Doctor Grumpy in the House

Dr. O is a psychiatrist, who says:

Occasionally patients make threats towards others. When that happens we're required to inform the individual in question.

In this case the patient was in the hospital, and had threatened pretty much his entire care team, including the surgeon who'd recently operated on him. So I had to call him, too.

Dr. Scalpel: "This is Dr. Scalpel, returning a  page."

Dr. O: "Hi, I'm the psychiatrist taking care of Mr. Haldol, who you saw last week. I just wanted to let you know he's been making statements about killing you."

Dr. Scalpel: "Oh, I signed off on him over the weekend, so he really isn't allowed to be doing that, if you could have psychiatry let him know."

Dr. O: "I am the psychiatrist, and I'm just calling to let you know he threatened you. Whether you signed off doesn't matter to him."

Dr. Scalpel: "Well, you'd think it should. Anyway, you should probably consult psychiatry to evaluate him, and let him know I signed off."

Dr. O: "Yes, that’s me. I'm the psychiatrist."

Dr. Scalpel: "He probably needs a psychiatric diagnosis."

Dr. O: "Yes, I'm addressing that."

Dr. Scalpel: "Yeah, that should happen, so consult psychiatry on him."

Dr. O: "I'm just informing you of what he said. Have a good day."

Dr. Scalpel: "Thanks, don't forget to consult psychiatry on him."

As of the time of this writing, me and the nurses are taking bets on whether Dr. Scalpel orders a consult for psychiatry.

Mary: "Dr. Grumpy's office, this is Mary."

Ms. Soap: "Hi, I was referred to you, and I need to get in right away. Dr. Tacky was sending over a referral."

Mary: "Hmmm, that hasn't come over yet, but the fax machine has been busy. I can schedule and call you back if there's an issue?"

Ms. Soap: "Oh, thank you!"

Mary: "Okay, let's see... Actually our 9:30 patient for tomorrow morning had to cancel a few minutes ago, will that work?"

Ms. Soap: "That's perfect! Thank you!"

Mary: "Okay, we will see you then."

Ten minutes later

Ms. Soap: "Hello?"

Mary: "Hi, this is Mary, from Dr. Grumpy's office. You made an appointment a few minutes ago?"

Ms. Soap: "Yes, did you get my referral?"

Mary: "I did, but it says you're supposed to see a neurosurgeon, not a neurologist. Dr. Grumpy is a neurologist, so he's not who you're supposed to see."

Pause

Ms. Soap: "So he's not the kind of doctor I was referred to?"

Mary: "No ma'am, I'm sorry. I can give you names of some..."

Ms. Soap: "And. You. Waited. Until. The. Day. Before. My. Appointment. To. Call. And. Tell. Me. This?"

Mary: "Ma'am, you just made the appointment 10 minutes ago."

Ms. Soap: "That's beside the point. And you also - deliberately - didn't tell me when I made it that Dr. Grumpy isn't the kind of doctor I'm supposed to see."

Mary: "I didn't know that until the referral came in. I told you I didn't have it yet."

Ms. Soap: "You people suck."

Click

Guy walks in, comes up to front desk.

Mary: "Hi, can I help you?"

Pete: "Hello, I'm Pete, I have an appointment with Dr. Grumpy at 1:45."

Mary: "Okay, let me have you fill this out... pens are over there... Can I get a copy of your insurance card?"

Pete: "Sure."

He hands over his card, starts doing the form.

Mary: "Oh, you work for Deuce Brown Plumbing. That's a big company, I think you guys have been to my house a few times."

Pete: "Yeah, we have people all over Grumpyville. I'm covering for this part of town today. Here's your form back."

Mary: "Thanks, here's your card back. Have a seat and the doctor will be out in a few minutes."

Pete sits down, picks up a magazine. His phone rings.

Pete: "Deuce Brown plumbing, this is Pete... Yes... A septic tank? Yeah, we... yeah, that doesn't sound good... overflowing out into your living room... hang on. Excuse me, uh, Mary?"

Mary: "Yes?"

Pete: "Can I reschedule my appointment? Sorry, but I have a work emergency. A lady has..."

Mary: "Yeah, that's fine. Why don't you take care of her, I understand. You can call back later."

Pete: "Thanks... I'll be there in about 15 minutes ma'am... yeah, uh, I'd probably take the dog outside and hose him down..."

Pete ran out of the office.

Dr. Grumpy: "Are you allergic to any medications?"

Mrs. Leavening: "Yeah, I don't know what it's called, but there's something they put in bread that makes me fat."

Dr. Grumpy: "Hi, folks, good to see you again, been a few years. What brings you in today?"

Mrs. Corn: "I wanted to get my MRI results."

Dr. Grumpy: "Hmmmm... I don't show that I've ordered an MRI on you for around 5 years."

Mr. Corn: "She had one last week, and we've been waiting to hear the results."

Dr. Grumpy: "I don't see that I ordered it. Who did?"

