Getting after hours urgent referrals approved

[flightdoc09]

Was recently on a field op to a remote area, and I needed to get a patient to see an opthalmologist in a town nearby. I could have sent them to the ER, but optho never goes to the ER, especially for what this guy's injury was. And the optho office was asking if the referral has been approved or not. Long story short, after hours of phone calls the patient ended up not even going to the appointment. But all I could do was place an urgent/stat referral in Genesis and tell the optho clinic that the referral has been placed.

1) If a patient needs a specialist, and I document the need in a note, can they see the specialist and get reimbursed by Tricare later?
2) How can I get a referral approved urgently after hours?
3) Any tips on how to navigate a situation like this?

I tried calling the referral management office at the hospital, but they don't pick up their phone. I called the appointment line number, and they said all they could do was send me to the same phone number I had already called. I tried calling Tricare directly, but after over 30 minutes on the phone, I gave up.

I'll try seeing if the referral management workers are remote/were remote, or if they're in the office. But curious if anyone has had this issue, either as a patient or as a physician, or just knows how Tricare works.


Thanks

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[Chonal Atresia]

Sad.

Do you not have an Optho guy on staff at your MTF? I would try that option first.

Only other option is the ER. Tricare has ruined goodwill with civilian providers so almost no one will see a Tricare patient without a referral because they won’t get paid.

 

[pawprint]

I’d strongly recommend sending to the ER in the future. Stat referrals usually require approval by the subspecialty office, and they are only going to be working during normal business hours. I couldn’t get the Tricare referral center to approve my stat outpatient referrals, only the subspecialist could do it and so I had to call the subspecialist before placing it.

Tricare can retroactively apply a referral but it’s complicated and your patient risks getting stuck with a bill. Especially if the subspecialty office disagrees with your reasoning for writing the referral, and doesn’t sign off on it.

 

[militaryPHYS]

Agree with above. If it’s urgent/emergent, especially after hours, send to ER. If it’s anything else, go through process of referral, but even a stat referral doesn’t mean immediate after hours.

This isn’t really a tricare issue

 

[flightdoc09]

Do you not have an Optho guy on staff at your MTF? I would try that option first.

Yeah, I called the nearest MTF with an optho residency and spoke with the resident who agreed that would be best to get an ophthalmologist (or at least and optometrist) to do an exam. We were about 7+ hours from the nearest MTF, and about an hour from the nearest ED.

I’d strongly recommend sending to the ER in the future.

Agree with above. If it’s urgent/emergent, especially after hours, send to ER.

I agree with both of y'all. However, this fell into the gray area of urgent, but not emergent. Ophto would not see this patient in the ER, and the ER would just send this patient back with a recommendation to follow up with opthalmology in 24-48 hours. I even spoke with the nearest 3 ERs to see if any had optho residents (best bet for getting an ophthalmologist in the ED), or if they could give me the name/number for an opthalmologist they recommend in town. I had the capability with my supplies to do everything they would have done in the ED, short of intraoccular pressures.

It was one of those instances where probably a 90% chance there was no retinal injury. But given mechanism and symptoms, and recent patients I've seen where they had subtle retinal injury that even ophtho said would be hard to pick up, I figured better be safe.

At the end, this 1stLt didn't want to leave his guys in the field by themselves. And called the ophthalmologist to cancel the appointment I made. Which, I can appreciate at least he didn't no show.

 

[HighPriest]

Yeah, but if they call ophtho and ophtho feels that they don’t need to see the patient asap, then they’ve bought that. It’s unlikely that an ophtho practice is routinely seeing patients that have permanent vision loss because they wouldn’t go see them in the ER. That’s a self correcting problem. So send the patient to the ER and let them (ER and Ophtho) make that decision. And if they think it’s truly urgent and they really can’t see them, they may send the patient to a tertiary center with ophtho coverage.
Plus, in my experience we get insurance coverage to sign off faster when the patient is being referred from an ER.

I get this kind of thing a lot, too. Call from an ER asking me to see a patient asap because their pcp sent them to the ER so that I would see them faster. The ER isn’t a fast pass, but it does draw the attention of the specialist and makes them decide on the spot how urgent something is.

