posted
I just started seeing an LLMD in September and have been trying to submit to my insurance company for reimbursement.
The insurance company says that they can't process the claim without his Tax ID number. The doctor refuses to give this to me, and refuses to communicate with the insurance company at all.
I'm wondering, is this policy common among LLMDs? My mom is a nurse and thinks it's shady. I don't want to switch doctors, because I really want to continue treatment without a break.
Posts: 25 | From PA | Registered: Sep 2011
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Keebler
Honored Contributor (25K+ posts)
Member # 12673
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- I know this puts you in a very tough position.
However, there are very reasonable explanations for this, really.
First, there are few LLMDs whose patients are reimbursed from a very few insurance carriers. But most are not.
If your LLMD said upfront that he may be covered, then it would seem odd for him not to provide the detail necessary to process a claim. But the Tax ID # seems odd, rather than another kind of identifying number. Still, I'm not up on insurance coverage as I've not had any real coverage for decades. If the tax ID # is what all other doctors submit, then that is not an odd request from insurance companies.
However, the person at your insurance company who is telling you they need this number is probably not aware of their lyme policy. It's not written but very, very quiet. And, yet, very strong.
Many insurance company report LLMDs for going outside of the typical care that insurance is willing to provide - and then they wind up with huge legal battles.
Backing up,
Did you communicate with the doctor beforehand about insurance? Did he say that he is not covered by insurance?
I'm guessing that is the case, as it is the way with 99% of the LLMDs. It's not that they don't WANT to be covered by insurance but insurance companies (99% of the time) will not cover LLMDs.
So, for him to give his tax ID # would serve no purpose if he know that there is no insurance in his coverage area that will cover his services.
To really understand this, it helps to see the documentary: "Under Our Skin"
So many LLMDs are harassed and beyond.
It's a terrible situation and it's really a shame as they are the doctor who take the effort to learn more - and it's a great deal of study to understand the way borrelia and other tick borne infections work, the damage they do and how to help patients.
This DVD and this book are essential in understanding the political climate that greatly oppresses LLMDs: --------------------------
To be sure your doctor really IS a LLMD, this thread may be of help.
Occasionally, there is a LLMD who is not exactly "ILADS-educated" on the surface but, in deeper conversation, you see that they really DO understand all the science of lyme, etc. just have their own methods and may not be an actual ILADS member.
Most LLMDs have their own methods based in individual care of each patients. They have in common, though, the kind of knowledge that ILADS strives to ____ (I can't find the word I want).
The term I use, "ILADS-educated" basically means that they have read the majority of works from active members of ILADS, attended conferences, etc. or in other manners have gone far beyond the IDSA's simplistic view.
Yes, it is typical that a lyme doctor does not accept insurance. The cost of the first visit is often extremely high.
You pay for the visits and the Igenex blood tests at the time of the visit. You can put the charges on a credit card. That's what everyone does.
You can then submit a claim to your insurance company and see how much they reimburse you. Generally, it is not much.
Why the lyme doctors do this is most likely because they have to in order to make any money. I never was in business as a doctor, but it makes sense that they can't make any money, and in fact will lose money, if they take insurance and treat lyme patients.
You see, the first visit with a lyme patient often takes 1 hour to 1 1/2 hours of the doctor's time. Yet, insurance will reimburse him very little for this.
Lyme is complex to diagnose and treat, but the insurance companies don't treat a lyme patient as needing any more time than the patient that comes in with the flu.
That's why insurance taking doctors can only spend 10 minutes with each patient. Did you ever notice that that is, on average, how much time they give you? If they want to make money and not lose money, that is what it comes down to.
Medicare reimbursement is even lower than regular insurance reimbursement, so many doctors are no longer taking Medicare patients. They have to in self defense. This is eventually going to become a crisis in this country. Many doctors (not lyme doctors) limit the number of Medicare patients they will accept into their practice since they lose money on every one they take.
The first visit with a lyme doctor will probably have you in the office for about 3 hours. That includes the interview with the doctor and the doctor's staff's time--the blood draw for Igenex, and the paperwork before the interview.
The doctor has to factor the cost of his staff's time into the charge for your first visit and all other visits.
Another consideration from the doctor's point of view is likely the insurance company oversight of his treatment.
My second lyme doctor took insurance. He said to me at my first appointment, "I'd put you on IV but the insurance company would give me a fit." Therefore, he put me on oral medications. I didn't understand what he was talking about at the time. But, now, looking back, I do.
So, that tells you that if the doctor takes insurance, he is not free to treat the lyme patient the way he wants to treat. If he doesn't take insurance, then he can treat the patient in the best way he knows and not worry about whether or not the insurance company agrees to pay for it.
In general, insurance companies will fight the lyme doctor if he tries to put the patient on IV for more than 30 days. The patient who needs IV needs it for much longer than 30 days. 30 days does nothing.
Also, some insurance companies fight the doctors on the high doses of antibiotics that the lyme patient needs, and the combos of antibiotics that the lyme patients need. The lyme doctor can raise red flags in the insurance company office for these meds and can get hauled up on charges with his state medical board and ultimately lose his license to practice medicine.
That has happened to many lyme doctors. So, the best way for them to operate is to make you the person who deals with the insurance and pays what the insurance refuses to pay. Now, that way, you can get good lyme treatment.
