Are you a pill mill?

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A guys calls the office and asks if we accept insurance. Receptionist says yes, which company? The guy says UHC. She tells him we do accept UHC.

He then asks if we are a pill mill. She says no.

+click+

Does anyone really expect a pill mill to say "yes"?

Darn, the one that got away, would have been so much fun

Originally Posted by Mister Mxyzptlk

A guys calls the office and asks if we accept insurance. Receptionist says yes, which company? The guy says UHC. She tells him we do accept UHC.

He then asks if we are a pill mill. She says no.

+click+

Does anyone really expect a pill mill to say "yes"?

I think that was the FBI. You answered correctly, it's all good

Tell Joanne to give me a call back.

Originally Posted by Mister Mxyzptlk

A guys calls the office and asks if we accept insurance. Receptionist says yes, which company? The guy says UHC. She tells him we do accept UHC.

He then asks if we are a pill mill. She says no.

+click+

Does anyone really expect a pill mill to say "yes"?

That's hilarious! I guess some people don't realize it's a derogatory term...

That is funny!!!!!!!

Originally Posted by 101N

I think that was the FBI. You answered correctly, it's all good

I don't hear of DEA agents ( or the Canadian version - whatever that is) busting in on docs 5-0 styles. Maybe I lead a sheltered life.

However, I have heard one ridiculous story that I'd like to share with the class:

An Canadian doc with dual citizenship goes to the US and sets up shop. He starts to sell scripts , gets busted by 5-0 , and is sentenced to 3-4 years in prison and license is revoked.

What does he do ? Why, goes to Canada - where he gets a monitored license.

Once the monitoring period is over he starts selling scripts again. Gets busted again. He's now serving out a 7 year prison sentence courtesy of her majesty.

What was the person thinking who gave him his Canadian license ? WTF ?? Someone at the MD regulatory comission looks pretty darned stupid.

Originally Posted by Mister Mxyzptlk

A guys calls the office and asks if we accept insurance. Receptionist says yes, which company? The guy says UHC. She tells him we do accept UHC.

He then asks if we are a pill mill. She says no.

+click+

Does anyone really expect a pill mill to say "yes"?

You should have your receptionist say,

"Yes, in fact we're an NSAID mill", and see how many say, "Awesome! I'll be right over."

Originally Posted by Mister Mxyzptlk

A guys calls the office and asks if we accept insurance. Receptionist says yes, which company? The guy says UHC. She tells him we do accept UHC.

He then asks if we are a pill mill. She says no.

+click+

Does anyone really expect a pill mill to say "yes"?

Whoaaaa, facepalm !

Had a narc paper review today:

Guy with a distant hx of HNP , titrated up to 880 mg of Oxycodone / day. Significant risk factors with an opioid risk score of 8.

Psychiatry prescribing the narcs, as the pt has a hx or bipolar d/o. Why psych is doing this I don't have the foggiest.

UDS ? Nope.

Pill counts ? Yeaaah, right.

880 mg / 40 = 22 tabs / day. That's a lot of scrilla on the street.

Originally Posted by ghost dog

Whoaaaa, facepalm !

Had a narc paper review today:

Guy with a distant hx of HNP , titrated up to 880 mg of Oxycodone / day. Significant risk factors with an opioid risk score of 8.

Psychiatry prescribing the narcs, as the pt has a hx or bipolar d/o. Why psych is doing this I don't have the foggiest.

UDS ? Nope.

Pill counts ? Yeaaah, right.

880 mg / 40 = 22 tabs / day. That's a lot of scrilla on the street.

based on the language of your posts your avatar should be ali g not borat

Originally Posted by ghost dog

Whoaaaa, facepalm !

Had a narc paper review today:

Guy with a distant hx of HNP , titrated up to 880 mg of Oxycodone / day. Significant risk factors with an opioid risk score of 8.

Psychiatry prescribing the narcs, as the pt has a hx or bipolar d/o. Why psych is doing this I don't have the foggiest.

