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General Surgery News
Sometimes, We Are Our Own Worst Enemies
A Surgeon's Rant After a Particularly Bad 48-hour Shift
By Mauricio Heilbron Jr, MD
As much as we physicians love to rage against the machine, condemning those political bureaucrats, HMO Mafiosi and rapacious lawyers who have altered our profession to something unrecognizable to the most senior physicians on our medical staffs, sometimes in fact the enemy is us.
For those of you who do not live in Southern California, what you need to understand is that our state-funded Medicaid program, Medi-Cal, makes all of your state-funded Medicaid programs look like the Oprah Winfrey Christmas show. That is the one where she gives everybody in the audience ungodly amounts of really nice stuff.
Medi-Cal pays decently for things like obstetrics and pediatrics, but when it comes to, say, a cholecystectomy or an amputation, surgeons are left holding the short end of the stick. For example, if a patient gets admitted for acute cholecystitis, and you get called the next morning to perform a consult, there is a small but definite chance you will get paid for that consult---at a fraction of Medicare rates. In six months.
You examine the patient, and given the fact she is elderly, diabetic and in extraordinary amounts of pain, along with lab values and imaging studies suggestive of a progressively worsening clinical picture, you decide to schedule her urgently the following morning for laparoscopic cholecystectomy. You remove the offending organ uneventfully and she recuperates almost magically. She is home within 48 hours.
How much would you expect to get paid? It's a trick question. You won't get paid. I naively thought that since I was consulted, and since she needed the surgery and did so well, I would subsequently receive some remuneration for my efforts.
Several months later, I see on my Explanation of Benefits that I was denied payment. Total for everything: zero dollars. Reason for denial? "No TAR [treatment authorization request]." You see, Medi-Cal deems that you must obtain a TAR to authorize the surgery. The TAR for the admission to the hospital covers your consult but, interestingly enough, not the surgery.
Getting a TAR is a process that takes weeks to months. An elderly, diabetic, septic woman with gangrenous cholecystitis would not benefit from the surgery at that remote time, because the family would probably not like their beloved matriarch to be disinterred from her grave simply to have her gallbladder removed. So I tried to be clever and suggest that since my consult comes under the hospital's TAR, I should at least get that. They shot me down like a vice-presidential hunting buddy. Doing the surgery means that the consult is included as part of the global fee. I did the surgery; therefore, the consult is part and parcel of my treatment of this patient. Which means they do not have to pay me.
OK, fine. They're out to get us. I get it. You get it. But many of our referring colleagues do not. I run a wound care center, and we have recently been inundated with Medi-Cal patients. Other doctors don't know what to do with these problematic patients, so they ship 'em over to us. I politely call each and every referring physician, and explain that since Medi-Cal doesn't really pay us for our work (if I have to do a simple dressing, it will cost me money to see a Medi-Cal patient), I would be happy to make treatment recommendations to help them heal up the wound.
I was sent a patient with a gangrenous toe, who already had a below-knee amputation on the contralateral side. Your first thought should be: why would anyone send a gangrenous toe to a wound care clinic? That's what I thought. That's what I told the physician. I asked him to send the patient back to her original surgeon, at her original hospital, 10 blocks up the street. A week later, tonight actually, I got called to see a patient with an ischemic toe, admitted to one of our general Med/Surg floors. The name sounded familiar, and sure enough, it was this very patient. She doesn't remember who did her last surgery, doesn't like the hospital up the street and didn't like sitting at home looking at her shriveled-up little toe. She presented herself to our ER, who promptly called the physician, promptly admitted the patient and promptly consulted me.
As I sat writing out my consult, with steam pouring forth from my ears, it dawned on me that some doctors just do not get it, or do not care. The enemy is us. Primary care doctors, who base much of their billing on E&M codes, have seen those reimbursement codes rise more than 35% since 1999. The surgical CPT codes, or at least the ones that have not been reduced, have gone up an average of 4%. So I have to do everything they dothe H&P (or consult), the daily visits and the discharge summaries, plus the surgery itself. And I get less than if I did the surgery, didn't tell anybody about it and only billed for my nonscalpel-oriented efforts.
I am told, however, that failing to report a surgery can be considered Medi-Cal fraud, so I am basically out of luck.
Now which class, exactly, did I sleep through when they discussed this in medical school?
Dr. Heilbron is a general, trauma and vascular surgeon from Long Beach, California.
