More Evidence of America's Leadership

 Opening an envelope from an international travel insurer, I expected a check but found only a form letter containing a dozen boxes, each listing a reason why payment was denied. An “X” through one box revealed that I had not submitted my invoice on an HCFA-1500.

That’s the claim form American doctors send to American health insurers. It’s complex, full of codes, questions, boxes, and charges – far longer than my simple invoice. Despite this, it’s badly organized. One must enter today’s date three times.

I found an HCFA form and filled it out, leaving many cryptic questions blank, guessing answers where I wasn’t certain, and including a fictional breakdown of services because I charge a flat fee. An American insurance clerk would post it on the office bulletin board for general amusement.

Two weeks later, a check arrived. Foreign insurers are not up to speed, but they’re trying.

 

 

Can I Submit This to My Insurance?

The guest’s symptoms suggested a urine infection, one of my favorite diseases. They’re miserable but respond quickly to antibiotics. This looked like a good visit. I quoted my fee.

“Oh… I didn’t realize it would be so much.”

This happens. I remember guests from the Four Seasons where room rates start at $600 who didn’t want to pay half that. In any case, once I mention the fee, I consider it tacky to refuse someone who complains. I quoted a lower fee. That was OK.

It was a good visit. I tested her urine, announced she had an infection, and handed over her medicine. She was grateful. As I left, she indicated my invoice.

“Can I submit this to my insurance?”

“You have travel insurance?”

“I think so. They made us buy something for this trip.”

It was too late to ask why, if she had insurance, she had objected to my fee. But this also happens. In every developed country except Russia and China, if you need a doctor you don’t first decide if you can afford it, so foreign tourists often pay little attention to insurance.

Why I Hate Appointments

“We have two guests with a cough and sore throat, but they’re at a conference. They’d like you to come at three.” This news arrived at nine a.m.

I love seeing two patients at the same time, but I prefer going immediately. Things happen if I wait….

 “No one asked for a doctor,” said the person who answered the door. Shown the names, he recognized them but added that they were at a meeting. He phoned and reported that they had lost track of time but would hurry back. Their conference was at a university five miles away. Their transportation was by city bus. 

I didn’t want to wait, but I have an exalted view of the medical profession. We are humanitarians, a superior breed.

All doctors agree but many feel that if they’re treated with disrespect (by the government, insurance companies, or a discourteous patient), their humanitarian obligations vanish, and they’re free to become jerks (google “concierge doctor”).

After weighing my options and taking no pleasure, I drove to the university, picked them up, drove back to the hotel, and performed my exam.

The World's Worst Travel Insurer

International Medical Assistance has a terrible reputation despite being my leading source of business. It often calls over a hundred times per year. Almost every doctor who knows IMA including the colleague who covers when I’m away, refuses its calls because it’s so hard to get paid.

Most travel insurers pay within a month or two. If they don’t, a call to the claims department corrects matters.

IMA never pays within two months. When I call, the claims department assures me that a check will be mailed in the near future or that my invoice never arrived. When I call a week later, I might hear the same explanation.

IMA was in business when I took up hotel doctoring in the 1980s and, for obvious reasons, happy to send patients. It didn’t take long for me to grow annoyed. Payment could take six month and required persistent phone calls. In 1993, with my practice prospering, I began refusing its calls.

In 1998, IMA changed ownership. A representative called to apologize for past difficulties and promise that it would now pay promptly.

But nothing changed. Checks didn’t arrive. I resumed pestering the billing department. By that time hotel doctoring was catching on so I had several competitors. IMA was irritating to deal with, but it provided plenty of business and – eventually – paid.

My frustration tolerance has diminished with age. In 2012 I was considering dropping IMA when a representative called to announce that it was again under new management. Payment would now be made every month directly into my checking account.