Mr. Corn: "We thought you did."

Dr. Grumpy: "No... What was it of anyway?"

Mrs. Corn: "I think it was my head."

Mr. Corn: "I thought it was your back."

Mrs. Corn: "I don't know, it was a body part. Do they do stomach MRI's?"

Dr. Grumpy: "Where did you have it done?"

Mrs. Corn: "Local MRI, across the street."

Dr. Grumpy: "Mmm... Nothing there on you for a few years."

Mr. Corn: "Maybe it was the place over on the north side? You know, the one with the MRI machine?"

Mrs. Corn: "I thought that place closed."

Mr. Corn: "Oh, maybe it was the one downtown, can you look there?"

Dr. Grumpy: "No, I only have access to the Local MRI system. Do you have it written down?"

Mrs. Corn: "It's on my desk at home. I didn't think you'd need to know that, since you ordered it."

Dr. Grumpy: "I didn't order it. What other doctors have you seen recently who may have ordered it?"

Mr. Corn: "We have them written down on the calendar on the fridge. I figured all the records were in the system."

Dr. Grumpy: "Maybe their system, not mine. You should probably check your recent appointments to see which doctor may have ordered it, and contact that office."

Mrs. Corn: "That seems like a lot of work. Wouldn't it be easier if you just ordered another MRI?"

Dr. Grumpy: "Do you have a medication list?"

Mr. Skoal: "Yeah, it's in my wallet, hang on. Hey doc, can I have your trash can next to my chair for the visit?"

Dr. Grumpy: "Sure, here it is, are you okay?"

Mr. Skoal: "Yeah, I just need something to spit my chewing tobacco in."

Dr. Grumpy: "Okay, uh... let's have a look at the med list."

Mr. Skoal: "Here you go. Ya know, my family doc has a spittoon in every room in his office. Maybe you should, too."

Dr. Oldasdirt is an internist across the street. He takes every managed care insurance known to man.

Occasionally one of his patients needs a neurologist and is referred to me. That's fine, it's my job.

The managed care patients he sees generally need a referral to see a specialist. This is pretty common in American medicine, and has been since at least the late 80's. A form shows up on the fax machine saying something like "AUTHORIZED: patient Kris Kringle, DOB: 8-17-29. National Illness Insurance HMO plan. 4 visits. To see Ibee Grumpy, neurology, for Rangifer's disease."

So Mary files it. A few days later, when Mr. Kringle calls to see if we got the referral she looks it up, says "yes" and schedules him. When we send in a bill for his visit we have to include the referral to make sure we get paid.

About 3 months ago one of his referrals showed up before Mary got in, so I pulled it off the fax. I was about to put it in her filing book when I noticed something different about it.

At the bottom it said: "Only valid for CPT level 2."

To explain this, medical office visits are billed by CPT codes, ranges 1-5, with 1 paying the least and 5 paying the most. The difference is based on how complex the case is, how much time you spend with the patient, what percentage of that time is spent talking vs. doing an exam, whether you're seeing them on a day that does or doesn't end in a "Y," if Mercury is in retrograde, etc. For the record, there are more than 10,000 CPT codes for different stuff,  but I'm just talking about office visits.

I began digging through Mary's file. No referral from any other doctor with that insurance had such a qualifier. It looks like the ones from Dr. Oldasdirt had started including the line about a week previously - fortunately I hadn't seen any of those patients yet.

Basically, what Dr. OldasDirt (or his office staff) were doing was putting a cap on how much I could get paid for the visit, no matter how much time I spent or how complicated the patient was. A level 2 new patient CPT code applies to visits between 15-29 minutes, and (as of 2024) pays a whopping $71. So that's what I get whether they take up 15 minutes or 90 minutes.

This isn't, at least to me, acceptable. Basically I'm agreeing to a set fee, without even knowing why the patient is coming in. Yeah, they could be simple, like carpal tunnel syndrome, but not likely in my field. You think you can take a history, examine, and explain to grandpa and his 7 person entourage what Alzheimer's means in 29 minutes? Good luck. The alternative is to have an alarm go off at 29 minutes, and say "Times up!" & leave the room.

Try calling Target and saying "can I buy any item in the store for $5, in advance, without you knowing what I'm getting until I check out?" I'm pretty sure they're not going to play.

So Mary called Dr. Oldasdirt's office and asked for a new referral without that line. She was told no, that was their new procedure, and if we didn't like it they'd stop sending me patients. With my approval she said okay, and shredded the referrals from them.

If they can find a neurologist desperate enough to work under that condition, more power to them.

Some out there are going to say I'm just here for the money, and don't give a damn about those patients. Whatever. The truth is that I'm here for the patients. This job is what I love. But I also have to pay both of my awesome staff their salaries, and my rent, and all the other overhead items. Not to mention my own mortgage, utility bills, kids college tuition, and so on. I can't help any patient if I can't keep my office open.

