Chaos Theory

Chaos theoryNoun – The branch of mathematics that deals with complex systems whose behavior is highly sensitive to slight changes in conditions, so that small alterations can give rise to strikingly great consequences.

Alternative definition:

Chaos theory – Noun – The branch of healthcare that deals with making the payment system increasingly complex and ever changing. This complexity and confusion impact physicians and patients in such a way that appropriate services in care of the patient are subject to rules and regulations that are deliberately complex, making alterations from the momentary rules inevitable.  This exists so that even small alterations will free the insurance company from the responsibility to pay for said service.

I am no physicist, but I honestly think that a grasp and understanding of the first type of Chaos theory is more likely than that of the second.  Let me give a demonstration of the second chaos theory in action:

Step 1:  Patient comes in to be seen.

Step 2:  What insurance do they have?

Step 3:  Patient produces insurance card

Step 4:  Office has to verify that this plan is actually valid for this patient, with several alternatives:

  1. The insurance is valid.
  2. The patient has changed insurance but still holds an old card.
  3. The patient has been dropped from the insurance due to nonpayment or losing employment.

Step 5:  Once verified, the patient does one of several things:

  1. Pays copay where that is required.
  2. Pays past due balance.
  3. However, if past due balance is due to the insurance company not paying on a claim yet, the patient won\’t be required to pay (as long as it is a reasonably short period of time).
  4. Does not pay (either because of insurance like Medicaid that pays in full or because of indemnity insurance).

Step 6: Insurance card is scanned in, documenting what patient presented at the time of the visit and giving access to the card by clinical staff for the rest of the visit.

Step 7:  Once settled, the patient comes back to the office to be seen by the medical staff.

Step 8:  Patient is seen by clinician.

Step 9:  If procedures are performed, they may or may not be billed by clinician, depending on insurance coverage.  Several possibilities exist:

  1. The procedure is covered.
  2. The patient has Medicare or Medicaid, which does not pay for certain services.  In this instance, the procedure code pays less than simply coding the visit at a higher level (E/M) due to complexity of the visit.
  3. The patient has HMO which is paid by cap and the procedure is not an \”over and above\” and so won\’t be covered.  Here it doesn\’t matter if the procedure is billed or not.

Step 10:  If immunizations are given, the insurance must be checked to see if the vaccine is covered.  Since there are numerous plans under a single insurer, simply knowing the name of the insurer (eg. Aetna, United Health Care) does not guarantee coverage.  Of ten this results in step 10a, which is for the clinical staff to call the insurance company and ask directly if the immunization is covered (the results of which are only somewhat reliable).

Step 11:  Once insurance coverage of the immunization is determined, several possibilities exist:

  1. The immunization is covered and so is taken from regular stock and administered to patient
  2. The immunization is not covered, but others are by the insurance company.  In this case, the patient is informed by the billing staff that they will have to pay out of pocket for this before the immunization is given.  The patient is generally aghast at the cost and often foregoes the immunization, making step 10 superfluous.
  3. Immunizations are not covered by this insurer or the patient has no insurance and the patient is a child.  In this case, the immunization is taken out of a different stock of vaccines (\”Vaccines for Children\”) and given.  The procedure is billed under an entirely different code.
  4. The patient has Medicare, and the immunization is not covered (like Zostavax, the shot for shingles).  In this case, the patient is given a prescription for the immunization and picks it up at the pharmacy, brings it back, and gets it administered by the nurse.

Step 12:  If the patient requires labs, the patient\’s insurance needs to be checked so they can go to the proper lab.  A single payer such as Aetna cab have different policies that require different lab facilities to be used, so there is significant risk that the sample will be sent to the wrong lab.  Here, too, several possibilities exist:

  1. The patient can get the labs drawn in the office, and it does not matter which lab is used.  In this case, the nurse sends the sample to the lab which is easiest for us to use.
  2. The insurance company allows \”pass through billing,\” which allows our office to bill for the labs and pay the lab a negotiated amount.
  3. The insurance company specifies a lab that picks up samples from our office, in which case we draw and put the samples in the collection bin for that lab.
  4. The insurance company specifies a lab that does not pick up samples, in which case we send the patient with a printed requisition to get labs drawn at that facility.
  5. The lab sample cannot be drawn here (needs to be frozen, for example) or the patient does not want the test drawn at the time of the visit.  In this case, the proper lab facility needs to be determined and the appropriate requisition filled out and given to the patient.

Step 13:  If the patient requires an x-ray to be done, it needs to be determined if the insurance requires authorization for that x-ray.  Several possibilities exist:

  1. The insurance does not require authorization and does not specify where the x-ray must be done, in which case the patient is given a requisition and told to go to the preferred facility.
  2. The insurance does not require authorization, but specifies a specific facility.  In this case, the patient is told to go to the appropriate facility.
  3. The insurance requires authorization, in which case a note is sent to our referral coordinator (full time position), who gets authorization and then informs the patient where the procedure needs to be done.
  4. The insurance does not require authorization, but the procedure must be scheduled.  In this case, the referral coordinator is notified of the request and schedules the procedure with the preferred facility.

Step 14:  If the patient requires a referral, it needs to be determined which physicians or facilities are on the list of providers for that insurance.  This too can vary under different plans, as HMO will be very specific, PPO\’s will be somewhat specific, and indemnity insurance will not be specific as to which providers must be used.  Furthermore, some types of referrals do not require referrals (dermatology, ob/gyn, ophthalmology, psychiatry) and so the patient is told to make their own appointment.  Once it is determined which physician to use, there are several possibilities that exist:

  1. The visit is urgent, and the insurance does not require authorization.  In this case, the patient stays until the appointment is made by the referral coordinator.
  2. The visit is urgent, and the insurance company does require authorization.  In this case, the referral coordinator gets authorization from the insurance company, then calls the referral facility to make an appointment, giving them the authorization number.  The referral coordinator must know just how urgent the visit is (immediate, today, this week?) and depending on that, either makes the patient stay until the appointment is made.
  3. The visit is non-urgent and the insurance does not require authorization.  The appointment is made by the coordinator and the patient is contacted by phone/email with details.
  4. The visit is non-urgent and the insurance requires authorization.  Same as above, plus authorization.

