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Abomination

Wayne Gray

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I manage medical labs. Part of that management is I decide which tests ordered by our providers are integrated into our EMR (electronic medical record). Some will never be "mapped," as it's called, because they're esoteric, or just too rarely ordered; it takes effort and time to do this mapping, so we pick and choose which get added.

Well at the request of a number of providers who particularly like this odd genetic-based test for cancer screening, I began the process of mapping this new item.

Part of that mapping process includes digging up something called CPT codes assigned to the testing. So I contact the company. I ask for the codes, as they're not available on their website (an oddity I could overlook). This lady tells me, "Oh the CPT codes change based on payor. You know, the insurance."

I sat there a moment, then finally found my voice. "So ... what you're telling me is based on how good someone's insurance is, your organization is picking and choosing which procedures to run, completely apart from the legal orders submitted by the provider?"

Silence for a good twenty seconds. "Uh," *whispering to someone* "I think I need to give you to my supervisor."

"That sounds great."

"Please hold."

"Sure."

I'm put on hold. Five minutes later I get a guy. "Hi, I hear you have questions about our test?"

"I sure do." I repeat my question, and add, "Feel free to tell me I'm wrong. Because unlicensed individuals making medical judgments based on financial situations is antithetical to everything my organization stands for. So I'd love to be able to tell my medical directors that isn't happening."

Silence. Finally, a cleared throat. "I feel as if there's no good way to answer your question at the moment. I'll have to do some research and get back to you. May I have your phone number?"

"Sure."

I hung up after I gave him my number.

Here we are. This ... right here, is why for profit healthcare is an abomination.

Edit: 18 June 2020 - Still no call. I've dropped this into the lap of our compliance officer. He's talking about turning them over to CMS (the folks governing MediCal - California's version of Medicaid) for fraud. That could end them entirely if CMS decides to go after them. Good riddance.

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9 minutes ago, Mikiesboy said:

OMG ... omg ... that is ... i can't even ... what will work here?  Horrific.. an abomination are the perfect words. 

I keep hoping they're wrong. Maybe I got the wrong information, and they're just mistaken. If it's not the wrong information, then they're breaking all sorts of laws. There's a lot of financial incentive to do so, and getting caught will mean a fine - one that is easily offset by the amount they stand to earn from this practice.

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18 minutes ago, Wayne Gray said:

I'll make them pay for it if they didn't. We will never send another test to them if this is true.

This is my sphere. If I tell my boss this company is committing fraud and using the names of our providers to accomplish it, then they will never see the name of another of our patients.

We'll see if that's necessary.

Wow. 

You are definitely doing the right thing. Insurance companies have no interest in the people they are there to serve. Bottom line will always  be profit. Same can be said for pharmaceutical companies. 

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19 minutes ago, MichaelS36 said:

Jesus, Wayne. Our system is not perfect, but I've never heard of this .. 

It sucks. It's the same system that let's companies offer insurance to their employees which cost the worker over $700 per month for a family plan which has a $6,000 PER PERSON deductible/$12,000 family deductible. Then you are still on the hook for 20% of all costs after the deductible is met. 

Throw in a government that penalizes you for not having insurance and only offers a subsidized plan if your employer dosen't offer you insurance. 

That's just one example. No matter how you do the math, most people are one major medical event away from bankruptcy.

It's more than broken, it's shattered. 

 

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3 minutes ago, Brayon said:

My last job before disability was working at United Healthcare as a Provider Phone Rep. I talked to medical providers all day about benefits and claims. The part that always got me was when a provider called in and said, "We billed $2000.00 for this procedure, but you only paid us $50.00." The typical response was, "That's the contracted rate you agreed upon when you signed said contract. Shall I give you the number to your contract sales representative to get a copy of your contract and to discuss future contracts?"

Then I cried a little inside, thinking how much people without insurance get charged because people can't read contracts. So they are recouping the loss upon them.

The companies will always get their money, and it doesn't matter who is in the way.

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1 minute ago, Wayne Gray said:

The companies will always get their money, and it doesn't matter who is in the way.

And Hospitals are the fucking worse.

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Ugh, that's just horrifying... I hate this world sometimes. 

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Thanks for the comments, all of you.

A little update: Still no call. I've dropped this into the lap of our compliance officer. He's talking about turning them over to CMS (the folks governing MediCal - California's version of Medicaid) for fraud. That could end them entirely if CMS decides to go after them. Good riddance.

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