"Just bear with me, one moment please..."

I was on the phone with various Humana agents for about 45 minutes, being ping-ponged from one to another. They do not have an HMO presence in my geographic locale but as a "provider" I may accept their Medicare Advantage/PPO members and bill the insurance company without any contracts. Or so they say. The current issue I am facing is that I am being treated as a primary care provider when in fact I am a specialist, a dermatologist. The copayments are different. I trained as a dermatologist and my claims need to be processed as such, not by a random high school dropout who sees my claim and does the automatic rote thing. I fight daily for such small humiliations to be removed from my hair.

For those of you who do not know, Medicare Advantage plans were all the rage in Florida as the new kid on the block about 4 years ago. They were "rushed like a fraternity in September" because they promised senior citizens zero out-of-pocket charges and they tossed in little goodies like gym membership discounts or prescription plans. In sum, seniors get Medicare premiums docked from their Social Security checks. Yes, that's right, what you "paid into" all those years as a working stiff is no longer enough, you must continue to pay for it even from your Social Security check. Then they are subject to a $140 calendar year deductible and 20% copayment of the allowed charge for all outpatient, or Part B, services.

When the retiree joins these Advantage plans, they no longer get the Medicare premium docked from their Social Security check. The Medicare Advantage plans get government grants, in a lump sum, to cover the senior citizen, and then they "deliver" services at a bundled rate. Part of that sum goes towards advertising and promotion, so government is funding non-medical activities in this method, by feeding a private sector entity. Patients pay a flat copay at office visits, somewhere between $15-50 depending on the plan they choose. Specific drugs, labs, etc must be used, and only doctors who accept the plan can be seen by the retiree. A doctor does not have to accept the plan even if they are a participating doctor with Medicare. There is a different fee schedule (LOWER OF COURSE) and more restrictions on types of services covered.

The controversy came in when fast talking salespeople came to town and offered seniors free coffee and donuts to get them to switch to their HMO-like system. You all know that people would sell their souls for a jelly donut. The insurance agents got huge commissions and bonuses for signing seniors up in bulk. The rude awakening came when plans over-promised and under-delivered. The infamous "Any Any Any Plan"-- literally that was the name of a certain Tampa-based plan-- got shut down by the feds for not paying doctors and hospitals and they went bankrupt. I refused to accept that plan many a time (simply because of their absurd name) and I faced harsh words from my patients who were on this, only to then hear their lamentations when the plan got busted. Sorry Charlie. If you yell at me I won't be your doctor.

In any event, I'll wait and see what happens with Humana. If they can't correct the glitch in their system that doesn't recognize what I do, I'll refuse to deal with them any further and drop it. I had long standing patients switch to their Advantage Plan and I took it and billed it, got paid within 14 days, and all was fine, until I read the fine print and saw they weren't able to code me as a specialist for mysterious reasons. We shall see if they will fix it. I'm not holding my breath.

Update on 10/15/2012: Not one letter, phone call, nor follow-up to this situation has occurred.  They haven't done one thing. I'm tired of this BS so I'm dropping it. Stick a fork in me. I'm done.

First Day of Summer

Doctors are under assault by the patients, FDA, the Feds, CMS (OMG did I use the correct modifier? Am I going to jail?) and by insurance companies. This is all a given. What I'm finding more cheery is that doctors are repeatedly hitting back. The AMA no longer represents physicians, and there is open revolt going on with PPACA. Increasingly, physicians are acting in ways that would've shocked me 10 years ago. Examples abound, but not taking certain insurance plans, going concierge/cash only, and going to work for industry are increasing examples of why we're seeing more doctor shortages than ever before. It's not that there are less doctors, but there are less PRACTICING doctors. Doctors have multiple talents and lots of corporate entities find that the background intelligence and training that doctors can bring to the table leads to a distinct edge in being placed on corporate boards and such.

Anyway, it's the first day of summer! YES! Plans for trips are swirling. Here are my current three obsessions this month:
1. Whole Foods' Mixed Berry Cereal Bars. Nutritious, not full of unpronounceable toxic shmutz, and yummy.
2. Palomar Starlux Laser Corp. has provided zero friendliness after purchase, but I must say their customer service and ordering dept. is excellent. THANK YOU, you know who you are.
3. Arnica is really great for muscle soreness. You can get it at health food stores, Whole Foods, etc.

