- Email: [email protected]
Receiving payment for patient advocacy
LETTERS TO THE EDITOR J Oral Maxillofac Surg 59:120-121, 2001
RECEIVING PAYMENT FOR PATIENT ADVOCACY
I know of no person who acts as an advocate in a professional capacity that does not get paid for his or her efforts. Attorneys get paid by their clients for being their advocate; special interest groups such as the Sierra Club, Audubon Society, and unions pay their advocates; and public interest groups, such as Common Cause, pay their advocates who represent the members’ collective positions. There is no reason why our expertise and time should be treated any differently when we are representing our patients’ interests against the insurance company’s decision. Canada, which is often cited as having an effective health care delivery system, allows doctors to charge for filling out forms. My brother-in-law, who is a Quebecois, recently suffered a heart attack and had to pay $100 to have 4 forms completed so that he could continue to collect his government sick benefits. As his disability continued, more forms were required and more fees for paper work were incurred. Additionally, I suggest that there should be code for duplicating radiographs. The request for radiographs by insurers has been increasing. Connecticut state law recognizes that duplicating radiographs requires time and expense and allows a reasonable charge for this service for legal proceedings. Providing duplicates for insurance companies should be treated no differently.
To the Editor:—As always, your editorials are thought provoking. I wholeheartedly agree with your position that we should not use deception to correct mismanaged care. I also agree that we should appeal decisions that deny payment so that our patients can receive the treatment to which they are entitled. However, this is a time-consuming and frustrating process. Therefore, I suggest that we should be compensated for our time and expertise. It is not a new or radical idea for doctors to be compensated for their time and expertise. There are procedure codes that recognize the value of time not associated with diagnosing or treatment; these are the ones that recognize conferring with other doctors and even our patient’s families (9935899359). A similar degree of expertise and time is needed to appeal arbitrary or erroneous decisions by insurers. We should make an effort nationally, together with colleagues in other disciplines, to require insurers to pay for this service. Requiring insurers to pay for this service would not only compensate us for our time and expertise, but also have have the added benefit of reducing the number of bad decisions and a subsequent delay in treatment. Under the present system, there is no penalty for bad and/or questionable decisions by insurers. By denying treatment initially, insurers are in a win-win situation. It is easier, more profitable, and less time consuming for insurance companies to initially deny benefits for a procedure than to go to a review process. If the decision is appealed and the appeal is successful, then the insurer has had the interest on the moneys improperly withheld, the patient’s treatment has been delayed, and the doctor’s payment has been delayed. Additionally, the provider has had to spend extra time formulating the appeal. If the decision is not challenged because the patient is intimidated by the appeal process or the doctor does not have the time to spend with endless appeals and repetitive submissions, the company is ahead because there was no treatment and hence, no claim. The insurer has again won. The patient and the doctor are in a lose-lose situation. The doctor and the patient may be out the money for an extended period of time, treatment may be delayed, and the doctor has expended time, effort, and resources (telephone bills, payment to employee to handle the problem) without compensation.
FRED R. BRAUN, DDS. Stratford, CT
doi:10.1053/joms.2001.19920
STARCH CELL GRANULOMA To the Editor:—In their recent report in the Journal, Keskin et al1 appropriately implied that until its precise cause is determined, the term hyaline ring granuloma should be applied to these jaw lesions. They used the Sartur reaction to confirm that their second case contained starch; however, this probably was not necessary because the lower half of the photomicrograph (their Fig 4) shows clear morphologic evidence of starch cells— oval cells containing pale eosinophilic starch granules separated by darker intensely eosinophilic septa of cytoplasm appearing as interconnected triangular or stellate outlines. Several investigators have carefully detailed the characteristics of these starch cells.2-5 Therefore, the cause of this hyaline ring granuloma is not a mystery; the granuloma was induced by leguminous foreign material, as Keskin et al1 correctly concluded. Simple recognition of starch cells permits a definitive diagnosis. If the pathologist observes a hyaline ring granuloma, he should search for starch cells; if they are identified, then the more specific diagnosis of “pulse granuloma” is warranted. “Pulse,” [Old French, pouls ⫽ porridge] referring to the seeds of a leguminous pod, is not in common usage. One does not hear “I had pulse and rice for dinner;” one hears “I had beans and rice for dinner.” In everyday usage, the surgeon knows what a pulse is, and it is not a bean. There-
Letters to the Editor are considered for publication (subject to editing and abridgment), provided they are submitted in 1 of 2 ways. If typewritten, they must be submitted in duplicate, signed by all authors, double-spaced, and should not exceed 40 typewritten lines of manuscript text (excluding references). You may also e-mail your Letters to the Editor to [email protected]. The same length limits apply. Letters should not duplicate similar material being submitted or published elsewhere. Letters to a recent Journal article must be received within 6 weeks of the article’s publication. Receipt of letters is not acknowledged and there is no guarantee that your letter will be published. We cannot provide prepublication proofs. Submitting the letter constitutes your permission for its publication in any current or subsequent issue or edition of the Journal, in any form or media, now known or hereafter developed.
