Best patients to take (insurance wise?)

core0 · Oct 12, 2007

I have tricare (hubbies Navy) and my doctor participates in Tricare Prime which means any office visit, as well as any tests he orders, are free for me. I *think* he must be getting reimbursed for everything he orders for me.. otherwise I don't see why he would do it? - He ordered 26 different tests. (maybe the LAB is the ones who seek reimbursement, though? I am not sure)
The thing is: As an NP someday, I want to feel like I can order a whole big panel of blood tests when I get a new patient...
I know when I was at Kaiser, my doctors would tell me they "couldn't order that" and I read somewhere that the more tests they ordered, the lower paycheck they got.
The other thing is; I wouldnt want to order a lot of tests for a patient who has a huge co-pay or pays a large percentage..
SO, what insurance provider do you guys works the best for you?
Will most insurance companies pay a portion of Almost any test that an NP orders for his/her patient?

What insurance company pays for which tests is not a good way to rate insurance companies. The better way to rate them is what they pay you and how much a hassle are they to work with.

Kaiser is a special situation since it is an HMO. The NPs there (and physicians) are employees of the HMO. They are rated on a number of things and there is pressure not to spend money.

Of the other payors Medicare/Medicaid generally defines the bottom of the barrel. Medicare in particular has a lot of rule about labs. For example they will only pay for certain labs once a month. The patient is on the hook for the costs if Medicare does not cover it. Tricare is very similar to Medicare and pays very poorly. They have trouble finding providers in some areas.

Standard insurance comes in a variety of flavors. There are HMOs, PPOs, etc. In addition within these there are different coverages depending on what plan you have. When I was in Colorado the big payor Pacificare had 134 different insurance contracts. The pay for you will be whatever you have negotiated with the company. Usually some percent above Medicare. There are usually very few prohibitions on labs unless it involves genetic testing or specialty testing which usually require a prior auth.

More irritating are the prior auths for Medications or radiology. These take a ton of time to get authed. My previous practice dropped an insurance plan after the manager figured out he was going to have to hire another person just to take care of the auths for the plan.

The newest wrinkle is the high deductible plan. These require the insured to pay for the first $2-5000 of any expenses. They will usually pay for one physician a year and some will pay for screening exams such as mammograms. The patient is on the hook for any radiology or lab costs.

Ultimately you work with the patient but you can't let the cost of a test determine how you practice. If the test is necessary then it is necessary if the patient has insurance or not.

David Carpenter, PA-C

diapason05 · Oct 12, 2007

What insurance company pays for which tests is not a good way to rate insurance companies. The better way to rate them is what they pay you and how much a hassle are they to work with.
Kaiser is a special situation since it is an HMO. The NPs there (and physicians) are employees of the HMO. They are rated on a number of things and there is pressure not to spend money.
Of the other payors Medicare/Medicaid generally defines the bottom of the barrel. Medicare in particular has a lot of rule about labs. For example they will only pay for certain labs once a month. The patient is on the hook for the costs if Medicare does not cover it. Tricare is very similar to Medicare and pays very poorly. They have trouble finding providers in some areas.
Standard insurance comes in a variety of flavors. There are HMOs, PPOs, etc. In addition within these there are different coverages depending on what plan you have. When I was in Colorado the big payor Pacificare had 134 different insurance contracts. The pay for you will be whatever you have negotiated with the company. Usually some percent above Medicare. There are usually very few prohibitions on labs unless it involves genetic testing or specialty testing which usually require a prior auth.
More irritating are the prior auths for Medications or radiology. These take a ton of time to get authed. My previous practice dropped an insurance plan after the manager figured out he was going to have to hire another person just to take care of the auths for the plan.
The newest wrinkle is the high deductible plan. These require the insured to pay for the first $2-5000 of any expenses. They will usually pay for one physician a year and some will pay for screening exams such as mammograms. The patient is on the hook for any radiology or lab costs.
Ultimately you work with the patient but you can't let the cost of a test determine how you practice. If the test is necessary then it is necessary if the patient has insurance or not.
David Carpenter, PA-C

Wow!! Well, I don't know if certain things would be deemed necessary by other physicians, but I know that hypothyroidism is more common than some people seem to think and I believe I'd feel lit was necessary to test for more than just the TSH in order to make sure my patients symptoms were not caused by this. Anyway, Thank you for your answer. I guess that is just something I will have to navigate in the future when I am finally a practicing NP. I do not think I will want to work for an HMO, though. :idea:

core0 · Oct 12, 2007

Wow!! Well, I don't know if certain things would be deemed necessary by other physicians, but I know that hypothyroidism is more common than some people seem to think and I believe I'd feel lit was necessary to test for more than just the TSH in order to make sure my patients symptoms were not caused by this. Anyway, Thank you for your answer. I guess that is just something I will have to navigate in the future when I am finally a practicing NP. I do not think I will want to work for an HMO, though.

