A No-lunch Day

The Langham called 11 a.m., a perfect time. I was finishing at the gym; I could shower, make the visit, and return home for lunch.

The gym is near the 405 freeway, a few miles from my home. It’s not my usual route for the 25 mile drive to Pasadena, being slightly further, but I decided to experiment. A mile after I set out, traffic stopped cold as far as the eye could see.

That’s when I remembered we are adding a single northbound lane to the 405 through Sepulveda Pass. There’s no room, so workers must rebuild every overpass, carve out and reinforce cliffs, and heap up dirt to widen the roadway. This six-mile addition will cost a billion dollars. I cannot think how much mass transportation a billion dollars would buy if there were any political support.

After fifteen minutes of creeping, I reached an exit and took old Sepulveda Boulevard past the construction. While driving, I answered a call from an insurance service and agreed to see a Brazilian boy with a fever in Huntington Beach. Huntington Beach is in Orange County, forty-five miles from my house. It could have been worse; it’s the same distance from Pasadena.

The Langham guest was a Washington Post reporter with a respiratory infection. He was covering a local convention, so the paper was paying for his room at the very posh Langham, but it wasn’t paying his medical expenses, so he had phoned several times before deciding on a visit. I delivered advice and medication before proceeding on my way.

The knowledge that I’ll miss a meal stimulates my appetite, so I suck on hard candy from a supply I carry. I never grab a bite at a hotel because I love eating and prefer to remain hungry and take care of obligations, so I can relax and enjoy it.

After shaking my hand, the Brazilian father reminded me that I had visited him a month earlier. Over most of the US, travel insurers send clients to clinics or emergency rooms. Having a doctor appear at their door is more pleasant, so Los Angeles travelers lose their inhibitions about asking for help, and I see many repeat customers. After examining his son, I explained this it wasn’t necessary to give him a cold shower for his 101 temperature. He would feel bad for a few days and then recover; I handed out four packets of Tylenol.

It was after 3 when I pulled into my garage and answered a call from the Westin at the airport. This was one of those what-might-have-been calls because I’d passed the freeway exit only blocks from the Westin half an hour earlier. I retraced the route to care for a lady with a painful eye, returning in time for supper.

The American Way

“This is AXA insurance about the patient you saw last month, Mrs. Diaz. We are asking you to accept a lower payment. In exchange, we list you as a preferred provider.” The offer was for less than half what I billed. I declined. AXA would eventually pay my regular rate although a few months would pass.

AXA sells travel insurance to Latin Americans. Its US agency and a dozen others phone me to make housecalls. Afterward, I fax my invoice, and (here American doctors will recoil in amazement) the carrier sends a check for the full amount. I’ve made thousands of such visits.

Working alone, I can’t accept American medical insurance with its complex requirements and unreliable reimbursement. The universal American claim form (called the HICF 1500) is cryptic and ambiguous, requiring mysterious codes and far, far more writing than the form I use. Thus, mine has a single space for today’s date; a HICF form requires today’s date in four or five places. Under “place of service” there is no box to check for “housecall.”

Not accepting American insurance is no problem for me, but I’m a special case. As soon as the average doctor opens an office, every American carrier makes an offer he can’t refuse. If he agrees to become a “preferred provider” and accept a reduced fee, the insurer will send patients. If not….

While foreigners look with horror on our medical care system, foreign insurance carriers have long admired their American counterpart’s techniques for saving money. Inevitably, the temptation has grown irresistible. I’ve long since stopped explaining that, including travel, a housecall may take ten times as long as a clinic visit. These callers are not negotiating; they want a “yes” or “no” answer. They lump all doctor visits together, so housecalls get no special treatment.

American doctors have not taken this lying down. One advantage of the Byzantine American billing system is that a resourceful doctor can tack on charges for tests, injections, medication, dressings, complexity-of-visit, length-of-visit, etc. so that he ends up collecting what he thinks he deserves. After decades of dueling with insurers, the typical American medical bill has become a purely fictional creation.

I quote my fee on the initial phone call. It’s larger if the call gets me out of bed or requires a long drive but never changes once I set off. I’ve made 700 housecalls for AXA over twenty-five years but only four during 2011. This is less tragic than it seems.

Confronted by my refusal to become a preferred provider, AXA and a few other travel insurers transfer their business to one of the national housecall services with names like Expressdoc, Hoteldocs, Travel-Med, AM-PM Doc. All boast that they can send a doctor on a housecall in any US city. Since none employ doctors, when a request arrives, their dispatchers consult a list of moonlighters and begin phoning. Tracking down a doctor willing to make a housecall can be a tedious business except in Los Angeles where calling me always succeeds. I’ve made thousands of visits for these services.

I quote my usual fee. To make a profit these services must bill AXA et al several hundred dollars more. If this seems illogical, you should realize that every insurance carrier knows that the “preferred provider” policy saves money, so no one questions it.

Returning from ten days out of town, I took my phone off call-forwarding, unpacked, and prepared to drive to Trader Joe’s for groceries. Before I left, the phone rang with a housecall at the Torrance Marriott, twenty miles distant. The good news was that it was Saturday evening, so freeway traffic was light, and the patient was seventeen, an age when illnesses are rarely complicated. The bad news was that he was Japanese, a people admirable in every respect except for their reluctance to learn English.

As I stepped out of the elevator, a middle-aged Japanese man rose from a chair. “Are you the doctor for the hotel?” he said.

I was delighted. “Yes. Are you going to interpret for me?”

