Today I got to experience a "chart audit" by Blue Cross. This is where BCBS sends me a registered letter informing me that they want to look at some of my patients' (and their insurance holders') medical records. They go through the records to see if my documentation of the visit justifies the charges they got. The trick is that they send the records to their physician reviewers and if the charges aren't justified in their view then they reject it and want me to give them the money back. Assuming they'll decide that some amount of the charges aren't justified, they'll give me an opportunity to appeal, but it'll still go to some "physician reviewer" (who may get bonuses for rejecting claims, as documented by Linda Peeno MD in SiCKO) who will just re-reject them. I asked one of the people who came to collect all the records what happens if they demand all the money back and the answer is that I just get nothing: I can't bill the patients, I just spent that time for nothing. Let's be clear: no matter how much time I actually spend with a patient and document clearly in my records and precisely, they can decide that it wasn't justified and demand the money back, regardless of how much benefit the patient got. In that circumstance, I would be better off working at McDonald's to pay my bills. At this point, they've only asked for a few patients' records for 8/06 to 7/07. If they decide that they don't want to pay me for those visits... I'm having enough trouble paying the bills now. What's to stop them from deciding, "hey we concocted reasons to deny a bunch of claims and got a bunch of money back, let's get more!" Can they eventually go back over the the whole past year and retroactively deny those claims, too? This would mean that any payment I get from BCBS PPO would need to be held in trust for 18 months in case they decide to pull their money back. This is a risk of taking any insurance. Medicare can be even more risky: if insurance decides I did something against their inscrutable rule-books, all they can do is demand their money back. If medicare decides something I did somehow violates their volumes of arcane tomes, I can go to jail. So why would I be so dumb as to set myself up for these risks? Is it that it's the only way I can get patients and get paid? No, I'm booked up for 4 months to get in to see me as a new patient. If some patients don't come because I'm not in their network, I'll still be fine. It's because my patients will lose out. The patients who can't afford to pay out of pocket or who can't afford the higher co-pays for out-of-network will get thrown back to the 6 minutes for a prescription and get-out-of-my-office treatment that is becoming the standard of care these days. Why did I even bother to appeal the last decision to kick me out of their PPO? For these patients who wouldn't otherwise be able to see me. Let me tell you about one of my early patients, a young lady who have been developing upper respiratory infections so often that she was going to the ER monthly. She had gotten to the point where she was allergic to just about every antibiotic, so there was nothing the doctors could do to help her. Her mom brought her in to see what other options she had. We tried some IV vitamin C and it worked fantastically. I was a bit nervous about using it in someone so young, so I started with small doses, and she got a little better but it would come back. I progressed to larger doses and got the infections to clear up. It worked so well, in fact, that her grandmother told me that the only side effect of the IV vitamin C treatments was that her eczema would clear up. Once we got the infections under control, we did some searching for the reason for her problems and found that she had several food allergies. Taking her off those foods kept her from getting sick and now she gets sick less often that the average kid. She hasn't been back to the ER since her first appointment with me, over two years ago, saving the insurance considerable money. She is one of the patients who will lose out. She's can only see me via the SCHIP program in Michigan called MiChild that allows working people who can't afford insurance to get their kids into BCBS PPO.
However, it has become clear that if I continue to subject myself to insurers' whims, I will be forced out of business and won't be able to help anyone. My days of participating in insurance are coming to an end.
