I have to write down my medical story, since I am starting to forget everything. May others find it informative or entertaining.
I hurt my knee playing soccer around May 1st. I was running along and heard a loud crunch and pain. I let it heal for two weeks, then tried soccer again, it slipped out of place with much pain. Waited two weeks and again it slipped, this time just from walking. So I realized it was something serious (probably a collateral ligament tear and meniscus damage) and needed to see a doctor.
I went to Dr. Mains office on June 1st. Dr. Main saw me for my other knee years ago. His office told me I needed a referral from my family doctor before they could see me. I don’t have a family doctor. So I went and inquired for a doctor at the main information desk. Somehow they looked me up and saw that I had seen Dr. Milosovich years ago for a physical, so they sent me to him.
I went to his office, asked to see Dr. Milosovich, told them I just needed a referral to a knee doctor and this is just a bureaucratic formality; they were all like ‘ok, fill out these forms and answer all these questions’. I did so and then they told me ‘ok your appointment is scheduled for August 28th’. Three months away.
I was like ‘Whut. Um, no.’
“I just need a referral from a doctor, any doctor. You don’t have anyone who can see me sooner?”
“No, that is our earliest available appointment.”
“Then I need to a different doctor. Should I go to the emergency room?”
“Oh, no, don’t do that, we can get you in now as an immediate needs patient.”
I get in later that day to see a doctor, Dr. Nanul. First I have to go through the nurse who asks me a lot of questions, takes my blood pressure, my medical history, drugs I am on, my insurance, etc, the whole time I’m repeating “I just need a referral”.
“We have to do our procedures.” is the response.
Finally Dr. Nanul arrives, spends maybe five minutes poking and prodding and twisting my leg. I keep saying I just need a referral. He tells me to talk to the nurse about that and leaves. I do so and she acts as if its the first time she hears the request. She listens to my story, then goes ‘Ok, we will fax something over.’
So I go back the six floors to Dr. Mains office and this time am able to make the appointment. I double checked to make sure they take my insurance.
I get a call on the 14th, two weeks later, and am told they have to cancel my appointment because they do not take my insurance. They also called my sister who is my emergency contact number to tell her my appointment was canceled, which I didn’t like and confused my sister and they shouldn’t have done that.
So I go back to Dr. Mains office to complain and ask questions. They explain that my insurance and the card could actually be several different insurance plans, and that is why they were confused.
I offer to pay cash, in advance.
“No, we cannot do that, your insurance does not allow us.”
“The insurance that you do not deal with?”
“The billing people would have to send you a bill and it would send up a flag in their system and they would not be able to bill you. It would be against the law.”
“Its against the law for you to accept cash?”
“Yes. We don’t make the laws we just follow them.”
So now I need to find a knee doctor. I call the hospital ‘find a doctor’ number. They look me up and say ‘you saw Dr. Shapiro for your right knee, go see him’. Which is true, I saw him for my right knee before switching to Dr. Main, but didn’t like him because he was kind of a jerk and initially mis-diagnosed my problem. But it looks like I have no choice, so I go downstairs to Dr. Shapiro. Suite 1020.
At the desk, I double check they take my insurance. Somehow they were able to look it up on the spot. I ask how they did that, since I wonder why Dr. Main’s office couldn’t do that. The receptionist says its not something I can do, and only health care providers can do it. Oh and no, they do not take my insurance, sorry. What I need to do, they say, is call my insurance and find a doctor that way.
So I step out into the hall and call the 800 number for my insurance. I go through the annoying voice prompts:
“If you have not heard your option, please say ‘Something else'”
“I’m sorry, we did not recognize what you said. Please hold for the next available representative.”
Finally I get to speak to someone alive, Jackie.
First she tells me there is no such thing as a knee doctor.
“I’m sorry, unless you know your specialty you need, we cannot help you, and we cannot suggest one. When you say knee doctor, that could be, you know, a neurologist, an orthopedist -”
“That one! Orthopedist. I need to see an orthopedist!”
“Ok, hold on…. what’s your zip code… You need to go to 6308 8th ave suite 1020”.
(wait, suite 1020? That sounds familiar. 6308 8th ave… that would be…. the building I’m standing in right now!) “I just came from there, they told me they could not help me.”