You do need more than a TSH to diagnose hypothyroidism. At the very least you need a T4 and a TSH to determine if it is primary or secondary hypothyroidism. Also thyroid antibodies can be helpful in a new diagnosis. Anyone who does not do tests to save the company money is not serving their patient well. After you make the diagnosis you only have to do TSH to make sure you are in range.

The real pain is radiology. You can get pretty good at guessing what symptoms you have to put down for a particular test to get it approved but every once in a while you would face the dreaded "independent review". These are physicians that are hired by the insurance company to review requests for radiology tests (yeah independent right). They need "clinical data" and determine whether the patient needs a test. Most of the time its a matter of waiting til they get on the phone then explaining things.

Every once and a while I would get some idiot who had a different medical diagnosis. If that happens then I pull out the big hammer. You start by asking for the spelling of their name and the medical license number. Then you inform them "Dr. X I am noting in the chart that you are making a medical decision without having seen the patient. My clinical assessment is that the patient needs the test. I am also noting that you are overiding this decision without having physically examined the patient and that you will be responsible for any untoward outcomes." That would result in a lot of spluttering and pretty much ends up in approval in short order.

In my current job its even easier. I just say well we transplanted the patients liver in xxxx. They usually give me whatever I want then:uhoh3:.

David Carpenter, PA-C

Trauma Columnist · Oct 12, 2007

My secondary insurance is Tricare Standard so I think I can speak to that. I live in a totally non-military area. Most providers in my area have heard of Tricare of course and it is of course billed, but I wouldn't want to live here with ONLY Tricare.

That said, I spend at least 20 minutes to 1 hour of each and every workday trying to get pre-authorizations for my patients. This is how stupid it has gotten! I have one pt who is now a dialysis patient for a failed renal transplant. He must stay on anti-rejection meds even though the kidney isn't functioning well. After obtaining a level, it was determined we needed to lower his Cellcept to 250mg instead of the h500mg he was on. Talk about a hassle: faxing lab results, talking to 2-3 folks on the phone, etc.. Very time consuming for me but necessary for the pt.

Most of my patients are in the ESRD Medicare program. However, some are still private pay because they are able to work. It is nothing but a headache to try to figure out which lipid-lowering med, which ;anti-rejection med, which whatever-I-want-to-order med is covered and how much it will cost the pt.

diapason05 · Oct 12, 2007

My secondary insurance is Tricare Standard so I think I can speak to that. I live in a totally non-military area. Most providers in my area have heard of Tricare of course and it is of course billed, but I wouldn't want to live here with ONLY Tricare.
That said, I spend at least 20 minutes to 1 hour of each and every workday trying to get pre-authorizations for my patients. This is how stupid it has gotten! I have one pt who is now a dialysis patient for a failed renal transplant. He must stay on anti-rejection meds even though the kidney isn't functioning well. After obtaining a level, it was determined we needed to lower his Cellcept to 250mg instead of the h500mg he was on. Talk about a hassle: faxing lab results, talking to 2-3 folks on the phone, etc.. Very time consuming for me but necessary for the pt.
Most of my patients are in the ESRD Medicare program. However, some are still private pay because they are able to work. It is nothing but a headache to try to figure out which lipid-lowering med, which ;anti-rejection med, which whatever-I-want-to-order med is covered and how much it will cost the pt.

Wow. Thats so not efficient. I really think something has got to give with the insurance stuff vin the next 10-20 years.

diapason05 · Oct 12, 2007

You do need more than a TSH to diagnose hypothyroidism. At the very least you need a T4 and a TSH to determine if it is primary or secondary hypothyroidism. Also thyroid antibodies can be helpful in a new diagnosis. Anyone who does not do tests to save the company money is not serving their patient well. After you make the diagnosis you only have to do TSH to make sure you are in range.
The real pain is radiology. You can get pretty good at guessing what symptoms you have to put down for a particular test to get it approved but every once in a while you would face the dreaded "independent review". These are physicians that are hired by the insurance company to review requests for radiology tests (yeah independent right). They need "clinical data" and determine whether the patient needs a test. Most of the time its a matter of waiting til they get on the phone then explaining things.
Every once and a while I would get some idiot who had a different medical diagnosis. If that happens then I pull out the big hammer. You start by asking for the spelling of their name and the medical license number. Then you inform them "Dr. X I am noting in the chart that you are making a medical decision without having seen the patient. My clinical assessment is that the patient needs the test. I am also noting that you are overiding this decision without having physically examined the patient and that you will be responsible for any untoward outcomes." That would result in a lot of spluttering and pretty much ends up in approval in short order.
In my current job its even easier. I just say well we transplanted the patients liver in xxxx. They usually give me whatever I want then:uhoh3:.
David Carpenter, PA-C