UDS ? Nope.

Pill counts ? Yeaaah, right.

880 mg / 40 = 22 tabs / day. That's a lot of scrilla on the street.

We have a shrink-a-toony round this area that also writes large doses of methadone > 100mg/day, mostly for pain.

Originally Posted by jsaul

based on the language of your posts your avatar should be ali g not borat

Great success...not !

Narcs at this dose ... why not put them under a GA 24 / 7 ? Almost as expensive.

Anyone seen " the dictator " yet ?

The Dictator: You are HIV Aladeen!

Originally Posted by ghost dog

What was the person thinking who gave him his Canadian license ? WTF ?? Someone at the MD regulatory comission looks pretty darned stupid.

I can guess what happened. They probably had an office of 5 people who are responsible for approving medical licenses to thousands of applicants. Ergo, they dont do proper background checks and idiots like this slip through the cracks. These agencies are hamstrung by poor staffing and they rely on self reporting. If people lie on their applications its difficult for them to discover it unless it is something blatantly obvious that they can spend 5 minutes verifying (i.e. prior prison stay).

I just spent a few months and several thousand dollars getting a Texas medical license, even though I dont have any red flags on my application. They have a staff of 7 people who are responsible for verifying apps for over 25,000 new applicants and recerts every year. Thats freaking insane.

Originally Posted by Socrates25

I can guess what happened. They probably had an office of 5 people who are responsible for approving medical licenses to thousands of applicants. Ergo, they dont do proper background checks and idiots like this slip through the cracks. These agencies are hamstrung by poor staffing and they rely on self reporting. If people lie on their applications its difficult for them to discover it unless it is something blatantly obvious that they can spend 5 minutes verifying (i.e. prior prison stay).

I just spent a few months and several thousand dollars getting a Texas medical license, even though I dont have any red flags on my application. They have a staff of 7 people who are responsible for verifying apps for over 25,000 new applicants and recerts every year. Thats freaking insane.

But DOOD: He had a MAJOR red flag : he had a prison record in the US as a result of opioids. You don't get a bigger red flag than that !

I hope someone in regulation got their ass fired over that boner.

Big pill mill bust in Florida today:
http://www.foxnews.com/us/2012/06/27...cipal-workers/

Hopefully none of you guys got pinched.

It's amazing that these large pill mills even exist. They must go to great lengths to conceal themselves, but still...

Originally Posted by facetguy

Big pill mill bust in Florida today:
http://www.foxnews.com/us/2012/06/27...cipal-workers/

Hopefully none of you guys got pinched.

It's amazing that these large pill mills even exist. They must go to great lengths to conceal themselves, but still...

Conceal themselves? The advertise in newspapers, ad magazines, phone book. The last time I was in Fl, I looked in the yellow pages. There were more pain clinics than PCPs. One had a hand-drawn picture of a sexy nurse in a short skirt. A definate class-act.

Not quite pill mill, but interesting. I didn't realize some docs (besides onco) were dispensing meds directly, for a big markup of course:

http://www.nytimes.com/2012/07/12/bu...pagewanted=all

“We did not institute this because of the money,” Dr. Marc Loev, a managing partner of the Spine Center, a chain of clinics in Maryland, testified last year at a public hearing in Baltimore. “We instituted it because we were having significant difficulty providing the care for workers’ compensation patients.”

Uh, yeah.

Originally Posted by facetguy

Not quite pill mill, but interesting. I didn't realize some docs (besides onco) were dispensing meds directly, for a big markup of course:

http://www.nytimes.com/2012/07/12/bu...pagewanted=all

“We did not institute this because of the money,” Dr. Marc Loev, a managing partner of the Spine Center, a chain of clinics in Maryland, testified last year at a public hearing in Baltimore. “We instituted it because we were having significant difficulty providing the care for workers’ compensation patients.”

Uh, yeah.