Let me just opt out. No Mail.

Today I went to check my mail at the medical center, where my office is located, and I found a big bunch of mail held with a rubber band, bundled in the mailbox in the driveway of the Urgent Care. On top, a handwritten note (on the same yellow/orange notepaper used to claim certified receipt notices) dated 5/31 stated that "the mail will be withheld until the mailbox is moved". I received no mail on June 1, 2, or 4th, until the situation was discovered.

I notified the "medical center operations manager" --really a data-inputting grunt--and thus the bureaucratic dance began.

The new mail carrier had a battle going on with the medical center staff. She refused to drive her vehicle into the driveway and wanted the mailbox moved to the "regulation of 3 inches within the curb" because in Florida, postal carriers do not walk out of their vehicles, they sit in the truck and deliver mail into mailboxes at the edges of the curbs. This is why they are all obese and full of varicosities and Type II diabetes. I know this because I treat some of them, as patients.  Oh and you, dear taxpayer, are paying for the most Cadillac-of-Cadillac-health plans to treat and correct these medical conditions, directly caused by the sedentary and molly-coddled lifestyle these persons lead.

The medical center manager went to talk to the postmaster. He was completely unaware of the withheld mail edict, apologized, and stated all mail would resume tomorrow. 

I am TOTALLY concerned about the fact that a mail carrier unilaterally decided to withhold my mail, along with the mail of the entire complex, in effect, holding it hostage. They have done this from time immemorial. Postal carriers steal mail, brightly colored birthday cards, welfare checks, you name it. They are underpaid grunts who can't be fired, handling our really sensitive documents, and it's enshrined in the Constitution. Sometimes they "go postal" and start shaking and shooting  or opening Pepsi bottles in WalMart aisles. And they wonder why they're going bankrupt. Any possible way that I can avert having to deal with the USPS, I follow. E-payments? Check. Email? Check. Electronic pathology reports? Check. Bloodwork results faxed? Check. 

But not everything can be handled electronically. The world is straddling the paper and the internet systems right now, and we have medical records coming in from Dr. Smith in Sheboygan, on paper. Mrs. Hunt sends in her copayment via handwritten check, via US Mail. And so forth. 

I am a physician trying to run a medical practice. I have bills, reports, payments, and sensitive mail that is coming to my attention, such as lab tests, pathology records, etc. This is clearly unacceptable behavior and crosses the ethical boundary of the mail carrier. What assurance do I have that no mail was comprised? How do I know if something was stolen, or lost, in this process? I need answers. 

Medicare has ruled that as a participating physician, I must have a physical address for mail, no P.O.Boxes are accepted. So that avenue is cut off. 

Can't I have what Kramer in "Seinfeld" wanted all those years ago, to "opt out" of mail? Seriously, why can't we just opt out? We can show an ID and pick up all the mail at a given post office. That's it. No carriers, no delivery. 

I will dance, sing, pour vodka over my head, turn cartwheels, and let fly all sorts of fireworks when two things happen. First, the USPS goes bankrupt and Congress overturns its monopolistic hold on First Class Mail. And second, Obama loses the election. Homer Simpson could be sworn in, and I'd be delirious. I just can't take the Stalinist "Forward" motto. It calls to mind "Pa'lante" (Castro) "Forward" (Mao and Stalin). 

http://www.theblaze.com/stories/forward-for-communism-is-obamas-new-forward-slogan-really-a-coincidence/

Long hiatus

Been away for a while, I got very sick. Bronchitis, sinusitis, otitis, and finally, bilateral conjunctivitis to wrap it all up. I was a mess, seeing multiple doctors, taking time off from work and everything else, numerous antibiotics and prednisone. Not fun, felt so powerless. If anything, it strengthened my compassion for the sick, and made me take stock of the horror of my work treadmill. SO I stopped accepting new patients, cut my schedule down drastically. Took some time off.
I'm much better for it.
Thanks to my husband for giving me a butt kick and forcing me to stay still and to rest, being supportive all the way. We recently celebrated our 10th anniversary and went away somewhere quiet and beautiful.
It's Memorial Day. While I appreciate the day off and the "start of summer" moniker, I always think of the vets I treated, their stories, their humility and sense of humor, when I worked at various VA hospitals. They are true American heroes, I respect them with all of my heart.
It saddens me so much when I hear of deaths of our service men and women in the combat theaters around the world. What a giant waste. I don't need perpetual reminding of the waste of war. We need to use more diplomacy, and we need to leave the heathens to themselves more often than not. We give them money and weapons and then they turn it on us, 9/11. We're not going to "fix" Iraq/Afghanistan/Iran/Syria whatever...I am so tired of the constant warring. Just think for a minute of our people in their prime who have been destroyed by war.

