Healthcare is a business, but often not for the right reasons. To ensure survival, any business needs to review outdated processes regularly, identify scope creep and corporate bloat, and introspectively consider its value proposition, goals, customer satisfaction, and employee engagement.
It's fair to conclude that healthcare is lacking in many areas. We need to have an honest conversation.
Let's begin with the cost of services. We have created a perfect storm of billing, reimbursement, and health insurance. This past week, I can see why administrators are pricing themselves and their patients into the red, and patients and healthcare providers are equally frustrated.
Let's Discuss:
For months, I waited to see a specialist. I arrived prepared and proactive about my care. I fulfilled my part of the arrangement; however, the group did not. If you schedule an appointment with a specialist, why are you met by a PA? Why do you enter a 20-minute or shorter appointment to review imaging, only for the PA to take notes, be unable to make decisions, and then repeat it all to the MD? Why do we dilute an already brief meeting, causing frustration for the patient? There is a time and place for everything, and I believe these types of meetings should be evaluated on a case-by-case basis. Are we double billing? Split billing? What are the rules? The language suggests that the PA/NP is doing most of the work; however, the MD must do 50% of it. Stay with me, and the "rules" are below:
I have observed the widespread use of PAs and NPs in large surgical practices and hospital groups, including students. I understand both perspectives, particularly when the surgeon is occupied in the operating room. Nonetheless, I believe patients should have a voice in the matter.
If you are getting your car fixed, you pick the mechanic.
For the record, I've encountered highly competent and effective PAs and NPs, and I'm not questioning their roles, skills, and contributions. However, in some instances, if you've arranged to see a specific MD, that is who you should meet with.
Stay with me. To be clear, I'm talking about an orthopedic practice.
Let's begin with the sell:
In the fall of 2024, I meet with the referring physician, and the meeting goes well. A history is taken, and the physician orders new imaging. I already know my spine is messed up; however, I am looking for a wild pitch of a "new" approach to help them.
Enter insurance and pre-approval.
Some time passes, and the imaging gets approved. I choose an imaging center and get the MRI.
They schedule a review with the ordering doctor and expect to review the results with the ordering physician.
I enter the exam room and am greeted by a young PA who does not introduce themselves. I ask where Dr. X is. The PA states they are helping him and proceeds to ask, "What brings you in?" Huh?
Reset the clock; wait, you can't.
I move past the fact that I'm not seeing Dr. X and review my extensive history again. Enter Dr. X. But now that the clock is running out, you just go with it.
The clock is running out, so they will not review the films with you and will only read the impression I already reviewed because I take ownership of my health.
FRUSTRATION
The MD, Dr. X, says you need to meet with his colleague, Mr. Pain Management. But you have gone down this road before and said that in the first meeting. I am an open-minded patient, so I agree.
More time passes
When the pain management appointment arrives, I feel like I might be participating in Groundhog Day, but I go anyway.
The plot changed again, and I was met with an NP. Again, I re-litigate my history, and they do not have my images. The NP is making appointments for Mr. Pain Management.
I politely ask, "I thought I was meeting with Dr. Pain Management." The NP politely says he is not in the office. The NP is compassionate and attempts to roll with it.
I spend 20 minutes explaining my history a 3rd time and am back to the beginning. I asked about the cortisone shot that I was told you would get in my hip in the first evaluation, and they said to schedule it the next time.
I left frustrated with the schedule.
Let's look at the billing:
What is Denial Code N476? Remark code N476 indicates that the claim was processed with issues due to an incomplete or invalid completed referral form.
M52
A reduction of 1-2% was applied to the provider payment for these charges. This payment reduction does not affect the amount shown under 'Your share'. [M52]
MAGNETIC RESONANCE IMAGING
Service Date: Feb 14, 2025
Amount billed
$1,044.00
Total cost approved
$0.00
Plan's share
$0.00
Your share
$0.00
Notes
M38
Your provider should have preauthorized this service and shouldn't bill you. You don't have a next step at this time. [M38]
The above is only for the first appointment; the MRI was denied. I fully understand the "system" and do not panic; I won't be writing a check for the MRI.
I called to schedule the recommended appointment with Dr. Pain Management, but they could not do so because the insurance underpaid your claim.
Now, imagine you really need help and do not understand how to navigate this business. Who are you mad at? Who suffers? How do we improve the outcome and experience?
Let's start with the group holding up their end of the transaction versus wasting time adding more appointments to the timeline and increasing the billing.
Now, pretend it is a more critical diagnosis, not just orthopedic. What happens to the patient because they began the journey in 2024? What if it is cancer? What if it is mental health?
Why does it take the 4th appointment or transaction to get "help?"
Whether we want to admit it or not, ideally, insurance has now paid 4x, but you have been participating in Groundhog Day.
Let's remove the patient from this equation. Where are the expenses to the group? What are the costs to the insurance policy? Oh, wait. There are mistakes. Whose responsibility is it to fix them? The patient.
I am sharing this to emphasize that change and transparency are necessary in every aspect. The sooner we electively admit it, the better. This will require the entire system to be redesigned, and brave people will have to speak up. I can recreate this timeline with any diagnosis, and it only gets worse.
The blame game isn't working for anyone.
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