As a hospitalist, I often get consult requests from family members or patients themselves for other subspecialty physicians to evaluate. Previously, when a patient or family requested an inpatient consult from a physician, the consulting doctor should have submitted a CPT code from the confirmatory consult CPT list (99271-99275), not the inpatient consultation codes (CPT 99251, 99252, 99253, 99254, 99255)
Confirmatory consults did not allow the physician to make any changes or initiate any medical management. These codes only allowed the physician to provide an opinion or advice on the matter they were being asked to evaluate. However, now that Medicare has eliminated consult codes, I think which consult codes to use under which circumstances is a non issue. We are just supposed to use the initial inpatient evaluation codes (99221, 99222, 99223) and it should get paid for no matter who requested the evaluation, whether it's the physician, family or the neighbor down the street.
This happens to me frequently. In fact, I would say it happens to me several times a week. As a hospitalist, I often get requests by family members for a subspecialist to evaluate. I know the patient does not need a cardiologist or a pulmonologist or an ID consult. But what do I know. I'm only the hospitalist, who does this for a living. Most of the time, these requests result from a lack of knowledge about what is an internist and what is a hospitalist and what is my skill set in the care of hospitalized patients.
The threshold for payment by the Medicare National Bank has always been whether or not the care being provided reached the threshold of Medicare medical necessity. Medicare isn't in the business of paying physicians to have patients come in and talk with them about the football game the day before. The visit must be medically necessary. So who decides that? Should the patient decide if the visit is medically necessary? It seems to me that they are.
Why should insurance pay for any consult requested by a patient or family that the attending physician feels is not medically necessary? If I want to get lab work or a radiology scan paid for by my insurance company, it requires an order from a physician, a physician who states the test is medically necessary. It's interesting to note, however, that patients can self refer themselves to specialists without any concern that it won't be paid for. The whole idea of gatekeeper medicine was destroyed in the HMO model of the late 1990s.
As a side note, one could argue that patients shouldn't have the right to self refer themselves to their primary care doctor either. Who's to say the PCP has a right to bill their insurance company for self referred walk ins off the street. Or for that matter, why should Medicaid pay for a self referred patient faking a seizure in the ER? Somehow, we've given patients enough intellectual respect to order their own medically necessary medical opinions but not their own medically necessary ancillary services. Why is that? Where did this tradition start? Why the double standard? What makes the self referred physician visit always medically necessary and the ancillary service not?
This double standard even exists for physicians. If I order an outpatient MRI or Protonix on my Medicaid patient, I have to jump through hoops to prove medical necessity. But I'll never be turned down if I refer a patient to another physician for their opinion. Why is that? Why the double standard? I don't know where or why this tradition started. It makes no sense to me.
Want to see an orthopaedic surgeon for your shoulder pain caused by a posterior labral tear or a dermatologist for your mole? You don't even need to talk to your primary care doctor. You can just call them up and schedule an appointment. But try and order an MRI or lab work on your own without a physician order and your insurance will deny the care as medically unnecessary.
Why the double standard? Why do we give patients the benefit of the doubt and allow them the right to order their own consult or referral, that will be paid for, but don't give them the right to order their own lab or xray or other ancillary service without a physician order?
Are insurance companies suggesting that medical opinions requested by patients or families don't meet the same threshold for medical necessity? It seems to me we practice medicine in a system where physician opinions don't need to be medically necessary, but the tests they order do. If that's the case, I'm going to start billing insurance companies for talking about the football game. It's a lot more fun than discussing end of life heart failure.
What do you think?
