Managed Care Medical Miasma

Article excerpt

From within the miasma of managed medical care, the diagnosis is trouble ahead: A man scheduled for an outpatient examination procedure at a large, well-regarded Washington area hospital is called the day before and told he will need an updated referral even though he pays extra for insurance so he can select physicians without referral.

The patient tries to explain why this isn't necessary under his insurance plan, to no avail. His medical insurance company, a major national firm, offers at the hospital both an HMO or health-maintenance organization (mandatory referral) and higher-priced PPO or preferred provider organization (with patient options). Evidently, the hospital can't distinguish between the two plans operated under one company. The specialist's office calls the HMO, not the PPO, and is told "get a referral," so a referral is demanded, even though the patient is covered not by the HMO but by the PPO.

The preprinted referral notices used by the hospital carry the address of the HMO, which operates from different offices in a different city than the PPO. This creates billing confusion and payment delays, even though correct billing information is provided on the patient's insurance card on file with the doctors, and on the pretreatment forms and in the central billing office. But sometimes the billing office punches in the first thing that pops up, and off it goes in a wrong direction. It takes follow-up to prevent deadbeat status.

But to avoid delays, since he has been told he will need a referral before the procedure can begin, the patient calls his primary care physician's office in the internal medicine department of the same hospital complex. That office later calls back to assure him a new referral has just sent to the specialist.

The morning of the procedure, the patient logs in at the reception desk and provides all his insurance data. His card is photocopied for the file again. All is going well, until the patient, already unclad on a gurney, is asked about his referral. They don't have it.

After much ado and an hour's delay or more, a nurse in the specialist's office at last finds it, in a clinic pigeonhole in another part of the complex. This even though the referring office had been asked to fax it to a specific phone number. Flushed with victory, the nurse who fetches the form says, "I had to speak to five people, but I finally tracked it down."

To prepare for this procedure, the patient had to fast for about 32 hours and consume a gallon of solution to flush his system. "I don't know what kind of insurance you have," the nurse explains. "But we are required to get referrals on everyone before even starting a procedure. …