We do that for WC pts.The amount paid is specified by law, so we get paid less than what the pharmacy would get paid, since the company that administrates the program takes a cut (of course). But it adds to our ancillary income.

Alternatively we can give a pt an Rx, they go down to Walgreens, fill out a form, hand it back in, go home and wait for that form to be faxed to the insurance adjuster, approved and faxed back. That literally can take days in some cases.

I see this as no different than having your own x-ray, MRI, PT, lab, ASC, whatever. If you invest in the infrastructure, why should not the doctor be able to make the money that is going to be spent anyway? Why should it go to a different for-profit company?

Yes, there is the risk of excessive self-referral. In WC, companies will cut you off if they feel you are doing that.

The days of doctors buying yachts off pt exam fees is long gone. E&M collections don't even cover my overhead. Medicare injections under fluoro often pay less than $100. Medicaid in my state is $2B in the red, and 9-12 months behind in payments. All the private companies are starting to require precerts for every procedure and script you write. Get paid for what you do is getting quite challenging.

If it weren't for ancillary income, our overhead would be around 65%. With it, it's less than 20% of collections.

If it weren't for ancillary income, our overhead would be around 65%. With it, it's less than 20% of collections.

More power to you. Let's cut out the middle men and run Obamacare ourselves. If we can't repeal it on 11/6/12.

I find physician dispensing morally bankrupt and solely for profit at the expense of quality care. Once you know the profit margin on the opiate, SMR, NSaid, and other adjuncts- there may be a bias to Rx those drugs, more of them together, and in higher quantities.

I believe this phenomenon occurs in every md owned dispensary. Except yours of course.

Originally Posted by lobelsteve

I find physician dispensing morally bankrupt and solely for profit at the expense of quality care. Once you know the profit margin on the opiate, SMR, NSaid, and other adjuncts- there may be a bias to Rx those drugs, more of them together, and in higher quantities.

I believe this phenomenon occurs in every md owned dispensary. Except yours of course.

This is a slippery slope. Do you think it is wrong for physicians to have ownership of imaging centers, ASC's, hospitals, and PT? Medicine is business - big business - but that doesn't mean that it's automatically immoral.

Originally Posted by lobelsteve

I find physician dispensing morally bankrupt and solely for profit at the expense of quality care. Once you know the profit margin on the opiate, SMR, NSaid, and other adjuncts- there may be a bias to Rx those drugs, more of them together, and in higher quantities.

I believe this phenomenon occurs in every md owned dispensary. Except yours of course.

OK, Mr. Holier than thou...another business that you don't agree with and you consider
" Morally Bankrupt"

Our large family groups in town now dispense their top ten most prescribed medicines in their office...Why
[url]http://www.nytimes.com/2010/05/20/health/20chen.html (short story-Rx noncompliance on filling is close to 20%)
-will they make $ ?....maybe they project an extra 10K a year per doctor... is this a bad thing?

You apparently don't own your business or you wouldn't be so quick to bash others' business models.

I know your motto is ETHICS>PROFITS, but it seems to me you start more blogs about the "expensive" gadgets you own than anyone else on this blog and you are not purchasing those things on a $150K salary a year

Originally Posted by lobelsteve

I find physician dispensing morally bankrupt and solely for profit at the expense of quality care. Once you know the profit margin on the opiate, SMR, NSaid, and other adjuncts- there may be a bias to Rx those drugs, more of them together, and in higher quantities.

I believe this phenomenon occurs in every md owned dispensary. Except yours of course.

Do you also feel the same way about physician owned ACSs, hospitals, and imaging centers?

Strikes me you are impugning the the morals of all physicians, rather than only those with greed as their prime motivator.

Seems like it could be considered an invasion on pharmacists' turf. Plus, the pharmacists I'm friendly with say they have to correct physician scripts all the time. Cutting out the pharmacist seems potentially dangerous for the patient.