OOo sounds like a hassle. I know the medical literature states that levothyroxine is the way to go when treating hypothyroidism, but I no longer believe it because when I take too much, I get heart palps and when I take "enough" I still have many symptoms of hypothyroidism. Also, because I have autoimmune hypothyroidism (hashimotos), I need to keep my TSH under 1. A lot of my doctors didnt think of this, though some knew. I get really mad when someone tells me a TSH of 3.56 is "normal" and I am just fine. My life has become a small hell since my thyroid started going down.

I am going on Armour thyroid this week and my doctor will be monitoring my TSH, T-4 and free T3. I've researched a lot about this and I don't feel like synthetic t-4 does the job. Its better than NOTHING yes, but its not working, in my opinion. I'm going to see how armour works for me. Anybody who might have thyroid problems is going to definitely have me on their side when I'm an NP.

I have already decided that a lot of doctors dont seem to take into consideration how the whole body works together. I want to be an NP that helps people get to the root of their problem. I pray to God I can get a job that allows me some time with my patients to get full medical histories/symptoms- I do NOT want to be like many of my previous doctors and just medicate someone to solve one symptom. (Like I was on birth control for stopped periods and anti-depressents for my depression- Ive only had two doctors ever show any interest in my medical history- Most ALWAYS cut me off and won't LISTEN- and show some knowledge about what could be going on. I had to diagnose myself initially and demand the tests.)

core0 · Oct 12, 2007

OOo sounds like a hassle. I know the medical literature states that levothyroxine is the way to go when treating hypothyroidism, but I no longer believe it because when I take too much, I get heart palps and when I take "enough" I still have many symptoms of hypothyroidism. Also, because I have autoimmune hypothyroidism (hashimotos), I need to keep my TSH under 1. A lot of my doctors didnt think of this, though some knew. I get really mad when someone tells me a TSH of 3.56 is "normal" and I am just fine. My life has become a small hell since my thyroid started going down.
I am going on Armour thyroid this week and my doctor will be monitoring my TSH, T-4 and free T3. I've researched a lot about this and I don't feel like synthetic t-4 does the job. Its better than NOTHING yes, but its not working, in my opinion. I'm going to see how armour works for me. Anybody who might have thyroid problems is going to definitely have me on their side when I'm an NP.
I have already decided that a lot of doctors dont seem to take into consideration how the whole body works together. I want to be an NP that helps people get to the root of their problem. I pray to God I can get a job that allows me some time with my patients to get full medical histories/symptoms- I do NOT want to be like many of my previous doctors and just medicate someone to solve one symptom. (Like I was on birth control for stopped periods and anti-depressents for my depression- Ive only had two doctors ever show any interest in my medical history- Most ALWAYS cut me off and won't LISTEN- and show some knowledge about what could be going on. I had to diagnose myself initially and demand the tests.)

While this comes close to giving medical advice, the symptoms you describe are not being caused by hypothyroidism, but are more likely being caused by autoantibodies. Here is a nice article of Hashimoto's:

http://www.postgradmed.com/issues/2000/01_00/fatourechi.htm

Hopefully you are seeing an endocrinologist since they are much better at understanding Hashimoto's than IM. It is not uncommon to see a patient go through several episodes of hyper and hypothyroidism (says the practitioner who causes several cases of Hashimoto's per year).

David Carpenter, PA-C

Editorial Team / Admin · Oct 12, 2007

Let's stay on topic: Best patients to take (insurance wise?)

We need to keep personal medical issues out of the discussion.

Thanks.

core0 · Oct 12, 2007

Let's stay on topic: Best patients to take (insurance wise?)
We need to keep personal medical issues out of the discussion.
Thanks.

OK I wouldn't take diapason05's insurance because we don't take tricare. Happy:D.

Dave

Editorial Team / Admin · Oct 12, 2007

Happy:D.

Very;)

Thanks!

Trauma Columnist · Oct 12, 2007

In my dialysis patients, most have the Medicare ESRD program for their primary insurance. The gov't is the worst. Oh and I'm sure this is no surprize for providers but the Part D's change formularies as often as I change haircolor! No kidding! You can write for one med and the next month, its not on the formulary and neither you nor the pt know it until they try to get refills. Yikes.