Sure enough, in January 2013, December’s payments appeared – minus several visits. Wearily, I picked up the phone. The problem remained when the February payment appeared, also for too little. The March payment was too much but it didn’t even out. April’s payment was also excessive; now I owed them. The May payment again missed several visits. By 2014 IMA had given up bank deposits and was back to sending checks. Slowly. That’s when I realized that IMA is cheap and stupid but probably not dishonest. Delaying payments saves money in the short run, but the P.R. damage far outweighs it. On the other hand, I have no competition for its business in Los Angeles.

A Guest I Didn't Help

A flight attendant at the Airport Holiday Inn was suffering an allergy attack. She couldn’t fly because of the congestion, and her airline required a doctor’s exam and note. This is a common request which I fulfill regularly, but I couldn’t fulfill hers because she was American.

When a British Air, Virgin-Atlantic, Emirate, Singapore, or Cathay-Pacific crew member falls ill, the local supervisor calls a national housecall service who calls me, and the airline pays. US airlines never do this. Their employees are on their own in a strange city with no transportation and their American insurance which is deeply suspicious of housecalls. 

I occasionally make a charity visit to an American flight attendant too sick to leave the room but not sick enough for the paramedics. Mostly I refer them to an urgent care clinic.

Cheating

“Could you put my name on the bill?” asked a guest. “I have insurance for this trip, but my girl friend doesn’t.”

“I’m afraid that’s illegal,” I answered. I’m not sure that was true, but it seemed a painless way to decline. The guest didn’t seem offended. From his point of view, there was no harm in trying.

Guests occasionally ask me to cheat on their insurance. A carrier once called to question a charge of several thousand dollars. It turned out the guest had penciled in a zero when he submitted the bill.

People are more likely to cheat if there’s no chance of getting caught. I still remember my anger when, thirty years ago, I witnessed someone put a quarter into a newspaper dispenser, open the cover, pull out a newspaper and then pull out several more to give to friends. These dispensers are stocked by an independent vendor who buys the papers himself. I informed the man who hurried off, less concerned about his thievery than this stranger abusing him.

Three Discouraging Words

In rudimentary English, a Hilton guest explained that his rash needed attention.

“I’ll be there within the hour,” I said and quoted the fee. He replied with a phrase that makes a hotel doctor’s heart sink.

“I have insurance.”

From an American, this usually means no visit. Collecting from American carriers requires either a trained billing clerk or far more patience than I possess. I refer these guests to a local clinic.

Foreign travel insurers are better. I send a bill, and (unlike American insurers) they send a check for the identical amount. I asked the name of his insurer. It was Assistcard, an agency that’s called since the 90s.

The proper step was to ask the guest to phone Assistcard who would confirm his eligibility, and phone me. This never happens quickly, but it’s rarely a problem because 95 percent of travelers call their insurance first, so I don’t hear about the visit until it’s approved. This guest had mistakenly called me. I told him I would arrange matters.  

After listening to my explanation, the Assistcard dispatcher said she would call the guest, confirm his coverage, and call back. To pass time, I booted up my copy of Sim City. This worked too well; after 45 minutes of wrestling with urban problems I realized the phone had remained silent. Calling, I discovered that my dispatcher had vanished, perhaps to lunch. After putting me on hold, another dispatcher assured me that the wheels were turning. I phoned the guest to make sure he hadn’t wandered off only to learn that no one at Assistcard had called and that his tour was leaving in two hours. I called the dispatcher who explained that the guest was Indonesian. Assistcard was in Argentina, so getting approval from Indonesia might take a while.

Once the guest left for his tour, the visit would evaporate, so I decided to drive down and take my chances. My phone rang while I was on the freeway. The dispatcher informed me that no one could find the guest’s proof of insurance, but it might eventually turn up. Learning I was on the road, he offered to call the guest and suggest he pay me directly and try to claim reimbursement. That rarely works, but it worked this time.

Warning! Make Sure You're Admitted!

This is strictly for American readers, but others will get a taste of the grotesqueries of our medical system.