Originally Posted by lobelsteve

I find physician dispensing morally bankrupt and solely for profit at the expense of quality care. Once you know the profit margin on the opiate, SMR, NSaid, and other adjuncts- there may be a bias to Rx those drugs, more of them together, and in higher quantities.

I believe this phenomenon occurs in every md owned dispensary. Except yours of course.

When they run the numbers and compare docs, there is a lot of room for improvement in utilization of the med dispensing at our clinic. Most of our docs are significantly under-utilizing it, even after 3-4 years of having it.

As a physician who owns an ancillary service, you must constantly question yourself if you are prescribing this more for your benefit or the patient's. Would you have prescribed this if you didn't get the profit?

The same thing goes for every treatment you recommend that you get paid for - injections, for example. We all know many docs who give everyone a "series of 3" ESIs that only the serves the purpose of making money for the doctor. It is very easy to recommend treatments you get paid for, whether the patient needs them or not.

how does the cost of medication compare to an outside pharmacy?

if the physician is dispensing, and they are charging the exact same price as a pharmacy, personally that seems to be less concerned with profiteering than, say, some of the cancer physicians who charge significantly increased cost.

the other aspect of this situation that concerns me is opioid prescription therapy. i dont know, but to be a physician that dispenses oral meds... that goes beyond the slippery slope, given the abuse potential.

Originally Posted by Ducttape

how does the cost of medication compare to an outside pharmacy?

if the physician is dispensing, and they are charging the exact same price as a pharmacy, personally that seems to be less concerned with profiteering than, say, some of the cancer physicians who charge significantly increased cost.

the other aspect of this situation that concerns me is opioid prescription therapy. i dont know, but to be a physician that dispenses oral meds... that goes beyond the slippery slope, given the abuse potential.

One Family Doctor gave me an example of Keflex for a 7-10 day script, Pharmacies charging close to $100 where they charge $20 .

NO one here has opioids in office

I think it is a bad idea for physicians to own their ancillary services.
Any ancillary services. Too much greed, and more so in pain medicine.

Several times a day I tell patients that we will not do a series of 3, we will not do an epidural for axial neck or back pain. I rip into folks all day who do what's profitable and not what's best for the patient.

There is too much pressure on physician ownership to overutilize.

My expensive toys include a 2007 Subaru STI, a 1978 Jeep J10 pickup, and a brand new Kia Optima (I splurged coming from the $168/mo Forte Koup). There are folks here who have watches costing more than my cars.

I am paid to be holier than thou by insurance, third parties, state agencies, and the DEA.
Walk the walk and talk the talk.

I have firsthand experience in time after time physicians doing the wrong thing for the worst reasons. MRI's, EMG's, VNG, WC pharmacy, etc. I like the idea of a Subway franchise or something outside of medicine to try and make my money earn money. For the time being I'll keep paying off student loans and the mortgage.

Hmm...

http://www.medassoc.com/Services/Dia...nt%20Page.html
http://www.medassoc.com/Services/Phy...apy/PTHome.htm
http://www.medassoc.com/Services/Nor...nEndoscopy.htm
http://www.stevenlobel.com/procedures.html

Originally Posted by 101N

Hmm...

http://www.medassoc.com/Services/Dia...nt%20Page.html
http://www.medassoc.com/Services/Phy...apy/PTHome.htm
http://www.medassoc.com/Services/Nor...nEndoscopy.htm
http://www.stevenlobel.com/procedures.html

Thanks for the ad support. I do not get paid for any ancillary services and I am not a partner nor owner. I love my workplace and work with great doctors.

And click on my procedures link and check the reference to the series of 3 embedded in the page. Nice!!!

But my site needs updating. Google my name and you'll find old jeep references, lots of subaru stuff, etc.

Timely.

http://www.msnbc.msn.com/id/48158693...ers-taxpayers/

[QUOTE=lobelsteve;12788199 I love my workplace and work with great doctors.

[/QUOTE]
I think it is a bad idea for physicians to own their ancillary services.

You practice exists because the partners that RUN your practice realized that the only way they can survive and offer your services is by having ancillary services.

