Bad advice on referrals
I strongly disagree with the advice on handling referral requests given by
Drs. Amy Rosenberg and Peggy Rothbaum in "Managing
anger in a managed care age" [May 7]. When we refuse to provide referrals
we risk provoking the very anger this article aims to teach us to manageand
we may end up on the wrong side of the law as well.
Verbally denying a referral will almost guarantee that your patient will regard you as a henchman for the health plan. A physician should just send the authorization form to the carrier and let the plan decide whether to approve or deny it.
Besides, the decision to deny a referral is not always totally the doctor's
call. In the case of the rhinoplasty discussed in the article, for instance,
the decision to approve coverage may have legal implications. California and
other states have defined reconstructive surgery in their health codes, and
whether a particular case meets the criteria for coverage must be determined
by a surgeon qualified to do the operation, not the patient's FP.
And don't discount the possibility that rhinoplasty might actually be covered under a liberal health plan's definition of cosmetic procedures. Or maybe it will turn out that the patient has a conditionlike a fracturethat qualifies him for the procedure anyway.
Remember that a patient has rights of appeal when a referral is deniedrights that he can't exercise if you never submit the referral in the first place. And woe to you if the patient decides to go after you for denying him the opportunity to appeal and files a grievance with the carrier, or if a Medicare beneficiary complains to the State Medical Board that you're not following state law. Investigations, chart reviews, and credentialing hassles may follow.
It's just business, nothing personal
Before he was sued by a patient who had given no hint of displeasure with
his care, I'm sure rheumatologist Mark Lopatin believed that our legal system
stood for truth, honor, and justice. ["Malpractice:
I knew she was trouble," June 4]. But by the time he was pressured into
settling this suit, he'd learned that it's all about money, with liability insurers
acting as indirect paymasters for attorneys.
Lopatin says he did his best to accept the fact that in litigation "it's just business; nothing personal." Sounds like a scene from The Godfatheronly this time it was Lopatin playing the role of the guy who gets gunned down, a victim of the legal system.
Just get a referral
With all due respect to your consultant ["Starting
a practice: 9-10 months out. Loans, leases, and credentialing," Apr. 23],
can you imagine a physician meeting with four or five banks to investigate
practice financing? What professional has that kind of time, not to mention
the additional time to evaluate and follow up on the bank's proposals? I recommend
checking with colleagues for referrals to banks experienced in such matters.
Steven H. Austin
Executive Vice President
Letters to the Editors. Medical Economics Aug. 20, 2004;81:8.