Sometimes, We Are Our Own Worst Enemies
A Surgeon's Rant After a Particularly Bad 48-hour Shift
By Mauricio Heilbron Jr, MD
As much as we physicians love to rage against the machine, condemning those political bureaucrats, HMO Mafiosi and rapacious lawyers who have altered our profession to something unrecognizable to the most senior physicians on our medical staffs, sometimes in fact the enemy is us.
For those of you who do not live in Southern California, what you need to understand is that our state-funded Medicaid program, Medi-Cal, makes all of your state-funded Medicaid programs look like the Oprah Winfrey Christmas show. That is the one where she gives everybody in the audience ungodly amounts of really nice stuff.
Medi-Cal pays decently for things like obstetrics and pediatrics, but when it comes to, say, a cholecystectomy or an amputation, surgeons are left holding the short end of the stick. For example, if a patient gets admitted for acute cholecystitis, and you get called the next morning to perform a consult, there is a small but definite chance you will get paid for that consult---at a fraction of Medicare rates. In six months.
You examine the patient, and given the fact she is elderly, diabetic and in extraordinary amounts of pain, along with lab values and imaging studies suggestive of a progressively worsening clinical picture, you decide to schedule her urgently the following morning for laparoscopic cholecystectomy. You remove the offending organ uneventfully and she recuperates almost magically. She is home within 48 hours.
How much would you expect to get paid? It's a trick question. You won't get paid. I naively thought that since I was consulted, and since she needed the surgery and did so well, I would subsequently receive some remuneration for my efforts.
Several months later, I see on my Explanation of Benefits that I was denied payment. Total for everything: zero dollars. Reason for denial? "No TAR [treatment authorization request]." You see, Medi-Cal deems that you must obtain a TAR to authorize the surgery. The TAR for the admission to the hospital covers your consult but, interestingly enough, not the surgery.
Getting a TAR is a process that takes weeks to months. An elderly, diabetic, septic woman with gangrenous cholecystitis would not benefit from the surgery at that remote time, because the family would probably not like their beloved matriarch to be disinterred from her grave simply to have her gallbladder removed. So I tried to be clever and suggest that since my consult comes under the hospital's TAR, I should at least get that. They shot me down like a vice-presidential hunting buddy. Doing the surgery means that the consult is included as part of the global fee. I did the surgery; therefore, the consult is part and parcel of my treatment of this patient. Which means they do not have to pay me.
OK, fine. They're out to get us. I get it. You get it. But many of our referring colleagues do not. I run a wound care center, and we have recently been inundated with Medi-Cal patients. Other doctors don't know what to do with these problematic patients, so they ship 'em over to us. I politely call each and every referring physician, and explain that since Medi-Cal doesn't really pay us for our work (if I have to do a simple dressing, it will cost me money to see a Medi-Cal patient), I would be happy to make treatment recommendations to help them heal up the wound.
I was sent a patient with a gangrenous toe, who already had a below-knee amputation on the contralateral side. Your first thought should be: why would anyone send a gangrenous toe to a wound care clinic? That's what I thought. That's what I told the physician. I asked him to send the patient back to her original surgeon, at her original hospital, 10 blocks up the street. A week later, tonight actually, I got called to see a patient with an ischemic toe, admitted to one of our general Med/Surg floors. The name sounded familiar, and sure enough, it was this very patient. She doesn't remember who did her last surgery, doesn't like the hospital up the street and didn't like sitting at home looking at her shriveled-up little toe. She presented herself to our ER, who promptly called the physician, promptly admitted the patient and promptly consulted me.
As I sat writing out my consult, with steam pouring forth from my ears, it dawned on me that some doctors just do not get it, or do not care. The enemy is us. Primary care doctors, who base much of their billing on E&M codes, have seen those reimbursement codes rise more than 35% since 1999. The surgical CPT codes, or at least the ones that have not been reduced, have gone up an average of 4%. So I have to do everything they dothe H&P (or consult), the daily visits and the discharge summaries, plus the surgery itself. And I get less than if I did the surgery, didn't tell anybody about it and only billed for my nonscalpel-oriented efforts.
I am told, however, that failing to report a surgery can be considered Medi-Cal fraud, so I am basically out of luck.
Now which class, exactly, did I sleep through when they discussed this in medical school?
Dr. Heilbron is a general, trauma and vascular surgeon from Long Beach, California.