Originally Posted by 101N

I think it is a bad idea for physicians to own their ancillary services.

You practice exists because the partners that RUN your practice realized that the only way they can survive and offer your services is by having ancillary services.

Originally Posted by lobelsteve

Thanks for the ad support. I do not get paid for any ancillary services and I am not a partner nor owner. I love my workplace and work with great doctors.

.

I guess if you feel so strongly about it you can take a pay cut and give the money to your partners so they don't have to rely on ancillary income

Originally Posted by lonelobo

I guess if you feel so strongly about it you can take a pay cut and give the money to your partners so they don't have to rely on ancillary income

I'm fairly certain I could readily double my income if I owned and ran my own business. The only problem would be the doubling of work hours to run the business. I see all that extra revenue generated by my work product going to the partners who have taken that risk in owning and running a large practice. I work M-F 730-430, no weekends, no call. I get a paycheck every 2 weeks. It is ample enough to live comfortably and take care of my family.

I do like to pretend I know nothing about business and care nothing about the business of medicine. I have seen the worst of the worst, and instead of walking the middle of the road, I've taken the high road. I do as little as possible for each patient to ge them to their functional goals. I tell them if I am not aggressive enough for their tastes, I can always ramp up care to meet their expectations. I am happy with the way my practice is run and enjoy reading about your criticism. This may not make me a better pain physician than you, just a better person.

i agree with your post, but that last line made me think...

to quote Ted Turner: "If I only had a little humility, I'd be perfect."

I am sure you are a "better person" than everyone on this blog.....good majority of your posts remind us of that "fact"

Originally Posted by lonelobo

I am sure you are a "better person" than everyone on this blog.....good majority of your posts remind us of that "fact"

I'm not better than everyone here. Just a lot better than you. But that's your problem, I can live with it.

Originally Posted by lobelsteve

I'm not better than everyone here. Just a lot better than you. But that's your problem, I can live with it.

I feel sorry for your wife must be saint, she has to listen to your crap 7 days a week... I on the other hand can just log you off.

So lets get to some of the hair-splitting on ancillaries:

Most docs would probably say that if you do it yourself, it's not-self referral, it's what you do. So a pain doc seeing a patient and then doing the LESI themselves would not count. Or would it?

Ok, maybe it's because it's therapeutic, so you can do it yourself and remain ethical. But what about diagnostic blocks? MBB, nerve block, similar. Those are not usually therapeutic, but may lead to a theray.

So if diagnostic things you do yourself are ok, what about EMGs? Most physiatrists do them themselves, and if they see a patient who needs one, they do it. Is that self-referral? Is that "Ancillary income?" Hmm, getting a little more grey now.

What about the neurologist who uses a tech to do the NVS and then does the needle himself. He's referred something to someone else in the clinic that he does not do, and is making money on it. NCS is billed as a seperate code form needle EMG.

Take it a step farther. Ortho has a PM&R in the office and orders EMG/NCS to do be done. Is this ancillary? What if the PM&R only comes in on Tuesdays to do it?

No we are getting quite into shades of grey. That same orthopod has xray in his office, because 90% of his patients need xrays. Is that ethical? Should he send all his patients out after he puts a cast on them and have them return later in the day or another day while they go across town for an xray? I don't know anyone who would consider in-office xray unethical. But maybe, just maybe...

So if the ortho can have xray, can the physiatrist in the office use it and make money. Few PM&Rs have xray when they are in solo or small group, so this would certainly be ancillary. Should he send these patients out, just to be sure to avoid a conflict of interest, when his partner has the xray in the office?

What about the hand surgeon who hires his own OT so that he knows his patients are getting the exact therapy he wants. Bad? Unethical? Greedy?

We are now getting further and further away from services the doctor performs himself, but it is still looking grey to me. Maybe not to others. Others might say, nope, that's greedy. But is it?

How about the PCP who sets up a lab in his office? Greedy or offering a service to his patients to save them time and paperwork?