“Ok, hold on… (ten minute wait in silence)… Go there and ask for Dr. Phpr, (Indian names are so cool) he is the one in our network.”
So I march back into suite 1020 and tell them I need to see Dr. Phpr. They give me a phunny – sorry, funny – a funny look and say
“Dr. Phpr is a back doctor. He doesn’t do knees. He wouldn’t be able to help you. Even if he was able to help you, we wouldn’t be able to see you without a referral. Even if you did have a referral from Dr. Nanul, that was for Dr. Main and we couldn’t accept it. And even if it were for Dr. Phpr, we still couldn’t accept it because Dr. Nanul is not in our network. And even if all those things were true we still couldn’t help you because Dr. Phpr is out of town.”
“Can I pay cash?”
“No, its against your insurance’s policy.”
“Dang. So there’s nothing you can do?”
“Like we said before you cannot see Dr. Shapiro because he’s not covered by your insurance. Maybe if you had a referral from the emergency room, we’d have to accept you then, but you don’t, so sorry.”
So I call the insurance again. (“Something else.” “I’m sorry, we didn’t recognize what you said, please hold.”)
I again get a hold of Jackie, who apologizes and says “we don’t know what doctors see knees, that’s just not part of our information”. Besides there is no one in Kenosha. I should go to Wheaton Fransiscan Hospital in Racine, we have lots of people in our network there, “one of them should be able to help you”. I get the address, am grudgingly accepting I need to make a trip to Racine and am about to hang up when she adds,
“But even if you go there they wouldn’t be able to help you without a referral.”
“What? I have a referral from Dr. Nanul.”
“No, sorry, that’s no good, that was for a different doctor. You’d have to get him to refer you to a specific doctor, one who is on our network.”
“How would he know who is on your network?!”
“See, John, that’s why you need a regular doctor who can refer you to the correct doctor in your area. You can’t just see anyone you want. Now if you had a referral from the emergency room…”
“Emergency room? What do you mean?”
“Any reference from an emergency room, the doctors have to accept you as a patient.”
Note this is the second reference to emergency room referrals, from two different sources, both saying the same thing, both offering me a path through the bureaucracy to see a doctor. It turns out, they were wrong, but I jumped on that solution. I went the emergency room in the basement.
I explained to the nice polite people behind the very thick bulletproof glass my situation. I said I didn’t like using the emergency room for non-emergencies, but would it solve my dilemma? The nice tired people behind the glass explained that yes, doctors would accept you, but A) They only have to see you once, there is no obligation for a follow up, and B) the doctor here in the emergency room might not give you a referral. But if I wanted to give it a shot, and didn’t mind waiting, they have to accept me as a patient.
So I check in and wait for three hours. Not bad, considering I have previously in an emergency room waited two hours with broken bones sticking out of my body. Three hours of relative comfort was nothing. There’s a lot of crazy people in the emergency room. Supposedly there was a bad accident that came in, some guy was shaking as he asked to see his brother and started yelling ‘Ghetto! Ghetto!’ (referring to the bulletproof glass which is difficult to speak through – you have to use a phone to talk to the receptionist in front of you) (turns out his brother was DOA 🙁 ), someone was talking about a bunch of drowning victims brought in, a blind guy was trying to navigate the stairs – pretty average for the emergency room.
While waiting, I call the insurance again and ask questions. I ask if I can look up doctors online, how the offices are able to look up my insurance, what if doctors refer to non-network doctors, and are there really three different plans but all use the same card. Jackie explains:
“You can look up specific doctors but you need to know their names. You can also get a list of doctors in the area that are covered as part of your plan but you need their medical specialty.”
“Health care providers – the receptionists behind the counter – can look up your health insurance information and they will know if they are part of your plan or not.”
“If a doctor refers you to a non-network doctor, then he needs to call the insurance company and let them know. The insurance will not pay anything out-of-network without a pre-approved payment override. No, we cannot take your word for it. The doctor needs to make the call.” (Which sounds pretty stupid. I’m not sure what motivates people to go to medical school, but I’m pretty sure its not to have to call insurance companies to negotiate payments for patients,)
“Yes, there are several different plans, they all have similar sounding names and use the same card, because they all fall into our ‘forward health’ category. The differences between the plans are minor.” (Ha!)
