A few Friday’s ago was an average day in my office.  We had 60 guests come through our door for medical services. 60 guests whose ages ranged from 6 years old to 85 years old on that particular day.  We took care of their needs ranging from ear infections, high blood pressure, cholesterol and diabetes management, infected wounds, anxiety, depression, pain and performed annual physicals. We established 8 new patients into our practice.  Over lunch my staff took a two hour break to do our monthly volunteer work at Lincoln Village. We communicated with over 35 patients who had called in that day with questions for us. We completed multiple referrals for guests needing specialists’ care.  I went to the hospital for a family meeting with a patient’s family.   We also met with the architect for our new building currently being designed.  Like I said, just an average Friday in our clinic.

​Upon completing the days work, I collapsed in my chair in my office to make sure there was nothing immediately urgent to be taken care of in my inbox before I go to have dinner with my children and husband.   And there it is… a letter from a major insurer in Alabama threatening to terminate me as a doctor in their network.  I can’t really describe how demoralizing that is.

Let me explain why this letter was sent to me…

With said Insurer providing plans on the exchange through the Affordable Care Act, they are trying to limit their costs on plans that have proven, as expected, to be too costly.  Thus, said Insurer has made an agreement with the laboratory who will give them the best cost for lab services, Quest Diagnostics, and deemed them their “Preferred Laboratory” for certain plans offered through the exchange.  And, they have previously mandated that physicians within said Insurer’s network can only refer Members (our patients) to the “Preferred Laboratory…,as they may be defined, in the network of providers described in the Member’s Benefit Agreement.”   So, apparently this Insurer’s data (which in my experience with this company is on average 12-18 months old) indicates that probably a year ago (I don’t know when they are actually referring to because of course it is not included in the letter), patients of mine went to their Oncology clinic to have labs and to Labcorp, which is the lab in our office when they should have gone to Quest.

What this practically means is that I have a patient who has cancer and is seeing an oncologist and both the oncologist and myself are following different sets of labs.  Cancer patients tend to be difficult sticks for blood draws and often have ports which enable less painful blood draws.  Of course, they would want to combine their blood draws at their oncologists office where all the blood could be drawn at the same time without having to go to two offices to have two difficult sticks.   Well apparently, this is not allowed by their insurance company.

And the other scenario, where labs were drawn in our office when they should have been drawn at Quest…well, I can tell you what happened there.  Not many of our patients know that their insurance plan requires them to use only certain labs.  So, within the past year we have spent hours of multiple staff members time setting up our Electronic Medical Record System to notify us at the point of lab order entry which lab you need to go to based on your insurance.  We’ve learned that patients are not usually aware of these details about their plans and we cannot rely on their information.  That method tended to result in angry patients calling us about a lab not being covered because “you ordered it wrong.” I suspect this letter is from lab orders that occurred before we invested the time into our system to try to help us with this issue, and of course, it’s not 100% correct.  The sad thing is, our representative for said Insurer is actually aware that we have already gone to great lengths to resolve this within our system yet still I receive a letter from her Manager threatening my termination.

​S​o, I know some of you are thinking there is an easy solution here.  Just change the lab in our office to the Preferred Laboratory so none of this will be an issue. Of course, that still doesn’t resolve my poor patients who are trying to combine lab draws with their oncologist office who can draw from their port. But even so, we have already tried this!  We have tried to have Quest lab integrate with our EMR system so that we can electronically order labs and electronically receive labs back.  (Without this integration, patients are sent with a paper order to the lab, blood is drawn and processed and the results are faxed back to us to be added to your electronic chart as a pdf, not as data within our system.  This process results in many, many errors that I’ve seen over and over and thus do not prefer to order labs from a Laboratory that is not integrated.) But we did try, only to find out that Quest refused to integrate with us because our volume with their lab would be too low for it to be worth their cost.   Beyond that, for other patients in our practice, Labcorp remains their preferred laboratory.

We continue to look for laboratory options that will work for at least the majority of our patient population and are committed to finding the best option.  Why I am really writing is to inform you, as a healthcare consumer, that YOU need to be aware of those little details about your healthcare plan.  Please for heaven’s sake, don’t assume that you can have your labs drawn anywhere, as reasonable as that sounds, because your insurance company is all about limiting your options if it means they can limit their cost.   When doctors and patients don’t work together, we have no chance of working together with your insurance company.  I need you to be informed healthcare consumers!  As you can see, not doing so, may result in your doctor being threatened by said Insurer.

There are two ways that doctors react to receiving threats like this.  1) Ignore it, don’t change anything and angrily throw the letter in the trash can.  2) Work tirelessly to try to continue to work with said Insurer for the benefit of their patients who just like all of us, need quality medical care.  There are not many that fall into option #2.  And let me tell you, for those of us that do fall into option #2, it is wearisome and demoralizing because still, despite the amazing care we give to our patients everyday and the personal investment of our lives to do so, we still end Fridays receiving letters like this.