - I do wear a long-sleeved shirt and hoodie most days, because I do cool down just sitting still and wiggling my fingers at the computer.

Like much of the country this weekend, we got cold.  As most of our coldest temperatures are set during the third week of January, it was expected.  The big issue, though, is we're usually eased into it.  Our average high temperature this week is in the low twenties, but today is one of those where we'll most likely remain below zero.  It's not unusual, but coming after the warmer weather, well, it takes some getting used to when dealing with weather like this.  And most of us aren't.

Other than that, been busy with work.  Most of my work days last year started at 7:30 am, ran until 6 pm or so.  Over the last two weeks, I'd start at 7 am, and keep banging away on the computer until into the evening, 7 pm or later.  I also discovered that I had worked on a...  well, I suppose celebrity might be adequate.  Thanks to HIPAA, I won't tell you any more than that.  

But my work days are busy because of what I do and who I do it for...  So I suppose that deserves some explanation.  

Let's say that you're someone who has gone into the hospital because you're not feeling well.  Doctors have examined, treated, and determined that you're going to live, but you need some help.  I work with two primary locations and cover a few dozen others as needed and when my boss says "hey, this one looks weird, can you take a look at it?"  I get about two of those a day.

The idea is for me to spend my eight or more hours making sure that insurance companies provide us the very least little bit of assurance that we may be able to collect payment from them.  Like most of what happens today, the legal disclaimers and excuses would terrify anyone who had to read them from scratch, but I hear them with every phone call I have to make.  Fortunately, thanks to some major industry upgrades, I only spend about 95% of my day on the phone waiting to speak to someone.  It used to be 100%.

But when you come home from your imaginary hospital stay, the infection you contracted and ignored, figuring it would just "go away" - or more likely "well, I don't want to ask the doctor if this is going to turn out to be nothing" needs continuing antibiotics.  As I myself learned the hard way about fifteen years ago, oral antibiotics - you know, the pills and the like?  Yeah, those take up to 72 hours to build up in your body before they really start to work, and can take a lot longer to get rid of the infection.  If they can.  And due to infections these days being from all manner of strange bugs, there are a large number of antibiotics that are called on to whack the bug right out of you.  

Very often I'll see patients on courses of medication that run 30 days or longer.  So what I do is I take the prescription your doctor wrote and ask your insurance company if they will agree to pay my employer for the medication, and for the cost of the supplies to get that medication into you.  I don't deal with oral antibiotics, I do infusions - that is, stuff you see when a person on TV is laying in a hospital bed and they want you to know the patient is really sick, so there's a couple of bags or a machine on a pole next to the bed, with tubing running down and into a person's arm or chest?  Yep.  These days, instead of laying in an expensive hospital bed while you get 30 days of this antibiotic, we send people home.  Seems that people tend to get better sleeping in their own beds, eating their own food, not having people poke and prod them every four hours...  Yeah.  It works like that.

Because of the locations I have, I'm one of those lucky folks who has to quite often use an on-line tool to check those items.  Luckily, I do not have to check each and every item you need.  Most of the time.  I usually check what are called "kit codes" - that is, if you're hooked up to a bag of medication and it needs to get pumped into you four times a day, I have a fairly specific code, for most insurers, that tells both of us that you are going to need X number of needles, X number of doses of this, that, and the other, and would they please consider paying my employer for 30 days of that service to keep you alive?

That's an easy one.  There are far more complex services we provide, up to and including a service for folks who have extensive, serious intestinal problems.  Sometimes they come because of another condition - such as cancer - that can cause people's intestines not to work.  In many years past, this would mean the person would die.  You can't eat, you can't get nourishment and the vitamins and minerals you need to keep your body working, well, you're dead.  That's it.  A death sentence.  Or it was.  Now, fortunately, there's a particular medical treatment that takes various medical items, combines them, and puts it right into your bloodstream, just like your intestines used to - it feeds you the energy you need to get through the day.

That's one of the more complex services we do.  It took me a couple years to get comfortable with it, and I'm still not, entirely.  I spend a few minutes checking the various components, checking a list the insurance company has negotiated with my employer to say which items they'll pay for, and which items need to be individually identified.  When we do this sort of service, it typically start with a doctor who says "definitely not working properly" about the intestines and the transfer mechanism that gets that energy from the food into you.  The doctor usually gets a specially trained pharmacist and a dietician involved, who use some pretty complicated math and formulae to decide what you need.  Then they bring this down into a formula.  That formula typically tells me you're going to get so many grams of amino acids, so many grams of dextrose, so many grams of lipids, and some other trace chemicals.  Amino acids come from proteins, if I have my brain right, and the lipids are fats.  You might think "nope, fat is bad, keep it out."  Fat converts to energy.  Most of the people I see on this service tend to get somewhere around 50 grams of lipids a day, and not every day.  I've seen some folks with one day a week, I've seen younger folks with seven days a week.  Definitely children.