Well, if it’s truly an emergency, I will go see the patient. If it’s a patient with nosebleeds who isn’t bleeding right now but just wants to cut the line, I won’t. And I have ER privileges. I go there frequently.

Point is: let ophtho and the ER work that out.

If it’s a soldier who doesn’t want to take medical advice then:
1-decide if you think it is really an urgent issue
2-if not, don’t sweat it
3-if so, tell him he needs to go regardless and make him do it until or unless his CO puts the kaibash on it.

 

[Apollyon]

Point is: let ophtho and the ER work that out.

If it’s a soldier who doesn’t want to take medical advice then:
1-decide if you think it is really an urgent issue
2-if not, don’t sweat it
3-if so, tell him he needs to go regardless and make him do it until or unless his CO puts the kaibash on it.

I thought it was the officer who was the pt, not Seaman Timmy or anyone. Just guessing, but, I wonder/think it's USMC.

 

[HighPriest]

I thought it was the officer who was the pt, not Seaman Timmy or anyone. Just guessing, but, I wonder/think it's USMC.

1st Lieutenant, he said. If that’s the top of the food chain and there’s a doc involved, I have other questions.

 

[Apollyon]

1st Lieutenant, he said. If that’s the top of the food chain and there’s a doc involved, I have other questions.

That's why I thought USMC platoon leader.

And the idea that he'll just go back to his unit. Blindness in one eye from retinal detachment, I thought, got you out of the .mil.

 

[flightdoc09]

Point is: let ophtho and the ER work that out.

If it’s a soldier who doesn’t want to take medical advice then:
1-decide if you think it is really an urgent issue
2-if not, don’t sweat it
3-if so, tell him he needs to go regardless and make him do it until or unless his CO puts the kaibash on it.

As an ER doc myself, I hate it when stuff gets dumped on us from PCPs (or, for that matter, post op/specialist patients they don't feel like squeezing into their schedule). Especially when the patient has googled just enough to say the right things that make me have to order that outpatient ultrasound that they already had an appointment for in 2 days. I also hate calling specialists from the ED for people trying to game the system.

The ER doc I spoke with did not share my concern. Probably wouldn't not have done as indepth of an exam as me either. 6 months ago, I would've agreed. But I'm sure you had those cases where something looked benign, but an atypical presentation was hiding, and it made you more conservative for a while? It was out of an abundance of caution.

If I had objective reason to believe there was high risk I would've definitely found a way to make him go.

That's why I thought USMC platoon leader.

Yeah, USMC.

 

[HighPriest]

Getting dumped on is at least 50% of my job too, fwiw. That’s why I don’t have time to work in every non-emergency that I get called about, because I’m booked out for months seeing not-sinusitis and neck masses where there’s already imaging demonstrating no neck mass.

But, at least a provider covering ER call has some obligation to take the call from the ER due to EMTALA.

 

[orbitsurgMD]

Anymore, many community hospitals do not support ophthalmic practice, including surgery or ophthalmic emergencies. The trend has been to move all ophthalmic care either to outpatient surgery centers or transfer to tertiary care centers. My local hospital has no eye lane, no operating microscope, no stock of ophthalmic instruments, implants or surgical supplies, no vitrector, nothing. In their view, eye surgery is a money-loser and they don't want it.

So good luck with calling the "on call" ophthalmologist who is listed in a quasi-fraudulent effort by the hospitals to claim status as a trauma center. Willing to help, they aren't going to have much to offer you. Under those conditions, it would be unethical to accept a transfer.

 

[flightdoc09]

Anymore, many community hospitals do not support ophthalmic practice, including surgery or ophthalmic emergencies. The trend has been to move all ophthalmic care either to outpatient surgery centers or transfer to tertiary care centers. My local hospital has no eye lane, no operating microscope, no stock of ophthalmic instruments, implants or surgical supplies, no vitrector, nothing. In their view, eye surgery is a money-loser and they don't want it.

So good luck with calling the "on call" ophthalmologist who is listed in a quasi-fraudulent effort by the hospitals to claim status as a trauma center. Willing to help, they aren't going to have much to offer you. Under those conditions, it would be unethical to accept a transfer.

Yup. It's kinda weird, compared to what's the textbook answer - at least in EM texts. At a community shop we rotated at in residency I had a definitive retinal detachment Sunday afternoon. Could see it flapping around on US. Ophtho said to send to his clinic Monday morning, he'd triage and call a retina specialist.