120
RECEIVING PAYMENT FOR PATIENT ADVOCACY
I know of no person who acts as an advocate in a professional capacity that does not get paid for his or her efforts. Attorneys get paid by their clients for being their advocate; special interest groups such as the Sierra Club, Audubon Society, and unions pay their advocates; and public interest groups, such as Common Cause, pay their advocates who represent the members’ collective positions. There is no reason why our expertise and time should be treated any differently when we are representing our patients’ interests against the insurance company’s decision. Canada, which is often cited as having an effective health care delivery system, allows doctors to charge for filling out forms. My brother-in-law, who is a Quebecois, recently suffered a heart attack and had to pay $100 to have 4 forms completed so that he could continue to collect his government sick benefits. As his disability continued, more forms were required and more fees for paper work were incurred. Additionally, I suggest that there should be code for duplicating radiographs. The request for radiographs by insurers has been increasing. Connecticut state law recognizes that duplicating radiographs requires time and expense and allows a reasonable charge for this service for legal proceedings. Providing duplicates for insurance companies should be treated no differently.
To the Editor:—As always, your editorials are thought provoking. I wholeheartedly agree with your position that we should not use deception to correct mismanaged care. I also agree that we should appeal decisions that deny payment so that our patients can receive the treatment to which they are entitled. However, this is a time-consuming and frustrating process. Therefore, I suggest that we should be compensated for our time and expertise. It is not a new or radical idea for doctors to be compensated for their time and expertise. There are procedure codes that recognize the value of time not associated with diagnosing or treatment; these are the ones that recognize conferring with other doctors and even our patient’s families (9935899359). A similar degree of expertise and time is needed to appeal arbitrary or erroneous decisions by insurers. We should make an effort nationally, together with colleagues in other disciplines, to require insurers to pay for this service. Requiring insurers to pay for this service would not only compensate us for our time and expertise, but also have have the added benefit of reducing the number of bad decisions and a subsequent delay in treatment. Under the present system, there is no penalty for bad and/or questionable decisions by insurers. By denying treatment initially, insurers are in a win-win situation. It is easier, more profitable, and less time consuming for insurance companies to initially deny benefits for a procedure than to go to a review process. If the decision is appealed and the appeal is successful, then the insurer has had the interest on the moneys improperly withheld, the patient’s treatment has been delayed, and the doctor’s payment has been delayed. Additionally, the provider has had to spend extra time formulating the appeal. If the decision is not challenged because the patient is intimidated by the appeal process or the doctor does not have the time to spend with endless appeals and repetitive submissions, the company is ahead because there was no treatment and hence, no claim. The insurer has again won. The patient and the doctor are in a lose-lose situation. The doctor and the patient may be out the money for an extended period of time, treatment may be delayed, and the doctor has expended time, effort, and resources (telephone bills, payment to employee to handle the problem) without compensation.
FRED R. BRAUN, DDS. Stratford, CT
doi:10.1053/joms.2001.19920
STARCH CELL GRANULOMA To the Editor:—In their recent report in the Journal, Keskin et al1 appropriately implied that until its precise cause is determined, the term hyaline ring granuloma should be applied to these jaw lesions. They used the Sartur reaction to confirm that their second case contained starch; however, this probably was not necessary because the lower half of the photomicrograph (their Fig 4) shows clear morphologic evidence of starch cells— oval cells containing pale eosinophilic starch granules separated by darker intensely eosinophilic septa of cytoplasm appearing as interconnected triangular or stellate outlines. Several investigators have carefully detailed the characteristics of these starch cells.2-5 Therefore, the cause of this hyaline ring granuloma is not a mystery; the granuloma was induced by leguminous foreign material, as Keskin et al1 correctly concluded. Simple recognition of starch cells permits a definitive diagnosis. If the pathologist observes a hyaline ring granuloma, he should search for starch cells; if they are identified, then the more specific diagnosis of “pulse granuloma” is warranted. “Pulse,” [Old French, pouls ⫽ porridge] referring to the seeds of a leguminous pod, is not in common usage. One does not hear “I had pulse and rice for dinner;” one hears “I had beans and rice for dinner.” In everyday usage, the surgeon knows what a pulse is, and it is not a bean. There-
Letters to the Editor are considered for publication (subject to editing and abridgment), provided they are submitted in 1 of 2 ways. If typewritten, they must be submitted in duplicate, signed by all authors, double-spaced, and should not exceed 40 typewritten lines of manuscript text (excluding references). You may also e-mail your Letters to the Editor to [email protected]. The same length limits apply. Letters should not duplicate similar material being submitted or published elsewhere. Letters to a recent Journal article must be received within 6 weeks of the article’s publication. Receipt of letters is not acknowledged and there is no guarantee that your letter will be published. We cannot provide prepublication proofs. Submitting the letter constitutes your permission for its publication in any current or subsequent issue or edition of the Journal, in any form or media, now known or hereafter developed.
120