wow all insurance kinda sucks

I love it when I'm held to the highest, most stringent standard possible, but everybody else can do whatever, whenever, why-ever. And nothing happens to them. There are no consequences for the rest of the world for a big general f*** up, but for the doctors, NOOOOOOOOOOO. Hellfire and brimstone will come your way, doc! Make sure the HIPAA 5010 data box doesn't include a PO BOX in your address or you won't get paid. I'm not making this up. (see letter below from MGMA to Kathleen Sebelius regarding the 5010 f*** up).


Department of Health and Human Services
Room 445-G, Hubert H. Humphrey Building
200 Independence Avenue, S.W.
Washington, DC 20201
Dear Secretary Sebelius:
The Medical Group Management Association (MGMA) requests that you take immediate
action to address the payment disruption issues that have occurred as a result of the federally
mandated transition to HIPAA Version 5010 electronic transactions on Jan. 1. Medical
practices throughout the nation are experiencing significant challenges implementing these
new transactions, a situation that has led to considerable cash flow problems for physicians
and their practices. Problems are being reported with both Medicare Administrative
Contractors (MACs) and commercial plans.
Should the government not take the necessary steps, many practices face significantly
delayed revenue, operational difficulties, a reduced ability to treat patients, staff layoffs, or
even the prospect of closing their practice. As the transition to Version 5010 is a mandatory
step toward ICD-10 implementation, this raises even more concerns, understanding the
magnitude of ICD-10 is exponentially greater than Version 5010.
MGMA-ACMPE is the premier association for professional administrators and leaders of
medical group practices. Since 1926, the Association has delivered networking, professional
education and resources, political advocacy and certification for medical practice
professionals. The Association represents 22,500 members who lead 13,200 organizations
nationwide in which some 280,000 physicians provide more than 40 percent of the healthcare
services delivered in the United States.
Version 5010 Issues and Concerns
Physician practices have reported numerous problems across various areas of the United
States stemming from the transition to Version 5010. The most frequently reported problems
have involved:
 Issues with practice management and/or billing systems that showed no problems
during the testing phase with their MAC, but once the practice moved into production
phase, found their claims being rejected
 Issues with secondary payers
 Rejections due to various address issues (pay-to address being stripped/lost from
claims; pay to address can no longer be the same as billing address; no PO Box
address)
 Crosswalk NPI numbers not being recognize



Apart from the atrocious grammar and numerous typos, my spirit is simpatico to this letter and I agree the whole thing needs serious pushing back.


My business insurance policy wanted to have some outsourced guy come to the office to photograph the contents, and probably make sure I'm not some fraudulent business. Ok, fine. But this individual failed to show up at the appointed hour, and when called to check on why HE no-showed, some vague ministrations about a long day and so forth were made. We called again and left a message, nobody to actually speak to. This was 2 weeks ago. Today I get a letter from the insurance company that since I "refused" the mandatory inspection my policy would be cancelled. Holy hell!
My agent was sweating bullets and I let him have it. He will have to actually work for a living and attempt to correct this huge mistake. If this is how they do business, the policy will be cancelled. There is competition, still, God bless 'em.
I think there are so many things that have gone awry in the insurance industry that it's beyond repair. The norm is fraud. Therefore, they're on high alert and double check every tiny detail, even my tiny little office in a medical building.

Who knows where this poor outsourced shmo is. He probably quit and there's nobody else who will do this grunt work for minimum wage. Whatever.

Lead in lipstick

"Lead in lipstick!!" screams the headline, and in come the panicked patients....

