Sunday, December 18, 2005

Why I ask patients about insurance status

An anonymous commenter on Kevin, MD wrote:
The first question out of the mouths of nearly all doctor's office staff is "What's your insurance?" I have lost track of how many doctors muse over what to do next and look at my chart murmuring, "What's your insurance?" Yes, they may be figuring out how to best work through the system of my particular insurer, but the net effect is thinking INSIDE the box. I have now taken to telling every doctor EVERY time I see them, "I don't care whether my plan pays for a particular course of action -- I want to know what YOU think is the best thing to do, regardless of cost, and then we'll decide what to do." I am looked at like I'm a Martian, because doctors don't think that way.
In sleep medicine, insurance status is crucial. Most sleep patients are going to need some type of sleep study to evaluate for sleep apnea. Insurance status is very important in properly carrying out and interpreting the sleep study. For example, if a person has Medicare, specific steps need to be taken in order to qualify the patient for the standard treatment of sleep apnea, CPAP. The sleep study pretty much has to be a full-night diagnostic study, rather than a split-night study. Like most insurance companies, Medicare requires an apnea-hypopnea index of at least 5 to qualify for CPAP. However, Medicare has a different definition of a hypopnea than other insurance companies. Medicare requires a 4% oxygen desaturation for hypopneas, most other agencies don't. Recently I had a young patient who I forgot to look up his insurance status before I wrote the orders of his sleep study. It turned out that he had Medicare due to a disability (there are a lot of non-elderly people with Medicare out there, you have to ask). The technician had to spend an additional 45 minutes rescoring the respiratory events to meet Medicare standards and I had to spend an additional 15 minutes reading the study again- Basically a wasted hour because I did not ask about insurance status.
Disclaimer: I have simplified Medicare requirements in the above discussion; it's actually more complicated, especially with the large number of dual-elgibles. This blog does not provide legal advice, you should consult an attorney if you plan on treating Medicare patients.

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