Step 15:  If the patient requires a prescription, it several non-clinical factors come into play:

  1. Is the drug on the formulary for the patient\’s insurance?  This can vary with plans, and so may be different under a single carrier.
  2. If on formulary, what tier is it?  If it is a higher tier, the patient may not be able to afford it or be willing to pay.
  3. If not on formulary, which drugs in the class are?  Have others been tried?
  4. If not on formulary and still necessary, what is the process to get this authorized?  In this case the prescription is given, the patient gets it filled, the pharmacy notifies us of the need for PA, and we try to obtain it.  This process can take up to 3 weeks.
  5. If denied by the insurance company and still necessary, what is the process for appeal?
  6. If patient has to pay out of pocket, then which drugs are cheap and which do we have coupons for?
  7. If patient is Medicare, then we cannot give coupons (because for some reason it is wrong to make the government pay less).

Step 16:  The patient is dismissed with a plan and is scheduled for a follow-up appointment.

Step 17:  The patient is asked to pay the remainder of the balance at check-out, depending on what the doctor ordered and what was done in the office.


There are a number of possible pitfalls.

  1. If the patient supplies the wrong insurance information, then all of the above is invalid and may not be covered
  2. If the patient (or their blood) is sent to the wrong lab, x-ray facility, or referral facility, the insurance company will not cover the procedure (even if appropriate)
  3. If the patient is sent for an appropriate referral to an approved facility, but the proper authorization is not gotten, the visit will not be covered.
  4. If the lab/referral/consult is sent with the wrong diagnosis code, or one that is no longer valid, the insurance will not cover.
  5. If the lab is done at all early (under 3 months for a Hemoglobin A1c, for example), the insurance will not cover.
  6. If the immunization is given even 1 day early, it will not be covered, and won\’t be counted as being given.

Who pays for these pitfalls?  Either the patient (who then gets mad at the doctor for doing it wrong), or the doctor\’s office.

Confusing?  Yes, that\’s my point.  Multiply all of this times the number of different insurances the office accepts (including all managed Medicare and Medicaid), and watch what chaos ensues.  Who benefits?

Not the doctor.

Not the patient.

Not nurses.

Hm…. Who\’s left?

11 thoughts on “Chaos Theory”

  1. This is why I feel ill any time I need labs done, or any sort of outside testing. There's no telling what kind of bill is going to show up in my mailbox sometimes months after the event. I'd say I'm irrationally terrified about it, but when money is short (even when one has employment and medical insurance), that fear starts to seem a lot more rational.

  2. Dr. Rob, that is one of the most accurate and concise overviews of our system as it exists now. Concise at, what, several hundred words?

    What an indictment.

    This post needs to go to every elected official you can think of, including our president.

    This may be a really ignorant question, but why isn't the AMA all over reimbursement reform? I mean as a major initiative? You doctors are smart guys. Why don't you have a more effective lobby? They have a nice website with many worthy advocacy projects. But if doctors can't get paid they're not going to become doctors. Does the AMA really want to consist only of specialists? Maybe I am just naive and unaware of any politics involved.

  3. I am not sure about the AMA. I am not a member, nor are many primary care docs. The lobby generally consists of retired docs or academics – neither of which have much of a stake in the game. The AMA burned its primary care bridges a long time ago, unfortunately.

  4. Another possible step is that you have a chronic disease, for arguments sake lets say Hepatits C, and then all previous steps will be invalid because no one will cover anything that is wrong with you, lets say a broken leg due to a fall from an ice storm. Not that that ever happens….

  5. Who benefits, indeed. And why have most people been calling it health-care reform and not health-insurance reform? Who has the money it takes to control the message that way? Hmm. Dr. Rob, please keep talking about this, it's so important. I agree with Marie that every lawmaker needs to see this. We need to do our parts too. I started sounding off about it after I joined the ranks of people with pre-existing conditions. I got a couple of form letters from my senators but one of my congressmen had his healthcare team leader call me. Will it help? Maybe not, but I feel better for raising heck about who should make care decisions.

  6. Yep, it is all about finding loopholes. There are a gazillion of them. I know because I get blamed a lot of the time when the insurance companies use them.

  7. That's a big part of why I do this blog. I got particularly peeved this morning during an office meeting and ended up writing this post. A lot of them happen that way. The more of us that talk, the more likely we are to be heard.

  8. This is all completely accurate and completely ridiculous. It has gotten to the point where its very difficult to practice medicine. There is no other job in the world where you have to work so hard to get paid for the work you do. Its like a second occupation. The first is being a doctor. The second is doing the work to get paid to be a doctor. We hire other people to do the second job, which means we have to pay $40-50k a year to have somebody that fights to get us the money that we and the patient are owed.

    It makes one want to open a cash practice and be done with it. Given the high deductibles that patient's have, it would be more economical for them for most things anyway.

  9. RE step 10/11 – or the immunization is covered and administered, but it turns out that the patient has exceeded the annual benefit limit, so gets an unexpected bill – a $168 bill that would have been covered in full if the shot had been postponed two weeks. Maybe that should go under pitfalls. If my next daughter gets the HPV vaccine, her third injection will be scheduled in a different calendar year than the first two!

    I had no idea there was so much red tape involved. Thank you for another informative post.

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