And at a trauma center we rotated at as well, open globe around midnight. Ophtho said to just eye shield, antibiotics, etc., and transfer to his clinic at 8am.

 

[Apollyon]

Yup. It's kinda weird, compared to what's the textbook answer - at least in EM texts. At a community shop we rotated at in residency I had a definitive retinal detachment Sunday afternoon. Could see it flapping around on US. Ophtho said to send to his clinic Monday morning, he'd triage and call a retina specialist.

And at a trauma center we rotated at as well, open globe around midnight. Ophtho said to just eye shield, antibiotics, etc., and transfer to his clinic at 8am.

Whereas I got ophtho to the ED on, coincidentally, a Sunday afternoon for an open globe, at the Uni hospital.The ophtho even called a retina guy (I think his name was "Mark"), of whom whose name I'd never heard. So, YMMV.

 

[flightdoc09]

Whereas I got ophtho to the ED on, coincidentally, a Sunday afternoon for an open globe, at the Uni hospital.The ophtho even called a retina guy (I think his name was "Mark"), of whom whose name I'd never heard. So, YMMV.

At a big university hospital? That makes sense.

 

[HighPriest]

I’ve never had a problem with it, and I do periodically run across globe injuries and I work at a community hospital, but I understand not every place works the same.

I suppose the alternative is that you just keep a guy with a globe injury in the field or in your office while you call around to Ophtho docs and get the same answer the ER is going to get, and the lawyer asks you why you didn’t send him to an ER. And you can tell them that you thought you’d get care faster outside of an emergency facility.

Or send him to a tertiary center personally. I suppose that’s an option too.

I don’t know $#!t about the literature for retinal detachments and I certainly came out of med school under the impression that it was an emergency, but I also know that half of the stuff we did in my specialty at 3am in the ER when I was a resident can actually be taken care of in a couple of days.

So the question is: is it actually a problem that the Ophtho guys are making the patient wait, or do we just think it’s a problem because it wasn’t that way where we trained?

I honestly don’t know. Maybe there’s been a massive uptick in blindness over the last decade.

 

[flightdoc09]

I suppose the alternative is that you just keep a guy with a globe injury in the field or in your office while you call around to Ophtho docs and get the same answer the ER is going to get, and the lawyer asks you why you didn’t send him to an ER. And you can tell them that you thought you’d get care faster outside of an emergency facility.

Or send him to a tertiary center personally. I suppose that’s an option too.

Yeah, I mean big difference between an open globe and a patient with a normal retinal US, fairly benign exam, the likely has a component of traumatic iritis, but could maybe have a tiny bit of something and you're being overly cautious. Getting a casevac to a true tertiary going close to midnight, several hours away, vs calling an ophto clinic in the morning that's about an hour away. Time to see an ophtho probably similar.

So the question is: is it actually a problem that the Ophtho guys are making the patient wait, or do we just think it’s a problem because it wasn’t that way where we trained?

Never said it was a problem. Although multiple ophthalmologists I talked to after that told me that was the wrong move on the ophto's part. I figure they know a thing or two more than I do. I'm just saying it's entirely possible that I could have sent this marine to any of the ERs I called, and likely would've been discharged at 3 or 4am and just told to go to follow up in clinic with an ophthalmologist. I guess it would've had ED documentation justifying it, which might have helped with tricare reimbursement?

I'm not trying to attack any specialty here.

 

[HighPriest]

Never said it was a problem. Although multiple ophthalmologists I talked to after that told me that was the wrong move on the ophto's part. I figure they know a thing or two more than I do.

.

Yeah well that’s why I ask. I think it’s hard to tell if you just have a lazy or inept consultant or if they just know more and what you think is urgent just isn’t.

And I don’t mean you specifically, the royal you. Anyone.

I didn’t think you were attacking ophtho. I just mean to say that your option are limited, but taking on the liability for something you truly feel isn’t being managed correctly, that you cannot yourself fix, is dangerous man. Don’t put yourself in that position if you can help it.

It’s one thing if you’re staffing an ER. It’s another when you’re not in that role.

I think the whole idea behind EMTALA laws is that if all else fails a patient can go somewhere where they can if nothing else get to someone who can help them. Theoretically with as little run around as possible.

