Doctors quickly learn that how much they make has little to do with how good they are. It largely depends on how they handle the business side of their practice. "A patient calls to schedule an appointment, and right there things can fall apart," she said. If patients don't have insurance, you have to see if they qualify for a state assistance program like Medicaid. If they do have insurance, you have to find out whether the insurer lists you as a valid physician. You have to make sure the insurer covers the service the patient is seeing you for and find out the stipulations that are made on that service. You have to make sure the patient has the appropriate referral number from his primary-care physician. You also have to find out if the patient has any outstanding deductibles or a co-payment to make, because patients are supposed to bring the money when they see you. "Patients find this extremely upsetting," Parillo said. " ‘I have insurance! Why do I have to pay for anything! I didn't bring any money!' Suddenly, you have to be a financial counsellor. At the same time, you feel terrible telling them not to come in unless they bring cash, check, or credit card. So you see them anyway, and now you're going to lose twenty per cent, which is more than your margin, right off the bat."
Even if all this gets sorted out, there's a further gantlet of mind-numbing insurance requirements. If you're a surgeon, you may need to obtain a separate referral number for the office visit and for any operation you perform. You may need a pre-approval number, too. Afterward, you have to record the referral numbers, the pre-approval number, the insurance-plan number, the diagnosis codes, the procedure codes, the visit codes, your tax I.D. number, and any other information the insurer requires, on the proper billing forms. "If you get anything wrong, no money—rejected," Parillo said. Insurers also have software programs that are designed to reject certain combinations of diagnosis, procedure, and visit codes. Any rejection, and the bill comes back to the patient. Calls to the insurer produce automated menus and interminable holds.