A Look At My World...

I found a rather interesting article on CNN that does discuss a little bit of what I do for my day job. 

I suppose the world being the world today, I should note here that anything I say here has absolutely nothing to do with my employer.  I'm not authorized to speak for them, I sure as hell am not speaking for them, and my opinions here are backed up with the last six years doing the job.

The article lays out a little bit of what is happening in corner of the insurance industry that I'm in.  I deal with incredibly simple therapies, compared to most medical services.  I have nothing to do with surgery, diagnosis, or any sort of time-critical life-saving operations.  In most cases I am seeing the records of patients who are being released from a hospital after a stay to discover what ails them, and specialists at those hospitals will order and interpret the results of tests, and using their experience, write prescriptions for therapies that will keep patients alive and feeling better.  

I'm familiar with most of the companies mentioned in the article, and as a bit of a caveat, I deal daily with some of them.  I have access to a tool for Aetna that requires that I enter specific codes - that is, the codes that define the medication a person will get, and usually other codes that help define how often the patient will be receiving that medication.  Some times it's just once a day.  Some times it may be as often as six times a day - every 4 hours.  Some times it's just once a day - running all day long.  

What I do is enter those codes and get the results that tell me in 99.99% of the time, I don't need authorization.  Over the course of six years, I think I've seen maybe three people with a code that Aetna needed to review.  But you have to remember, I'm on the very low end of medical complexity.  Sure, there are things my employer does that look pretty complicated, but modern medical science is doing miracles that I have literally nothing to do with.  

Cigna, another payer I'm familiar with, has a web site that has a, last time I checked earlier this week, 396 page document listing most of the medical codes someone like me would need to use.  Out of that list (8 point type, but its a table that runs across the page, every code has at least one line of text, some have a dozen), maybe ten codes that I run into regularly need authorization.  Which is where it gets frustrating.  

Cigna used to have a portal where I would log in and provide the patient and doctor's information - the location I was working with for my employer was stored in my login for the web site, all I did was pick it from a list, so they had all of the information bits), then I'd select the medication (again, by code), tell the web site the start date, the end date, the size of the dose, number of doses a day, and then update a few other things, and wait.  Sometimes I'd get a response in minutes, other times it would take several days, but I'd usually get approval.  

These days, instead of using a computer and multitasking, I have to call a phone number, where I have to work my way through some pretty fiendish questions that will eventually get me to the right group, where I have to speak to someone, who will, very often, give me approval over the phone for an immediate 30 units.  Sometimes that means I've got thirty days of service.  Sometimes the patient is getting two medications that use the same supply code, so 30 units may only last 15 days.  Which means if the doctor has ordered two medications for six weeks (sometimes the case for some therapies), after two weeks I need to call back and get another thirty units, a process that often takes 20 minutes or more.  

You might think "well, ask for more" - and for some patients I do.  If it's going to be a therapy the patient gets daily, I will usually ask for six months of approval, or longer.  The balance there is that I then have to fax in documentation, hope that they don't manage to lose it (a process which means I call back the day after I fax and if they haven't gotten it, I resubmit, this time I'll also send the fax delivery report our system gives me when it confirms the fax has been received on the other end).  Cigna, being a large organization, means I never get a change to speak with the reviewer, sometimes I get a quick response.  After a week or so, I know they're dithering, so I call back, and press.  Sometimes I'll give up and get the 30 units immediately, and try again for the longer period.  Sometimes it's just not worth it.

But the deal is that these two are more often the exception to what I see.  There are some companies that have really changed their procedures over the past year.  One payer I deal with regularly now requires that any service for a patient is either requested by their Primary Care Physician, or PCP, as we call them in our shorthand.  If the PCP is unwilling or unable to order the service, the or there is the specialist who usually saw the patient, ordered and reviewed the tests, then decided what the patient needed.  If the PCP has not notified the insurance company they are asking a specialist for help (which in my world is called "A Referral") some payers will not even let me ask for authorization.

Some are so finicky that they'll tell me a referral will be needed if the address isn't exactly what they have on file.  I have had payers tell me a new referral is needed if part of the doctor's address is abbreviated where they have it written out.  The deal is that doctors are pretty busy people.  They've got a lot to do, a lot of pressure on them, and I don't know about you, but I know I haven't run into any real jerks.  And let's be honest - doctors these days are caught i a real bind, knowing their patients pretty well and yet being told by someone who's looked at a couple of sheets of paper or documents on screen that they are off their nut, the patient doesn't need that, or any other "expensive" therapy.  

