Saturday, January 28, 2012

A Pittance

I glanced quickly at the papers on my desk. I had a few minutes between patients, and the biller had placed the statement neatly on top of a pile of labs. The word denial stood out amongst the jumble of letters on the page. I read further.

Claim denied due to duplication of care. Services payed already to emergency physician.

I shook my head in disbelief.


The notification that John was in the emergency room came blinking across my screen. Of course, he hadn't called me to say anything was wrong. I looked down at my watch. I could be out of the office and in the emergency room in five minutes.

I ran down the steps and pushed my way between pedestrians as I crossed the hall entering the emergency room. The morning rush had yet to materialize. John was one of the only patients.

I scanned through the nursing notes and the emergency physician's impressions. A cat scan of the chest was already ordered. When I entered the room, John was sleepy from a dose of morphine. We discussed his chest pain. Although he felt a little worse then usual, it was the same pain that had been present for years. I palpated his right rib cage and he yelped in pain.

His labs, EKG, and chest X-ray were normal. When I perused the medical record further, I found that the same emergency physician had scanned his chest the month before when he showed up with a similar complaint. In fact, He received five CTs in the last year. Surprisingly, none of them showed a pulmonary embolism.

It took a few moments to find the ER Attending. When I questioned her about the need for another cat scan, she looked at me appraising.

He said he never had chest pain before.

I gently reminded her that she saw John recently for the same complaint, and she started to blush.


I discharged John with a diagnosis of costochondritis and a prescription for a non steroidal anti-inflammatory. By the time he followed up a few days later, his pain was gone.

As I see it, I saved John an unnecessary dose of radiation and IV dye. I relieved the emergency room physician by doing her job for her. And I reduced the cost to the insurance company by hundreds of dollars.

Apparently the pittance I bill for my services,

is asking too much.


Anonymous said...

Maybe it would have saved time by talking to the ER doc on the phone. I cover ER and do primary care, and discourage ER use unless it is an emergency. I get burned all the time by people who go to the ER for routine care, causing me to leave my scheduled patients to wait for me. Then, the ER patients don't pay. Once someone shows up in the ER, if they are not my patient, I have to treat them assuming the worst. What I really hate is getting up at 2 am to see some deadbeat drug seeking freeloader. Still have to assume the worst and treat them with respect.

sjdmd said...

Thank you for responding to my tweet last evening. I take your point.

I'm writing here because your response raises an issue where you have an opportunity to help alter the outcome.

The involved emergency physician's Chair/Chief must know of this patient encounter if s/he hasn't been told previously you must do so immediately. I say that speaking as an Em Phys, trained in EM in the 1970's w/35+ years of practice and many years as a Chair.

This is a hugely important teachable moment for the members of the Department of EM--more important than the instant failure of professionalism by the one Em Phys--a hopeless exercise at this date weeks-to-months after the patient care event.

The Department of EM must get involved in reducing over-utilization for patient benefit, institutional benefit and their own benefit. I could write more, but enough for now on a blog post.

Thank you for sharing what must have been a frustrating patient encounter that kept on 'giving.'