Posted by: notdeaddinosaur | October 2, 2008

Yet Another Racket

When you go to see a doctor, whatever the specialty, it’s generally coded for insurance purposes as an “Evaluation & Management” service. If you need a procedure of some kind, the doctor may want to do it in a hospital or other facility, often the “Short Procedure Unit” as an outpatient. (Oh, did I mention that the facility then bills for the procedure too?) If you’re just going for the procedure, then it certainly makes sense to be seen in the facility setting, though as a general rule if you’re seeing the doctor for the first time for an evaluation (as opposed to, say, a gastroenterologist for a screening colonoscopy) they’re not going to know what kind of procedure you might need until they actually see you.

Several of our HMOs require us to write referrals for patients to see specialists, often including a separate one for the facility if there’s a procedure involved. No problem.

Here’s the problem: there’s a new specialist who works at a satellite facility of the hospital — presumably the location of his office — who requires that these HMO patients have referrals for both him and for the facility for every visit, including the initial evaluation.


We did the specialist referral for the patient, but when the guy’s office called for the facility referral, I went postal. I spoke with the specialist’s staffer (the doctor couldn’t be bothered, of course) and here’s what I got:

It wasn’t the doctor; it was supposedly the hospital’s policy (the one that owned the satellite facility.) All patients seen by him were charged both a doctor’s fee and a facility fee, so both referrals were needed.

What about self-pay patients? I asked.

“We don’t see self-pay,” came the answer.

It took awhile for me to pick my jaw up off the floor. Either that, or the girl had no idea what she was talking about. Clearly it was her job to just get that paperwork, and it didn’t matter much what she said or who she said it to in order to get it. I pointed out that I didn’t think the arrangement was legal. Her answer:

“Oh, it must be! The hospital wouldn’t do it if it weren’t.”

OMG! Um…yeah.

What a sweet deal for the hospital! Instead of just charging a fair market rental for office space, they get to charge a full facility fee for every patient seen in their satellite for every visit by doctors they’ve gotten to sign on to the arrangement.

I pointed out that my only recourse was to stop sending patients to that particular specialist. His staffer chippy suggested I talk to the hospital, since it was “their” policy. Right. Like anything I might say is going to change the way they do business, especially as long as they’re getting away with it.

Excuse me while I go puke.


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