We DO have this kind of issue with our omfs guys locally. There are about 9 of them in our catch basin and not one will come to the ER or see an uninsured patient who doesn’t pay them up front. It’s a problem at least monthly where I get called for an infected molar or something like that. So I do realize the system doesn’t always work.

 

[eyeeye_captain]

On the authorization question, color me surprised you couldn’t get in touch with someone after hours. I would guess most practices would go the route of self-pay then take it up with Tricare.

If you want a patient seen that night, there are really only 2 scenarios. You have a hospital with residents, or you have a Level 1 that enforces a policy of every patient must be seen before discharge. I agree that the time to eval is going to be about the same by calling the office in the morning, and the patient likely winds up with a better exam. True ophthalmologic emergencies are pretty rare, so 3 AM isn’t generally needed.

The scenario sounds like flashes/floaters after a trauma. Immediate detachments aren’t super common. There was a pretty big case series last year on patients with commotio retinae, retinal bruising from a high energy injury. The subsequent detachment rate was 4%.

Somewhat counterintuitive, but worse detachments are actually less urgent to repair. One so big that you can see it flapping with an US probe in the ED is almost always going to have the macula (central vision) involved. The cat’s out of the bag at that point, and statistically you wind up with the same visual outcome if it’s repaired within about a week. If one isn’t as bad and needs to go within 48 hours, you can still temporize it with a gas bubble in the office or even just use that bubble with cryo or laser in the right candidate. That option generally isn’t available in a hospital. Laser for a retinal tear might be, but would be a pain.

Most non-trauma hospitals don’t have an on call eye scrub, so even if you wanted to fix a detachment overnight, you’re setting up a machine that’s only not quite as big a hassle as a Da Vinci and then scrubbing your own case. That’s a recipe for bad outcomes.

The open globe story is weird. The logistics to fix one aren’t nearly as complex, and now he would have made things much more difficult by taking the patient away from the hospital and back again. That’s a big waste of time when the standard of care is repair in under 24 hours as the infection rate is around 3.5x higher if it goes later. I’ve had EDs call to try to send a globe to my office as a hot potato because they didn’t have ophtho on staff. I had to let them know that this would delay care and the patient needs immediate transfer to a tertiary center. I’m also not going to take on all the liability of finding an OR while the clock is ticking with no guarantee one is available.

Surprisingly, there are some ophtho folks who like ED and inpatient stuff. A decent number of residencies have a chief year where you’re basically the head of the consult service. Some have faculty where that’s their entire clinical load. There’s some guy in Ohio who’s a private contractor covering up to 6 locations at a time. Not for all the tea in China, personally.

 

[Chonal Atresia]

Yeah well that’s why I ask. I think it’s hard to tell if you just have a lazy or inept consultant or if they just know more and what you think is urgent just isn’t.

And I don’t mean you specifically, the royal you. Anyone.

I didn’t think you were attacking ophtho. I just mean to say that your option are limited, but taking on the liability for something you truly feel isn’t being managed correctly, that you cannot yourself fix, is dangerous man. Don’t put yourself in that position if you can help it.

It’s one thing if you’re staffing an ER. It’s another when you’re not in that role.

I think the whole idea behind EMTALA laws is that if all else fails a patient can go somewhere where they can if nothing else get to someone who can help them. Theoretically with as little run around as possible.

We DO have this kind of issue with our omfs guys locally. There are about 9 of them in our catch basin and not one will come to the ER or see an uninsured patient who doesn’t pay them up front. It’s a problem at least monthly where I get called for an infected molar or something like that. So I do realize the system doesn’t always work.

We refuse to see any odontogenic pathology from the ER anymore. Once you accept a single patient, the onslaught arrives and they think ENT is the same as dental. If we don't have OMFS on-call, we make the ER transfer. As you well know, you can drain neck pus but if you don't take care of the source it will come right back.

I've actually told the CMO of the hospital when questioned about this issue that it a hospital problem, not an ENT problem. If they are too cheap to employ OMFS and/or pay them enough for call, that's on them not me.

Drives me nuts that these non-physicians make a ton of money shucking molars and then don't take ER call to take care of their complications.

