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Insurance denials of MRI's…..

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  • Avatar Ykcor 
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    Seems to be getting harder to get insurance to approve MRI requests. Patients with obvious cervical or lumbar radiculopathies and severe pain, they want plain X-rays plus six to eight weeks of conservative Rx before getting scan. Unfortunately, patients in USA want fast results. Myself, being in private practice, I don’t have time to do face to face appeals, so I just refer the patient to a neurosurgeon, which ultimately costs the insurance company more money.

    MRI breast? Forget about ordering one, even though there is a State Law here in Alabama that on a mammalogram radiologist’s report involving a dense breast, they have to suggest having this test. (Apparently A state legislature’s wife had a breast cancer missed on a regular mammalogram several years ago).

    #213099 Reply
    CordMcNally CordMcNally 
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    You’d be surprised at the amount of people referred to the ED for non-emergent MRIs. Then the patient gets upset when we tell them no.

    “But investing isn’t about beating others at their game. It’s about controlling yourself at your own game.”
    ― Benjamin Graham, The Intelligent Investor

    #213100 Reply
    Avatar G 
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    I lost my cool one night on a crazy family and pointed out when their little Johnny made as much money as Lebron, he could buy a hospital and get his knee MRI. until then they had 2 options: leave now with crutches or leave in a squad car with a trespassing charge (and crutches).

    #213104 Reply
    CordMcNally CordMcNally 
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    I lost my cool one night on a crazy family and pointed out when their little Johnny made as much money as Lebron, he could buy a hospital and get his knee MRI. until then they had 2 options: leave now with crutches or leave in a squad car with a trespassing charge (and crutches).

    Click to expand…

    Professional athletes are usually my go to for examples and how even professional athletes don’t get emergent soft tissue/joint MRIs. Sure, they usually get them the next day but that’s not my point. If a $100M knee can’t get an emergent MRI in the ED then the chance that Joe Blow (who was told by urgent care to come straight to the ED for an MRI) can get one is going to be pretty slim…zero, actually.

    “But investing isn’t about beating others at their game. It’s about controlling yourself at your own game.”
    ― Benjamin Graham, The Intelligent Investor

    #213108 Reply
    Liked by jz
    Avatar snowcanyon 
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    We do them in our ER. Drives me insane.  Part of it is because we do see a high number of professional athletes, and their coaches insist, which is funny, because ortho never wants them on follow up.

    My guess is insurance never covers them ha ha.

    #213135 Reply
    CordMcNally CordMcNally 
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    Part of it is because we do see a high number of professional athletes, and their coaches insist, which is funny, because ortho never wants them on follow up.

    Click to expand…

    Do you really see professional athletes in the ER for their sports related injuries? And do their coaches really come in with them? Every professional team has a team doctor (usually orthopedist) and they will contract with certain hospitals. I guess I’m saying I find it hard to believe that a pro athlete comes to the ER with their coach and they have no orthopedic coverage/follow-up. They’re usually evaluated by the team physician and once a life-threatening injury isn’t suspected, they’ll get an MRI as an outpatient whenever they get back to their city if it’s a road game.

    “But investing isn’t about beating others at their game. It’s about controlling yourself at your own game.”
    ― Benjamin Graham, The Intelligent Investor

    #213138 Reply
    Liked by jz, MaxPower
    Avatar HandFellow 
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    Way too many MRI are being ordered as it is. Getting an MRI because there is radiculopathy is unnecessary if you haven’t done first line of treatment like PT and NSAIDS. If you haven’t done the first line of treatment, you get the MRI which shows a disc and then you send to therapy. I would think many patients would like to avoid the cost of an MRI unless it is necessary

    #213142 Reply
    Avatar Panscan 
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    In 30 yrs we will realize we are way over aggressive with spine surgery. All kinds of people living with bad on imaging discs and nerves yet completely asymptomatic. There has to be more to the picture than our current understanding.

    I feel same way with FAI. Now every 20 something with hip pain needs their hip scoped and ground up when there are numerous of their peers with similar hip morphology who have no pain.

    Avatar snowcanyon 
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    Part of it is because we do see a high number of professional athletes, and their coaches insist, which is funny, because ortho never wants them on follow up.

    Click to expand…

    Do you really see professional athletes in the ER for their sports related injuries? And do their coaches really come in with them? Every professional team has a team doctor (usually orthopedist) and they will contract with certain hospitals. I guess I’m saying I find it hard to believe that a pro athlete comes to the ER with their coach and they have no orthopedic coverage/follow-up. They’re usually evaluated by the team physician and once a life-threatening injury isn’t suspected, they’ll get an MRI as an outpatient whenever they get back to their city if it’s a road game.

    Click to expand…

    Yes. We see this weekly, or more, during the season.  A fair number of them are international athletes or from out of town, so they don’t have follow-up nearby.  I agree- I don’t see why they don’t follow up with their ortho, but it’s hard, I guess, if they are from out of town, traveling, or international.  And they know we have good ortho, so they are happy to be seen at our facility. Their traveling docs seem to be FP, if they have one. It’s a long way back to France/China/Japan/Canada.  Sometimes they have a huge competition coming up and they want to know exactly what the injury is and if there is any way they can compete or if they can get surgery sooner.

     

     

    #213152 Reply
    Avatar G 
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    Skiers? If we’re talking high maintenance with lousy follow up, gotta be skiers!

    #213163 Reply
    CordMcNally CordMcNally 
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    Part of it is because we do see a high number of professional athletes, and their coaches insist, which is funny, because ortho never wants them on follow up.