But I need to go to your insurance company, and instead of asking for every microgram of Magnesium Sulfate, Potassium Chloride, and every other element in your formula, I ask for a few codes.  The fat, those lipids, are usually counted in ten-gram units, the code is B4185.  If the patient is an infant, they may be getting a special kind of lipids which is B4187 - this can also be given to other people, though not often.  The Amino Acids are another can of worms, almost literally.  I've been doing this job long enough now to see a few trends, and one of those types of Amino Acid I see, something called Clinisol, used to be a real challenge, some insurers would pay us for it, some would not, some were not really sure.  Most often these days, for the organizations I deal with, they don't care.  That is, if you're getting it, that's fine.  Because when I ask your insurance company about paying for this service, aside from the lipids, the other thing they really care about is the overall volume.  They want to know if it's less than a liter a day, between one and two, two and three, or more than three liters a day.  There's a different code for each one of those levels, and the insurers want to know if it's going to be seven days a week, four days a week, or whatever your doctor and pharmacist have worked out.

The point of this, though, is that after I figure out what it is we're doing for you, I have to go back to that list of things that your insurance company says they'll usually consider paying for - and I'll refer to a tool.  Many of my current patients do not require individual authorizations for things like that.  Their insurance companies have figured it is less expensive for them if they very clearly explain what is covered, and if it's a confirmed benefit, then I check their list, and it tells me I do not need to submit a request for "authorization" - they don't need to know.

This makes my work year very easy for eleven months.  It's that first month of the year that gets difficult.  Because the way we do things is we know that if you're going to be changing insurers, it's usually around the beginning of the year.  Some folks, like my wife and I, change insurance during the rest of the year due to a job change.  Most folks, however, don't change all that often.  Now, mind you, there are often people who get coverage through an employer but due to their illness, they can no longer work, so they may start with one kind of coverage, and change to another kind.  

Regardless of why it changes, what really happens is that, if you're getting a therapy, we check your insurer's system and confirm whether authorization is needed or not.  If it's needed, I follow their process - which does tend to vary by company - and get some form of confirmation that we're OK to continue to provide your therapy, we'll get paid for it.  And when I do that, I have to enter a confirmation of what's been approved, if it was required, and what did not require approval, and when we need to check it again.

For some therapies, insurers will tell us "sure, for this prescription".  That is, they may approve your thirty days of the antibiotic.  If your doctor looks at your lab tests and decides that no, this needs to go on longer, you get another prescription, we send it to the insurer, they usually say "yeah, sure, doctor said so."  Some therapies, and some insurers, they're not that easy.  Others, hey, if they didn't need to provide us individual confirmation for the first 30 days, we're ok.  Those sorts of insurers we tend to record the approvals we get to last until the end of the current calendar year.  

Now, that means that if you're getting a therapy that continues over December 31, we got a lot of work to do.  I started January 1 with over 400 patients whom I had to check.  Check to see if their therapy was continuing or if it had ended.  If it was continuing, I had to go in and figure out how to get another authorization, or confirmation that authorization was not required.  Some therapies, and some insurers, will tell us "yes, sure, we'll cover that this year."  They know or expect the therapy to continue for most of the year if not all, they're good.  But I have to record that confirmation so we have another year to go.  

So that's why Januarys are typically busy months. As of when I punched out yesterday (yes, I worked Saturday after working 12 hour days all week long), I was down to under 50 patients I had to get authorizations for.  Many of them were missing what we call "face-to-face clinicals" - that is, a document where your doctor has said they saw you, they looked at your tests, and they've made the determination that this needs to continue happening.  An industry standard is we need documentation like this every twelve months.  Which makes sense.  If you're sick enough to need this kind of therapy, your doctor should be monitoring your progress.

Then there are some insurers who don't like that "what, it's been ten months since your doctor said this has to continue?"  I had one this past week where the insurer insisted they needed more current records, within the last ninety days.  Where, a few years ago, this sort of thing would have had me begging my folks who are in contact with the patient to get me updated documents, this past week, I took a look at everything - and noted that the doctor's signature on the prescription was very faint.  That it could be possible that the reviewers, who undoubtedly see many sorts of documents every day, may have slightly overlooked the existence of the signature.  

So in response to their fax requesting updated clinical information, I responded with 'are you refusing to accept documents from a visit four months ago?'  And I asked them to respond to me, the ordering doctor, and the patient with reasons why they are refusing my request.  Less than 24 hours later, the approval came in.  Now, mind you, had this been a very complex therapy, I'd most likely have sought more updated documentation, but I knew what I had, and I knew I was in the right.  I did flag the patient for further review so that our people that get the money from the insurance company can be sure we're getting what our contract says.  Because insurance companies that say things like this one did can be pissy when it comes time to write the check.  And rather than dump this sort of stress on a person who is trying to get through the day and survive, I'd much rather deal with it and use our professionals - including the people who collect the payments from the insurance company, who point out "look, we've followed all of your requirements, we have a contract that says you're going to pay us for this service, are you going to pay what you agreed to pay, or are there other steps we need to take?"  

Yeah, most of the insurance companies I get to work with due to the locations I have, they're good folks, easy going, and we don't have that sort of problem come up often.  And the difficult payers are getting smaller, which does make life a lot easier for us.  

So other than that, not a whole heck of a lot going on around here.  Dithering, trying to keep my blood sugars low enough that the doctor will be pleased with me eventually, and trying to keep the dogs from chewing anything else of value (the puppy got the forefinger of my right hand on the only decent pair of winter gloves I have right now), and stay ...  well, what passes for sane.  These days.  

Yep, I'm definitely full-on boring.  That's me.