The public needs to know that the lead is not an added ingredient in the lipsticks. Lead is a natural element that gets measured by the fact that it is present in the dyes used in cosmetics. These dyes are elements, and the lead is a contaminant in these inert powders that are used to confer color. That is why generally speaking, the sheerer the lipstick, the lower the lead level.

Ever read the ingredient lists? "FD&C red #7", "iron oxide #4" "aluminum lakes #8" and the like, are derived specifically for the FDA and no cosmetic in the US can be sold without these specific dyes, which have been vetted by the FDA and they continue to be. These dyes often have aluminum too, and though I'm not a chemist, the way I understand it is that these metals impart color fastness and stability, so the red lipstick will remain a red lipstick.

Lead has a very long and ancient history as a cosmetic dye because it makes the pigment more stable. Queen Elizabeth I wore a lead based facial paint to cover up bad facial smallpox scars. Supposedly she also suffered from lead poisoning along with untold others.
Currently lead poisoning affects children the most because their growing systems can't handle exposure to this substance, and the old flaky paint used before 1975 ( I think) shed lead particles nto the air. The lead dust can be inhaled and cause lead toxicity. But that's a whole other story.

In the past century there have been no cases of lead poisoning from a cosmetic in the US. In fact, pigment is what gives lipsticks their variable inherent SPF level. It has been shown that women have much lower rates of cancer of the lip vs. men because women tend to cover their lips with lipstick, and though not formally rated, the zinc oxides and pigment bases provide some level of ultraviolet protection. Lead is well known as a UV and radiation blocker, which is why you get a lead apron draped over you when you get Xrays at the dentist :-)

There are many flaws in the FDA's logic, namely that lipstick isn't a "food". They are lumping the lead risks from lipsticks together with the lead risk from other cosmetics, no other cosmetic gets ingested, only lipstick. Eileen, to answer your question, I believe the FDA has set the safe threshold for lead in a color additive at 20 parts per million, similarly Canada and the EU. All of these lipsticks tested on their list fall below 5 parts per million.

To conclude this long rant, knowledge is power. Nothing is perfectly safe in this world. Don't take anybody's word for it. You must educate yourself and form your own opinions about what you're willing to use and not use. It's your body.

However, if we wanted to be perfectly natural we'd wear zero makeup. But where's the fun in that?

Musings on happenings

A cold front came in yesterday and it's been in the 50's today, which is cold in FL. When the northeast gets a cold front it often pushes cold stuff all the way down.....Weird. 

Every year I get bioterrorism training, the anthrax thing was diagnosed by dermatologists in New York City, people had sores on their hands and faces that weren't healing, they didn't go to the ER when they had just the cutaneous anthrax.  The poor people who inhaled the spores and got sick right away obviously were in ER's first but nobody knew what they had until 3-5 days later when the cultures came back. So every derm conference is super pro active about the skin manifestations of every single bioterrorism agent, from nuclear skin burns to smallpox to anthrax to bubonic plague, which was used against Genoa in the 14th century as a bioterror weapon by flinging dead infected corpses over the city walls by the invaders du jour. I thought you'd like that tidbit. 

There was a fantastic dermatologist speaker, the deputy surgeon general, Dr. Boris Lushniak. He had to go investigate the monkeypox epidemic in 2003 from people importing prairie dogs as pets. He showed up at this little rural clinic in Indiana in his full CDC protective headgear and full body white jumpsuit because they didn't know what they were dealing with, and he says,"you can imagine how big everybody's eyes got when I show up in my regalia and say 'now don't  worry, you're fine, I'm from the government and I'm here to help' " and the whole audience roared in laughter just imagining this. Monkeypox turns out to be a fairly benign thing, not lethal, but when he was sent by the CDC they were thinking it was potential smallpox. The fear and panic such a thing would cause is unimaginable. I always pray that this never comes to pass again. The military gets vaccinated against smallpox as soon as they are deployed. Civilians still are not. We were vaccinated in the 70's and it turns out that it still confers some level of immunity but not the best. The gov't is stockpiling vaccines still, they aren't commercially available. The anthrax vaccine performs very poorly, you need so many booster shots to get immunity, most people would balk. He said only those high risk military get vaccinated, I presume the ones sent to Afghanistan, where it is endemic from sheep and goats. Needless to say I had so much food for thought, like I do after every derm meeting, it is a ton of info to process!