Sometimes, I Don't Know Why I Even Bother

Well, I really do know why I bother with all of the hassle and red tape that is the hallmark of modern medicine – I do it for my patients.

I often order an NMR profile by LipoScience when following a patient’s lipids. I think it gives me some good information about LDL particles and helps me determine which medication to use. Some docs aren’t excited about it. I like it.

Some insurance companies cover the cost, others don’t. I give my patients the choice to get it but let them know it will cost about $65 if THEIR insurance doesn’t cover it. I provide them a letter that explains WHY I use this NMR profile and hope that between the letter and the paid receipt from the lab, the patient can get reimbursement.

So I got a call recently from an Aetna patient. Apparently Aetna wants more information on why I order this test. They want to know if it’s “medically necessary.” I figured, “Well, I ordered it, so it must be ‘medically necessary’.” I mean, I am a doctor. It’s not legally necessary, electrically necessary, and for sure, not plumbingly necessary. I reached an Aetna rep and explained my case and when I said that I gave the patient a letter explaining why I ordered the NMR profile, the rep actually said, “Cool beans.” But apparently the claims department never got the letter. He gave me the number where the patient should fax the letter. I’m not holding my breath.

On an even more frustrating note… I explained in a previous blog about Cigna’s prior authorization mechanism, a configuration that demands an MBA to figure out. To refresh: I can prescribe the statin Crestor only if I have already tried a generic AND Lipitor and failed to achieve goal, during a trial period of indeterminable length, or due to an intolerance to the statin. But if the patient is in AvMed, then I can prescribe Lipitor if I have tried a generic AND Crestor, and had a failure to achieve goal, during a trial period of indeterminable length, or due to intolerance to the statin…

Ain’t medicine fun?