The trick I've learned with some of these companies is to play a little dumb.  There's a tool we use that's called the NPI lookup.  NPI stands for, I think, National Provider Identifier.  It's a ten-digit number, and every doctor, nurse, hospital, pharmacy, pharmacist, and a bunch of other people/places have one.  I use that tool to confirm the doctor's name, NPI, practice address, phone number, fax number (if they provided one), and their specialty.  And just like the rest of us, if a doctor changes from one hospital to another, or an office, or whatever, they need to update the NPI.  I don't have one, so I don't know what that process is, but there are enough folks moving around that my trick is to provide the insurer the ordering doctor's name and NPI.  If it's one of those outfits that needs referrals, I'll say "well, I'm not exactly sure which address is the right one, but I'm OK using what you've got on file."  I've only had two people tell me that they couldn't do that, the beautiful thing is if they didn't, sure I'd end up back on 45 minutes of hold music to speak to someone else, but the odds were very good the next person would.  

The thing is, though, that I know there are some payers out there who do seem to delight in denying my requests.  They make it difficult to submit, the denial process is usually a black box type of situations, I don't know why, they'll use vague phrases like "not medically necessary" as noted in that article.  Anyone who's done my job long enough has seen it, and has had a hell of a time trying to get a straight story out of an insurer.  Now I know why that's happening.  They're gaming the system.  I'm sure I am too trusting when it comes to this stuff, I know there are doctors and other medical people out there who have chosen to game the system in such a way that people like me are now flat out required.  The bad actors have, in the past, bilked millions of dollars out of state Medicaid, and other programs  I've seen the aftereffects myself, where some state Medicaid programs require us to account for every single syringe, needle, 10 ml (milliliters) of sterile water, and etc.  Yes, I am an expert in completing forms and getting things like that approved - but I'm also a heck of a lot more familiar than I wanted to be with how to get forms completed, which means how to get the doctor to sign them in a timely fashion because, based on our business rules, I do my part, send the form over to the folks who can get the doctor to review, add their part if needed, and then provide their signature, and get the form back to me while it's still good.  

Some of those programs out there will deny a request if I submit it AFTER we've done the therapy (it is prior authorization, after all).  Some will deny an entire six weeks of authorization if we're one day into it.  Because I cannot modify the form once it's been signed by the doctor.  I mean, if I did, I might get an approval - but that's not how I do things.  I'm not going to break the rules, because I know that there are only three things you can lose once.  That's Life, virginity, and credibility.  Lie once, and people will be questioning you all the time.  

I'm not going to do that.  And fortunately, we no longer deal with some of those insurers, so I don't have to worry about it.  But the rest of the industry, well, there are about as many quirks out there in the system as there are people who need health care.  The important thing is that there are people like me who are careful, detail-oriented, and know what they're doing - and if we don't, we ask.  I've got a team at my employer who have worked with a lot of these insurers - I deal with the insurers in perhaps a dozen different states on a regular basis, some of those I'm very familiar with, while others I'm still learning.  That is the way it goes.  

Would I be sorry if the system changed?  A little tip - I've learned over the years that there will always be people of questionable ethics drawn to places where there's a great deal of money and opportunities to insert themselves into the process in various, sketchy ways.  I've got access to a lot of private information.  But the thing is that, a very very long time ago, I decided that my mental health would be far better off by being an honest man and not snooping into other people's business.  Unless it was part of my job description.

Which was why, more than twenty years ago, when I was asked by one of my co-workers why it was taking so long for her graphics being emailed to our professional printing house were taking so long to transfer, I went and took a look.  One of my jobs back then was managing the email server.  Which meant I needed to monitor the systems.  I found a couple of logs which would tell me what was being sent - not just the name and numbers, but the actual files.  Which was how I discovered that one of my coworkers had been sending my employer's upcoming advertising schedules to her boyfriend, who worked for a competitor.  That's what jumped out at me, when I scanned the log and saw large files being sent to an email address that ended in the competitor's domain.  

It did not take me long to look at the files, figure out what they were, then take the printouts of the logs and documents to my boss, who took me to the co-worker's boss.  And yes, I had to stand there while my co-worker got terminated.  I said nothing other than responding when my boss and my co-worker's boss asked me questions, and I said nothing when anyone asked why they were no longer with us.  I didn't lose too much sleep over it, because I'm pretty comfortable with my own ethics.  I do have lines I won't cross, even if asked or ordered by a supervisor.  I'm not going to go rob a bank, for example, but I'm also not likely to work for an organization that will ask me that, either.  

So yeah, the medical industry has it's weird and strange rituals.  I happen to work in one of the corners where I get to be a good guy.  As I've told more than a few people, I've been the father next to the new-born baby in the Neonatal Intensive Care Unit, I've been the husband waiting for the wife to come out of surgery, and the guy in the hospital bed, hoping to get out, if the authorization comes through in time.  So I know what some of my patients are going through, and I'm going to do my best not to let them down.  Or my employer.  And fortunately, those folks tend to be on the same side, so that makes it pretty easy on me.  I'm no great hero in this story, I'm just the guy who spends an awful lot of time waiting around for the insurance company to get me an approval.