Finally, the doctor (Dr. Murray) rushes in and boy is he pissed, or really hopped up on adrenaline or something. Really quiet and still and tense body posture. Seemed angry. Didn’t ask any questions about my knee, just why I was here, who I talked to, and what did they say. He whipped out his pen and asked for the names of the receptionists, which I was regretfully unable to supply. He then walked out with a terse ‘I’m going to make some phone calls”, and I settled down to wait some more.
“Paging Dr. Nanul” comes over the hospital intercom.
“Dr. Nanul returning the page, ER please pick up” a few minutes later.
After about half an hour the doctor returns, hands me my discharge papers and says “I talked with Dr. Gershtenson, he said he will see you, call him tomorrow.”
“And if they tell me they won’t accept me because of my insurance?”
“That’s the best I can do for you.”
“Ok, I understand. Sorry for taking up your time. Things are messed up and you’re the only one who can help me.”
“Yup, its messed up, started about 3-4 years ago, and its only going to get worse. Good luck.”
That’s when the bomb threat happened. I’m not kidding. There was a bomb threat less than an hour later and they had to evacuate the building. Fortunately I was already out the door. I arrived at the hospital around 2pm and got out before 7pm, referral in hand. Not bad.
I went and got a drink at a bar I had never been to and, overhearing a passing remark about Game of Thrones, struck up a conversation with a random person and shared all my embarrassing escapades (Yes, I was that person), only to have her inform me she knew me and all about me and then proceeded to tell me all about me. And yes, she did know me. I was so embarrassed. I mean, what are the odds of that happening? Drive a man to paranoia.
Anyways, back to my story. Next day arrives. So I have a referral from the Emergency Room to see Dr. Gershtenson. They have to see me now, right? Wrong. I went there today and spoke with the receptionist, Linda, (I got her name this time), and she told me they cannot accept me as a patient because of my insurance.
“But I have a referral from the emergency room!”
“Yeah, but you can see other doctors. He could have referred you to someone on your network. We are not on your network. Here, call this number to your insurance and ask for a doctor who can see your knee-”
(Denouement. I interrupted her, told her the ER doctor personally talked with Dr. Gershtenson and he personally said he could see me. Linda took down my name and number and said she will “investigate” and call me back. I am currently waiting for the call.)
Everyone is just doing their job, and from the looks of it, doing their job correctly. Insurance people are there to make money and are not going to pay someone if they have not negotiated a rate in advance – else they might get ripped off.
The lady on the phone cannot recommend a doctor for me – she’s not a doctor herself, what if she gets it wrong?’
The receptionists don’t do the billing, they don’t know the laws, they are just following orders from the billing department. They’re not even hired by the doctors – else doctors would be spending all their time overseeing staff instead of treating patients.
I can’t pay cash because the hospitals are ripping people off and billing them directly, because they are more likely to pay than the insurance companies. This wouldn’t be so bad if prices weren’t so high. And prices are high because of lots of regulation and because insurances aren’t paying doctors their fair worth, so they have to make up for it somehow, and that means raising prices.
And you have to have a referral from a general doctor, because patients are too dumb to know what sort of doctor they should see. I’m an exception because I had this happen to my right knee.
The only solution I can think of is eliminate the insurance companies. Have someone who is not interested in profit running it (ie. the government). Have hospitals send bills directly to them.
But that’s never going to happen in America. People are already flipping out over Obamacare as some sort of government takeover. Obamacare doesn’t even do that much – it says everyone has to have health insurance and if you cannot afford it, the government will subsidize insurance providers who accept you. It doesn’t cut out insurance at all.
Maybe a different solution is force insurance companies by law to pay for anything from any doctor. There will be a lot of abuse and resistance but, meh. Another helpful thing would be eliminate the whole referral concept. Sure, people are stupid and will end up wasting a lot of doctor’s time, but at least it will empower the people. Right now insurance is controlling everything.
And the last solution is deregulate everything. Create a competitive market. Backyard MRIs. Outsource surgeries to Mexico. At least I’d be able to see a doctor. He’d probably get my diagnosis wrong and screw up my knee even worse, but maybe I’d get lucky. 🙂