"Magi D. Shepley" <
[email protected]> wrote in
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> Not for a new patient [that the wait is typically 9 days].
> This isn't the first time this has happened,
> either. It happened in my last state too: I picked a doctor, but when I
> called, she only saw new patients 3 times per month, and didn't have any
> appointments for 2 weeks. The fact that I had no voice, and a fever of
> 100 didn't make any difference. I was told to go to the ER. Which I'm
> not wiling to do, as that isn't covered by my insurance and is just flat
> out silly.
I agree that it would not have been appropriate to go to the ER (and so
agree with the insurer not paying for it). However, three months for a new
patient, while certainly not unheard of, is also not the norm. I also don't
think it is good practice and would say that the doc in question probably
should just close to new patients until (s)he can better serve the current
ones (since you know they also have quite a bit of a wait). It is reasonable
to expect to be seen expediently so if the insurer does not want to pay for
ER visits (or urgent care?) then it would be reasonable for you to ask them
for help indentifying where you might obtain the care you are paying for.
Most practice management experts say that the current standard should be to
try to get sick patients seen within a day or two (same day or next) and
there are a number of scheduling schemes to help do this. The biggest
barrier is that many docs, through years of poor mangement, have accrued a
backlog that they would have to work through in order to catch up and
implement them. FWIW my office offers to see all sick patients the same day
provided they are not calling too close to closing (in which case they can
be seen the next day).
Another hurdle, which I suspect is operative in your case, is that docs
never really fully embraced the implications (as far as their
responsibilities) of HMO's. With fee for service patients it is clear who is
and is not your patient. If you have seen them they are and if not there has
never been any relationship. In captitated HMO's the doc is paid a set fee
every month for being your doc whether he sees you or not. One upshot to
this is that one way to make capitation profitable is to limit their access
(another, the desired one, is to provide good care). In this case, however,
the distinction between an established patient and not is artifical since
(s)he has been collecting money for some time for being your doc. It is a
bit disengenuous of him/her to collect all that money and then suddenly
claim to not be your doctor when you actually ask to be seen.
If this is the case one approach that might work (has in the past) would be
to contact the insurance company and explain that despite collecting your
capitation the doc is now claiming no relationship and giving you less
access than his other patients (which when you word it that way is hard to
not view as wrong). Suggest that if he will not see you that you switch docs
to one who will have have all previous payments retroactively switched to
the new party. That would probably get the attention of both the old doc and
the new one. Not all insurers will do this but I have seen some do it in
the past. Keep in mind that the insurance company is in the busienss of
keeping you happy (within a certain cost limit) and does not care which doc
you see or who they send the check to (within their panel, of course).
--
CBI, MD