He stepped back in alarm and waved his English-Japanese phrase book. Hiding my disappointment, I followed him to the room. When he began flipping through the booklet, I shook my head and pointed to the phone before dialing the guest’s Japanese insurance service for an interpreter. There followed a lengthy encounter as the phone passed back and forth between me, the parents, and the patient. The young man had suddenly complained of fatigue the previous day. He was otherwise in good health; he had no other symptoms, and I found nothing abnormal on examination. Sudden fatigue is an ominous sign in the elderly but rarely in an adolescent. I suspected an emotional problem, perhaps from the stress of travel. This is hard to explain across both language and culture, made even harder because I didn’t give a medicine. Giving medicine is a universal language; that’s why doctors prescribe even when it isn’t necessary.

Luckily these were Japanese, so they listened to my advice (get a good night’s sleep, continue with their itinerary, call if the problem persisted) with unfailing courtesy, nodding approval, and thanking me effusively as I left.

Can I Submit This to My Insurance?

The phone rang at 9:30 a.m., the perfect time. I was finishing breakfast. My routine is to work an hour on the computer and then go to the gym, but I’m happy to do a housecall instead. If two housecalls arrive, I skip the gym, an even greater pleasure.

The hotel was the Holiday Inn at the airport. The patient, a young Australian woman, had arrived after a tiresome flight during which she was forced to run back and forth to the bathroom. Urine infections are among my favorite diseases. They’re miserable but respond quickly to the antibiotics I carry. Patients are always grateful. This looked like a good visit. I quoted my fee.

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

This happens now and then. I remember guests at the Beverly Hills Hotel where room rates start at $300 who didn’t want to pay half that. In any case, once I mention the fee, I try not to refuse someone who thinks it’s too high. So I asked if $100 was OK. It was.

It was a satisfying visit. I tested her urine, announced she had an infection, and handed over a packet of pills. She was grateful. As I left, she indicated my receipt.

“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 happens regularly. In every advanced country outside the US, except Russia, China, and South Africa, if you need a doctor, you don’t first decide if you can afford it, so foreign tourists often pay little attention to their insurance.

“Can you make a housecall in Larkspur?”

I’d never heard of it. Google Maps revealed that it’s four hundred miles away, north of San Francisco. The dispatcher seemed disappointed at the news.

Half a dozen travel insurance agencies serving clients from Latin America have US offices in Miami, and it’s natural that they’re unfamiliar with California geography. Looking up cities is easy, but it’s even easier to call me. I'm sure you've phoned your family doctor, wading through voicemail, answering services, receptionists, and leaving messages. Hours may pass, but eventually the doctor calls except when he doesn’t.

Pity these poor dispatchers. Once a sick client phones, the dispatcher retrieves a list of doctors from that city and begins calling. Even after she finds one willing to make a housecall, her task is not finished because everyone knows doctors are terribly busy. I can confirm from my own experience that a colleague who agrees to help might not give this a high priority. Early in my career my requests were invariably followed, a few hours later, by a call from the hotel informing me that the guest was still waiting. Now I extract a promise that he will go quickly and then phone later to make sure he does.

I’ve never had an office. My number reaches my cell phone; I always answer in person, and I try not to decline visits within reasonable driving distance. Without being asked, I always tell the caller when I’ll arrive.

This turns out to be good for business. Tracking down a doctor remains a tedious process in other cities but requires a single call in Los Angeles, so dispatchers find it easiest to call me. Some phone whenever a California client calls, so I often deliver the bad news that they must begin working down the list for San Francisco, Sacramento, or San Diego.

Various Way in Which I Didn't Get Paid -- Part 4

I didn’t charge eight guests because theirs was the first call from that hotel, and I wanted to make sure they had a good experience. I stopped when I realized that most hotels that call for the first time never call again. The important call is the second.

Assistcard, which insures travelers from Latin America, owes me for six visits from the 1980s. Other doctors had warned me of its reputation as a slow payer, but I was eager and young. After several years, innumerable calls to its billing department, and with my business prospering, I began refusing its requests. A few checks owed to me drifted in over the following year but not all.

After ten years, an Assistcard employee called to announce that the company was under new management and to promise to pay more reliably. Since then I’ve collected on every visit but often after months of reminders. I finally decided to cut back on pestering but add $100 to my fee. Assistcard knows this, but nothing has changed. Most of its bills are vastly higher than mine because they come from hospitals and emergency rooms, so delaying payment helps their bottom line so much that making an exception for me is probably too much trouble.

Various Way in Which I Didn't Get Paid -- Part 3

Four times I arrived to discover another doctor in the room. The hotel had summoned another doctor. After waiting a few hours, the guest complained, so the hotel summoned me without mentioning the other call.

Eighteen guests gave me a bad check. Almost all were single males, and these occurred before I accepted credit cards. While everyone I managed to contact expressed surprise and promised to correct matters, this was not always a lie. In six other cases, guests sent a second, good check.

I mailed a refund to three guests on Medicare. Early in my career, I simply informed elderly American guests that I was not a Medicare doctor. Most assured me that was no problem, but it turned out many believed I meant only that I didn’t bill Medicare myself. When Medicare rejected their bill, they were outraged. Since then I explain in more detail that they can collect nothing from Medicare or any Medicare supplement insurance. Some agree to a visit; others accept my directions to an urgent care clinic.

I also reimbursed a guest who was unhappy to hear that an antibiotic would not help his flu. He went to an urgent care clinic later that day, received the traditional antibiotic, and felt better as soon as he swallowed the first pill. The hotel manager who passed on his complaint expressed sympathy, but I felt it best to make a refund.