Let’s say you’ve been vomiting for a few days and drag yourself to an emergency room. The doctor says you need IV fluids, so an aide wheels you to a room where you spend the night and most of the next day and then return home, feeling better.

Or you have chest pain. The ER doctor doubts that it’s a heart attack, but he wants to keep you for observation. After two days connected to a heart monitor and getting blood tests, you’re discharged, feeling better.

In both cases you’ll get a bill for at least $5,000, and YOUR HOSPITAL INSURANCE WON’T PAY!! 

Hospital insurance only pays if you’re admitted to the hospital, but remaining in a holding area for a few days or being kept “for observation” is not admission. You’re still an outpatient, so you’d better have good outpatient insurance.

If you’re over 65 and have Medicare Part A (which is free) but have decided to skip Part B (which costs $109 a month) you have no outpatient coverage. Part A only pays for the hospital. If you’re under 65 and have the usual Blue Cross or Blue Shield, you’re largely covered for hospital charges. Depending on the policy you’re willing to pay for, outpatient coverage varies. A lot. 

The solution, when the ER doctor announces that you need to stay for a while, is to ask: “am I admitted or not?”

Of course, you’re probably miserably sick or frightened (if not, maybe you shouldn’t be in an emergency room), so asking about insurance is not a priority. Woe unto you if you don’t.

Failures in Communication, Part 3

After a forty minute drive, I arrived at 4020 Los Feliz Blvd. No one answered my knock. Thinking the patient might have stepped out, I took a walk around the neighborhood and knocked again and also phoned to no avail. I returned home in a good mood. It was an insurance call, so I’d be paid.

Another call arrived at 5 p.m. I dislike driving during the rush hour, but the patient lived near Beverly Hills only five miles distant. The address was 821 Coldwater Canyon Drive, but I discovered that Coldwater Canyon addresses begin with 900. I continued north, assuming the numbers would drop when Beverly Hills became Los Angeles, but they kept getting higher.

Coldwater Canyon is a not-so-secret alternative to the freeway into the San Fernando Valley, so it’s bumper-to-bumper during the rush hour. Finally, I gave up, pulled into a side street, and phoned the patient. It’s not 821, he said, but 1821. The dispatcher had told me wrong or perhaps I had heard wrong.

That evening an insurer called to ask me to return to the Los Feliz patient. Insurers usually refuse to authorize a second visit to a no-show, but I was happy to go. The dispatcher repeated the address: 1420. Whoops. Whose mistake was that?....

The Easiest Part of Medical Care

The phone rang at midnight for a housecall in Long Beach, 35 miles away. So far, so good. Freeways were clear, and the caller was a reliable travel insurer who agreed to my fee. Good.

The patient was young and suffering a fever. That sounded easy. The patient was a student at California State University, Long Beach. Uh oh.

Navigating a college campus is a nightmare. The address of a university is the administration building where no one lives. College buildings have names or numbers, but they follow their own logic.

The patients are foreign, unfamiliar with the geography, and unhelpful. Finally, campus police may be slow responding to rape and burglary, but they pounce fiercely on an illegally parked car. You don’t want to park inside a college campus without a permit.

Taking no chances, I parked on Bellflower Boulevard outside the entrance and walked far across the campus to the dormitories and International House where I assumed he was staying. As I approached, I saw that the barrier to the lot next to the building was raised, and I could have parked. C’est la vie. As usual, delivering medical care was the easiest part.

Do You Accept My Insurance?

That’s the most stressful sentence a hotel doctor hears – more than “I’m having chest pain” or “my mother stopped breathing.”

American insurers look with deep suspicion on housecalls, and no hotel doctor wants to bill them. But almost no American has experience handing money directly to a doctor – and a housecall costs a good deal more than an office visit. Many of these guests agree to pay, but I often sense their discomfort. Other doctors are not so picky, but if they sound too reluctant I inform them of local walk-in clinics.

