Electronic claims

May 1

It never ceases to amaze me that I am one of the few physicians in my community who use an electronic clearinghouse for medical claims. It's not that the other docs aren't computerized; most of them use the same office management software that I do. But they print their claims and mail them rather than utilizing the electronic claims capability of their program.

Mike, my software rep, attributes this to the fact that paper is so tangible (you can print out claims, stuff them in envelopes and actually observe the mailman taking them off to the post office) whereas electronic claims go off somewhere into cyberspace, perhaps never to return. Maybe. Or maybe my colleagues don't mind waiting six weeks to get paid or to get a rejected claim back for correction.

What converted me was receiving Medicaid payments in nine days and Medicare in less than two weeks. Even the most recalcitrant insurers usually cut me a check in under a month when we bill electronically. What's more, we get real-time feedback when we make mistakes, and we're able to correct them on the spot and resend them.

Go back to paper? That makes as much sense to me now as using leeches for phlebotomies.

Complementary medicine

May 8

Jack is one of my most amazing patients. He came to me as an unassigned patient when I was on call for medical admit over a year ago. Initially, he looked to have a routine but extensive bilateral pneumonia; however, after failing to clear with intravenous antibiotics and, in fact, worsening and showing hyperinflation, bullae and a pattern of shifting infiltrates, he was air-evacuated to a tertiary care center where bronchoscopy revealed a diffuse interstitial pneumonitis and pulmonary fibrosis. He avoided intubation but was kept there for three weeks. He was discharged on steroids and oxygen and with a grim prognosis.

Jack is a guru of the alternative medicine movement. For over 30 years he has promoted personal health trainings through an institute he founded and has conducted seminars throughout the world. His approach is eclectic, utilizing guided visual imagery, breathing exercises and homeopathic philosophy. A year after his illness, not only has he outlived his doctor's predictions, but his disease process has stabilized, and he maintains on 10 mg of prednisone daily and oxygen as needed. On his last visit, I asked him how he accounted for his success.

“Well, Sandy,” he began, “I don't accept that I have a disease, because once you do that, you own it. I do have symptoms, and I deal with them when they come up. When I'm short of breath, I slow down and concentrate on my breathing. I work with my energy fields. I do a lot of visualization. And I take care of myself.”

How interesting, I thought. We allopaths tend to group constellations of symptoms together to create a diagnosis, which then dictates a treatment plan. Jack's way of handling his disease is to deal with his symptoms as they arise. He doesn't reject conventional therapies; he merely supplements them with his own. In doing that, he empowers himself and his body's ability to heal itself.

Portal to portal

May 14

If medicine is largely about disease, then law is largely about money and who gets it. There is a veritable river of money that flows by lawyers and, occasionally, when we're not being sued by them, we have an opportunity to stick our toes in it — by being expert witnesses.

I have been called on four times to be an expert witness and have yet to go to court. I've had my deposition taken twice but have mostly just reviewed documents — other people's depositions, medical records and the like. For someone like me, who loves intellectual challenges, this cognitive work is the sliced bread. Being paid exorbitantly well for it is the jam.

The first time I was asked what I charged for my medicolegal services I was flummoxed. I merely asked the lawyer to pay me per hour what he charged his clients. That seemed fair. “You're new at this, aren't you?” he asked. I confessed, but he was pleased. “Juries like virgin expert witnesses. They detest the guys that make their living doing it.” I then learned that expert witness fees are multitiered. He meant, “What do you charge for document review, deposition time, court time and travel time?” I had to admit I didn't have a fee schedule for that sort of thing and took his recommendations (which I have since learned were ridiculously low), but I was intrigued by the idea that I would be paid to drive my car. “Do you mean you will pay me $150 per hour just to drive to where you are to have my depo taken or to give testimony?”

“That's right,” he said, “and back again. It's called portal to portal.”

Living four hours from the nearest airport, I've had lawyers offer to send a chartered plane to my local landing strip to bring me to Fresno, Oakland and even Los Angeles. I graciously decline, explain I have a fear of flying and, thinking of my car as a yellow cab with the meter running, say I really don't mind the drive.