What about the GI who does scopes in his own office instead of at the hospital, hiring/contracting with an anesthesiologist? Is that greedy or unethical? He'll get paid more in his office most likely.

I could go on forever, ut my point is, where do you draw the line? It's not always back/white.

I think the line is crossed when physicians start performing the duties of an already existing profession, pharmacy in this case.

There's also the whole monopoly thing our government seems to dislike.

Originally Posted by lonelobo

I feel sorry for your wife must be saint, she has to listen to your crap 7 days a week... I on the other hand can just log you off.

1+

http://www.urbandictionary.com/define.php?term=blowhard

PM&R, the examples you give are all of a physician referring a patient to a different provider who then performs a procedure. the physician charges a set fee based on what that patient's insurance will pay.

an in-office pharmacy is different, inasmuch as the physician charges an huge markup (stocking fee, etc.) to generate a profit.

of the examples you give, the most appropriate one to these profitable in-office pharmacy might be this: an ortho doc sees patients, and orders xrays to be done in office, "because if you go to the other xray place it will take 3-5 days before they can get it done with your WC insurance". He then charges 3 times the typical amount a radiologist can bill, and gets paid for it.

Originally Posted by Ducttape

PM&R, the examples you give are all of a physician referring a patient to a different provider who then performs a procedure. the physician charges a set fee based on what that patient's insurance will pay.

an in-office pharmacy is different, inasmuch as the physician charges an huge markup (stocking fee, etc.) to generate a profit.

of the examples you give, the most appropriate one to these profitable in-office pharmacy might be this: an ortho doc sees patients, and orders xrays to be done in office, "because if you go to the other xray place it will take 3-5 days before they can get it done with your WC insurance". He then charges 3 times the typical amount a radiologist can bill, and gets paid for it.

The only way anyone gets paid 3x someone else's rate is on PI cases. All other rates are based on the payor's fee schedule. The only caveat is if the group is so large that is has market power to leverage a higher rate, but that is generally not the case.

Originally Posted by ampaphb

The only way anyone gets paid 3x someone else's rate is on PI cases. All other rates are based on the payor's fee schedule. The only caveat is if the group is so large that is has market power to leverage a higher rate, but that is generally not the case.

and that is why, in my mind, those above examples are not the same as an in-office pharmacy making significant profit.

My point was, the ortho doc doing an in-office x-ray on a WC patient may charge 3x as much as the imaging center, but gets paid the same amount. WC has a set fee schedule, regardless of who takes the x-ray, or where it is done.

Originally Posted by ampaphb

My point was, the ortho doc doing an in-office x-ray on a WC patient may charge 3x as much as the imaging center, but gets paid the same amount. WC has a set fee schedule, regardless of who takes the x-ray, or where it is done.

Thats interesting. I'm now seeing a few orthopds that take an xray somehow and do the 'interpretation' in their office. w/o a radiologist. To me that seems like they are opening up themselves to some liability, if they miss something.....

Originally Posted by PinchandBurn

Thats interesting. I'm now seeing a few orthopds that take an xray somehow and do the 'interpretation' in their office. w/o a radiologist. To me that seems like they are opening up themselves to some liability, if they miss something.....

Orthopods don't miss anything EVER!!! Didn't you learn that in med school

Originally Posted by PinchandBurn

Thats interesting. I'm now seeing a few orthopds that take an xray somehow and do the 'interpretation' in their office. w/o a radiologist. To me that seems like they are opening up themselves to some liability, if they miss something.....

We've been reading our own xrays for many years. If I'm not sure about something I have about 50 other eyes to run it by. If really neccesary, I can send it to a rads group for a read as well. Then the pt gets pissed off when they get yet another bill. Turn-around time for a typed report is about 48 hours with the rads group.

"So doc, is my leg broken?"

"I don't know Mr. Smith, this big gap in the bone is confusing to me. Let me send this out and get back to you in a couple days..."