Why is Dr. Oldasdirt doing this? I have no idea. Other doctors haven't sent patients from the same insurance to me with that limitation, so I doubt it's the plan. Maybe he was hoping I'd start refusing to see his patients for whatever reason. Maybe the insurance is secretly letting him pocket the difference as a kickback.

I don't know, probably never will.

Dr. Grumpy: "So let's work on that MRI... What dates, or days of the week, work best for you to have the study?

Ms. Dixon: I'm not sure yet, I need to make a call."

Dr. Grumpy: "That's fine, just call back after you know what days work with your job to get this done."

Ms. Dixon: "Actually, I need to call my astrologer."

Dr. Grumpy: "Your astrologer..."

Ms. Dixon: "I don't want to have it done at a time when the planets are in the wrong position to affect the results, you know what I mean?"

Dr. Grumpy: "Uh..."

Ms. Dixon: "I mean, if Mercury is in retrograde that can screw up the machine's magnetic field, right?"

Dr. Grumpy: "Actually..."

Ms. Dixon: "She knows a lot about this stuff, she went to a special school or something like that."

Phone person #1: "Thank you for calling Low-Cost Radiology, where our prices reflect our quality every day! Can I help you?"

Annie: "Hi, this is Annie, at Dr. Grumpy's office. I'm trying to get insurance approval for a patient to have an MRI there, and to submit the form I need your facility's tax ID number."

Phone person #1: "What's a tax ID number? Is it how much we paid in taxes? Last year I paid..."

Annie: "No, it's the number your facility is assigned for tax and business purposes. The insurance companies need it so they can pay you for the MRI."

Phone person #1: "Is that the same as my social security number? I can give you that. It's 738..."

Phone person #1: "Let me transfer you."

On hold with a subdued piano & cello version of "Smells Like Teen Spirit."

Phone person #2: "Thank you for holding. Can I help you?"

Annie: "Hi, this is Annie, at Dr. Grumpy's office. I'm trying to get insurance approval for a patient to have an MRI there, and to submit the form I need your facility's tax ID number."

Phone person #2: "Hmmm... Is that the number you just called to reach us?"

Annie: "No, that's your phone number. It's..."

Phone person #2: "Oh, is that like a special number the IRS calls us on?"

Annie: "No it's..."

Phone person #2: "Let me transfer you."

On hold with a subdued piano & cello version of "Safety Dance."

Phone person #3: "Thank you for holding. Can I help you?"

Annie: "Hi, this is Annie, at Dr. Grumpy's office. I'm trying to get insurance approval for a patient to have an MRI there, and to submit the form I need your facility's tax ID number."

Phone person #3: "I don't think we have one."

Annie: "No, you do, every business has one, it's assigned to you before you open by the..."

Phone person #3: "Let me transfer you." 

On hold with a subdued piano & cello version of "Paint It Black."

Phone person #4: "Thank you for holding. Can I help you?"

Annie: "Hi, this is Annie, at Dr. Grumpy's office. I'm trying to get insurance approval for a patient to have an MRI there, and to submit the form I need your facility's tax ID number."

Phone person #4: "Oh, hang on. Let me look that up for you. Hmmm. I thought I had it on a Post-It note somewhere... maybe it's behind the take-out menu for Blumenthal's Chinese... no, maybe it got stuck to the menu for the place we ordered lunch from on Monday, I can't remember the name though... that may be over by the fax machine with the Chipotle forms, hang on... you know, I may have accidentally thrown it out because a bunch of stuff got marinara sauce on it when I was eating yesterday... let me transfer you."

On hold with a subdued piano & cello version of "Girls Just Wanna Have Fun."

Phone person #5: "Thank you for holding. Can I help you?"

Annie: "Hi, this is Annie, at Dr. Grumpy's office. I'm trying to get insurance approval for a patient to have an MRI there, and to submit the form I need your facility's tax ID number."

Phone person #5: "I hate you phishing scams. Fuck off."

click

Sir, if you don't stop tapping "Rock Lobster" out on my desk with your horribly untrimmed fingernails I am going to have to kill you with a Trömner.

Mr. Lewy was brought in by his son.

Dr. Grumpy: "So, what happened? I mean, I spoke to the police earlier, but want to..."

Son: "A neighbor called the police, Dad was chasing invisible people down the street, screaming at them and waving a golf club."

Mr. Lewy: "There were people all over the house! And in my yard! And they were having a party, and I told them to leave, and they wouldn't! So I told them to get out or I was going to clobber them, and when they didn't I chased them outside and down the street!"

Son: "The police calmed him down and searched the house and yard, there were no signs of anyone besides Dad. They also took away the golf club."

Mr. Lewy: "It wasn't just a golf club. It was a 3-wood. And I need it back before the tournament next week."

Son: "Dad, you aren't in a tournament next week."

Dr. Grumpy: "Okay, so..."

Son: "And it was a 9-iron, not a 3-wood."

Mr. Lewy: "I'm not that far gone. It was a 3-wood. Know your damn Callaways."