Foreign insurers are different. Many call me directly. Resigned to our rapacious medical system, they expect immense bills. I charge everyone the same, but I’ve been contacted by doctor-entrepreneurs who offer triple my usual fee to make their hotel calls in Los Angeles. They can afford this, they assure me, because they charge several thousand dollars for a housecall. This sounds creepy, but it apparently works because I’ve heard from these doctors more than once. 

Screwing the Guest

A February 13 Craigslist ad is recruiting hotel doctors.

If you read this blog, you know that I keep track of new arrivals and offer to work for them. They often take me up on it because it’s not easy to find a doctor on the spur of the moment. 

A few hours after my response, the phone rang. The caller introduced himself, adding that he knew me, admired me, and was certain that I was a perfect hire.

He operated a concierge hotel doctor service in big cities, he explained. Clients were busy businessmen who absolutely could not interrupt work to be sick. His doctors made sure this happened through aggressive treatment and powerful drugs, perhaps more powerful than a doctor would use in an office. He asked what injectables I carried and suggested others. His doctors sutured lacerations, drained boils, administered IV fluids and breathing treatments, incised hemorrhoids – whatever a guest need to keep going.

The charge was $3250.

“They pay that?” I asked.

“Just about everyone,” he responded. “Because there’s NO OUT-OF-POCKET EXPENSE!” (I write in caps because his voice grew loud). “We deal mostly with foreign businessmen. They have travel insurance that pays whatever we bill, so I promise they’ll have NO OUT-OF-POCKET EXPENSE, and no one has complained.”

This was probably true. Aware of the rapacious American medical system, foreign insurers may be inured to spectacular bills.

When I asked about American guests, he segued seamlessly into another monologue. American insurers are less generous, but his service was vastly superior, effective, convenient, and cheaper than the five or ten thousand dollars charged at an emergency room. Hearing this, many paid and express gratitude afterward.

Unlike the previous harangue, this was not true, but I encounter it on web sites and publicity from competing hotel doctors. It puts me in a bad mood.

“So you’re not screwing the guests, you’re screwing the insurance companies.”

“Why shouldn’t I? They screw us!” he exclaimed, adding that many of his doctors are forced to work for him to make ends meet because of piddling insurance reimbursement. Surgeons who once made $1500 for repairing a hernia are now getting $1000.  

This did not improve my mood although I share his low opinion of American health insurers. Foreign insurers give me little trouble, but I’m not billing them $3250. 

“You’re selling yourself short,” he exclaimed after learning what I charge. I responded that I have no complaints about my income.

“You do realize you’re running a business,” he added on hearing that I don’t charge for phone calls. That’s probably true, but I’ve noticed that every doctor who announces that medicine is a business is an asshole.

He is not the first entrepreneur to discover that sick hotel guests, trapped in a strange city, are an easy mark and that foreign insurers are even easier. You can read about another on my September 3 post. 

D as in "Dog"

A travel insurer sent me to Koreatown, an older area of Los Angeles, home to a mixture of Koreans and Hispanics. It’s a colorful neighborhood, and like all colorful neighborhoods, parking is a chore. I found a spot several blocks away from the apartment.

Travel insurance patients are subletting or visiting friends, so searching the directory near the locked entrance never reveals their name. Phoning her number, I heard a voicemail message. That was not bad news because insurance services pay for no-shows, but I had to make an effort. I phoned the agency to explain. The dispatcher urged me to wait while she tried to contact the client. I waited. After five minutes, a resident entered the building; I followed and knocked on apartment 1D. The lady who answered denied that anyone needed a doctor.

After another ten minutes, I decided I’d done my duty and returned to my car. My phone rang as I arrived.

The client was taking a shower, said the dispatcher. She was now ready to receive me. I recounted my experience at apartment 1D, but 1B turned out to be the correct number. In my defense, during the original call I confirmed that the patient was in 1D as in “dog.” But English was not the first language for both guest and dispatcher.