    Click to expand…

    Do you really see professional athletes in the ER for their sports related injuries? And do their coaches really come in with them? Every professional team has a team doctor (usually orthopedist) and they will contract with certain hospitals. I guess I’m saying I find it hard to believe that a pro athlete comes to the ER with their coach and they have no orthopedic coverage/follow-up. They’re usually evaluated by the team physician and once a life-threatening injury isn’t suspected, they’ll get an MRI as an outpatient whenever they get back to their city if it’s a road game.

    Click to expand…

    Yes. We see this weekly, or more, during the season.  A fair number of them are international athletes or from out of town, so they don’t have follow-up nearby.  I agree- I don’t see why they don’t follow up with their ortho, but it’s hard, I guess, if they are from out of town, traveling, or international.  And they know we have good ortho, so they are happy to be seen at our facility. Their traveling docs seem to be FP, if they have one. It’s a long way back to France/China/Japan/Canada.  Sometimes they have a huge competition coming up and they want to know exactly what the injury is and if there is any way they can compete or if they can get surgery sooner.

     

     

    Click to expand…

    Aha…I was thinking more along the lines of MLB, NFL, NBA, and NHL.

     

    I was picturing Bill Belichick in the room with Tom Brady wanting an MRI.

    “But investing isn’t about beating others at their game. It’s about controlling yourself at your own game.”
    ― Benjamin Graham, The Intelligent Investor

    #213166 Reply
    Zzyzx Zzyzx 
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    Joined: 09/24/2018

    We do them in our ER. Drives me insane.  Part of it is because we do see a high number of professional athletes, and their coaches insist, which is funny, because ortho never wants them on follow up.

    My guess is insurance never covers them ha ha.

    Click to expand…

    any pro athlete with an “on the job injury” has to be covered by their workcomp.  have your ED billing dept look at the reimbursements for these emergent MRI’s; if there is a high number of denials then you might have an argument to take to admin.

    I believe the only same day MSK MR’s we did for our pros and collegiates were for spinal injuries, knee dislocations, neuro stuff (seizures, ICH, …)

    It’s psychosomatic. You need a lobotomy. I’ll get a saw.

    #213172 Reply
    Zzyzx Zzyzx 
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    Status: Physician
    Posts: 175
    Joined: 09/24/2018

    In 30 yrs we will realize we are way over aggressive with spine surgery. All kinds of people living with bad on imaging discs and nerves yet completely asymptomatic. There has to be more to the picture than our current understanding.

    I feel same way with FAI. Now every 20 something with hip pain needs their hip scoped and ground up when there are numerous of their peers with similar hip morphology who have no pain.

    Click to expand…

    nonop MSK is a gaping hole that ortho keeps making bigger which keeps them rich

    everyone wants to run a half or full marathon but not train correctly for it or even wear the right shoes

    some hips just aren’t meant to be distance runners

    It’s psychosomatic. You need a lobotomy. I’ll get a saw.

    #213177 Reply
    IntensiveCareBear IntensiveCareBear 
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    Status: Physician
    Posts: 235
    Joined: 12/22/2018

    Way too many MRI are being ordered as it is…

    … I would think many patients would like to avoid the cost of an MRI unless it is necessary

    Click to expand…

    Yeah, MRI or other advanced testing should really only be for decision tree forks, such as surgical yes/no decision making or surgical planning. I agree 90% probably didn’t need to be ordered/done (MRI or many other imaging/labs/etc). MRI is just not going to change the tx for shoulder, Achilles, spine, knee, etc for most people… the response to conservative treatment (PT, bracing, inject, etc) is what will decide if they need surgery or not. If an ER doc or ortho surgeon can’t tell 90% of the time if a tendon is ruptured from clinical exam or if a bone is broken from xray, then what they probably need is a fellowship… not a MRI.

    As long as hospitals/centers make money off the testing, it will be ordered early and often (before much/any conservative tx). Docs like the info and/or get RVU for it, and many also think they are being smart from a medical-legal standpoint by ordering nonsense. I’m glad those over-utilizers have to put up with tons of time wasted on paperwork, denials, peer-to-peers, results to review and discuss, etc.

    Patients like the info too. They are paying way too much for health insurance, so they try to get their money’s worth. They all want MRI when xray would suffice and complete lab work when a BMP would be fine. Then, not surprisingly, their insurance premiums go up since they all think that way.

    It is a nonsense cycle, but it will perpetuate as long as insurance does. When it is a big anonymous entity that is viewed as paying for the stuff, nobody cares. If people were cash pay, they’d be refusing tests left and right… and docs would learn to keep it to important and true decision tree test orders only.

    "Hmm, that sounds risky." - motto of the middle class

    #213178 Reply
    Avatar snowcanyon 
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    Status: Physician
    Posts: 511
    Joined: 10/22/2018

    We do them in our ER. Drives me insane.  Part of it is because we do see a high number of professional athletes, and their coaches insist, which is funny, because ortho never wants them on follow up.

    My guess is insurance never covers them ha ha.

    Click to expand…

    any pro athlete with an “on the job injury” has to be covered by their workcomp.  have your ED billing dept look at the reimbursements for these emergent MRI’s; if there is a high number of denials then you might have an argument to take to admin.

    I believe the only same day MSK MR’s we did for our pros and collegiates were for spinal injuries, knee dislocations, neuro stuff (seizures, ICH, …)

    Click to expand…

    Are internationally-based athletes or those who make money by endorsements are covered by worker’s comp? I’m pretty sure worker’s comp is only for W2 employees in US-based jobs, no? The international ones come with weird travel policies. If they are covered by worker’s comp, that’s great, but I don’t think so. I meant ortho doesn’t want the MRI, not the patient! They are happy to have cool, pro athlete patients.

    Sure. That’s medically correct. That’s not what we do, unfortunately. I don’t agree with our standard. I’m not sure what your point is.

    #213183 Reply

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