 

[HighPriest]

We refuse to see any odontogenic pathology from the ER anymore. Once you accept a single patient, the onslaught arrives and they think ENT is the same as dental. If we don't have OMFS on-call, we make the ER transfer. As you well know, you can drain neck pus but if you don't take care of the source it will come right back.

I've actually told the CMO of the hospital when questioned about this issue that it a hospital problem, not an ENT problem. If they are too cheap to employ OMFS and/or pay them enough for call, that's on them not me.

Drives me nuts that these non-physicians make a ton of money shucking molars and then don't take ER call to take care of their complications.

Oh yeah. We don’t see them either for all of the reasons you just mentioned. They go to elsewhere.

 

[flightdoc09]

I just mean to say that your option are limited, but taking on the liability for something you truly feel isn’t being managed correctly, that you cannot yourself fix, is dangerous man. Don’t put yourself in that position if you can help it.

Good points. Sometimes I get carried away thinking I can do more than I really can.

On the authorization question, color me surprised you couldn’t get in touch with someone after hours.

Even the next morning, during business hours, was trying to get that referral approved before the appointment and was just calling around in circles.

The scenario sounds like flashes/floaters after a trauma. Immediate detachments aren’t super common. There was a pretty big case series last year on patients with commotio retinae, retinal bruising from a high energy injury. The subsequent detachment rate was 4%.

Yeah, recently I've had a surprising amount of eye trauma. A few close proximity/higher power nerf guns, and BB guns. The nerf gun injuries have resulted in pretty bad hyphemas, and the one that keeps getting me is one with retinal dialysis. US looked totally normal, visual acuity slightly diminished compared to the other side, only a small corneal abrasion, and a tiny trace of a hyphema present. Can't remember exactly why I sent them upstairs, perhaps because he said he completely lost vision in his superior visual field for 5 minutes, though it was now back to normal. I called ophto to see if I could send to their clinic (upstairs in the MTF), they deferred to optometry. And optometry identified "retinal dialysis," and got them to an ophthalmologist who did the repair.

Spoke to the ophthalmologist later who said that particular injury would not have been visible on US. Which is why I'm a little more cautious with these now.

Drives me nuts that these non-physicians make a ton of money shucking molars and then don't take ER call to take care of their complications.

Yeah, I rotated in the ICU at a community shop in residency. Neither ENT, nor OMFS on staff. And they accepted a patient with post extraction bleeding on blood thinners. No one wanted to touch him, and him and his daughter refused to allow us to turn down his heparin (baseline on coumadin for strokes, with a higher than normal target INR per his cardiologist). We ended up transfusing a couple units over the course of a few days until able to get his oral surgeon to come to the hospital and take care of it - the hospital actually credentialed him in about 2 hours to work there. We tried transfer to nearby hospitals with OMFS on staff, and even an OMFS residency, but they wouldn't take it.

I actually remember that OMFS that came in saying "You know, if you have ENT here, they can take care of this too."

 

[orbitsurgMD]

Whereas I got ophtho to the ED on, coincidentally, a Sunday afternoon for an open globe, at the Uni hospital.The ophtho even called a retina guy (I think his name was "Mark"), of whom whose name I'd never heard. So, YMMV.

Totally the opposite at a hospital with a residency. There will be a resident on call with an assigned attending backup. There will also probably be better after-hours support for the OR. If you need to do a pars-plana vitrectomy and endolaser after hours, you will want an OR crew that already knows how to set up and circulate on the equipment. That is not the time to start training a tech with zero experience in ophthalmic surgery, there is too much to need to know. That is why the retina people defer to the next regular workday. Just having a "retina guy" isn't going to be enough.

 

[Apollyon]

Totally the opposite at a hospital with a residency. There will be a resident on call with an assigned attending backup. There will also probably be better after-hours support for the OR. If you need to do a pars-plana vitrectomy and endolaser after hours, you will want an OR crew that already knows how to set up and circulate on the equipment. That is not the time to start training a tech with zero experience in ophthalmic surgery, there is too much to need to know. That is why the retina people defer to the next regular workday. Just having a "retina guy" isn't going to be enough.

This was the ophtho attending, as was the retina guy. No ophtho residency there.

She (ophtho) had a 2 story high ad with her face on a billboard that was right next door to a 3 story strip club, which was right off the expressway.