In my experience, my first two lyme doctors took insurance and they could not get me well. I spent 2 years, which I now consider wasted, with these doctors. Then, I switched to a lyme doc who did not take insurance and got cured in one year.
In general, not even talking lyme doctors now, the best doctors don't take insurance. We have learned this in my family. So, my husband's internist does not take insurance, neither does his psychiatrist (hardly any of them take insurance), and neither does my endocrinologist.
I heard a doctor say on the radio about 10-15 years ago that he now had to see twice as many patients as he used to in order to make the same money. That is how insurance controls the health care in this country.
Not talking lyme doctors now--when you go to a non-insurance taking doctor, he generally will spend at least 1/2 hour with you if not more at each visit. He can talk leisurely with you, listen to you without interrupting, and teach you things because he doesn't have to watch the clock so that he doesn't lose money on you.
My husband's internist (doesn't treat lyme) told us that his brother (also a doctor) has a rule in his practice that if the patient takes more than 3 medications, he cannot be his patient.
That is how he limits his practice to the easy to treat patients who will not take much of his time. All this is to keep the doctor from losing money. They lose money if they spend more than 10 minutes with you. They have done the math, figuring all of their overhead and staff salaries, and that is what it comes down to every time.
My husband's doctor (doesn't take insurance, doesn't treat lyme) told us that he is losing money treating the old fashioned way--spending time with the patient, as much as the patient needs, and educating the patient. So,he has to try a new business model to make a decent living. He refuses to give up practicing medicine the way he believes is right.
He is moving to a membership only practice. To see him, you pay a high membership fee up front at the beginning of the year.
So, just know that there is a major upheaval going on in the world of doctors in private practice. They are really scrambling to make a living, having to run faster and faster on the treadmill set up by insurance company reimbursement schedules, just to make a decent living. That is why many Americans are no longer going into medicine and many, many people from foreign countries are filling the doctor vacancies in the U.S.
About 10 years ago I talked with a man who quit his medical practice due to insurance companies dictating to him how he would treat patients. So, this is being told to me by many, many doctors over at least the last 10 years.
So, get to a good lyme doctor and pay for his expertise. Don't let insurance concerns get in the way of you getting your health back. These doctors are legit. No rip off. Good for you for wanting to understand what is going on.
(TF) -
Posts: 48021 | From Tree House | Registered: Jul 2007
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Keebler
Honored Contributor (25K+ posts)
Member # 12673
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- Without all the details, I find my answers try to cover all the bases.
So, if you doctor may have told you at your first visit that insurance reimbursement might be possible and if that has changed, it could be because of some political pressure.
After seeing the film "Under Our Skin" you can see that things can change very quickly for some LLMDs if insurance companies and the IDSA get involved.
I hope you will find that all will look brighter very soon.
Take care. -
Posts: 48021 | From Tree House | Registered: Jul 2007
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Tracy9
Frequent Contributor (1K+ posts)
Member # 7521
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Ask him straight out if you are able to get insurance reimbursement or not. IF so you need his number. If not, that should have been disclosed right up front.
You do need it to get reimbursed. Is he covered under your plan? Is he willing to have you submit his bill? If so, he HAS to give you his number, or he is treading into malpractice territory.
13 years Lyme & Co.; Small Fiber Neuropathy; Myasthenia Gravis, Adrenal Insufficiency. On chemo for 2 1/2 years as experimental treatment for MG. Posts: 4480 | From Northeastern Connecticut | Registered: Jun 2005
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quote:Originally posted by Keebler: If your LLMD said upfront that he may be covered, then it would seem odd for him not to provide the detail necessary to process a claim. But the Tax ID # seems odd, rather than another kind of identifying number. Still, I'm not up on insurance coverage as I've not had any real coverage for decades. If the tax ID # is what all other doctors submit, then that is not an odd request from insurance companies.
I have a friend who works for an insurance company so I have a bit of an inside view on this. The insurance company has to report the money they pay out to the government - it's like how your employer has to report that they are paying you. This is how most (non-LLMD) doctors make money, so their income needs to be reported somehow. So this is analogous to you refusing to give your employer your SSN, and then wondering why they aren't able to give you a paycheck. Except I'm stuck in the middle.
quote:Did you communicate with the doctor beforehand about insurance? Did he say that he is not covered by insurance?
I'm guessing that is the case, as it is the way with 99% of the LLMDs. It's not that they don't WANT to be covered by insurance but insurance companies (99% of the time) will not cover LLMDs.
So, for him to give his tax ID # would serve no purpose if he know that there is no insurance in his coverage area that will cover his services.
I think that you aren't clear on what "covered" by insurance means. Most LLMDs do not *contract* with insurance companies, because this means that the insurance company will tell them how to treat their patients. Any doctor who "accepts" insurance, and who you do not have to pay up front, contracts with your insurance.
However, I have out of network coverage, which means my insurance will pay on doctors that aren't contracted with them. They don't pay directly, but they reimburse you. This should cover any doctor that I see, anywhere in the world.
quote:To really understand this, it helps to see the documentary: "Under Our Skin"
I've seen it, I'm familiar with these issues. I'm just wondering if it is common for LLMDs to refuse to provide this information.
quote:So many LLMDs are harassed and beyond.
Yes, my insurance company told me to report him to the American Medical Association for not providing the tax ID #. Of course I won't do this but it's frustrating.
Posts: 25 | From PA | Registered: Sep 2011
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quote:Originally posted by Tracy9: Ask him straight out if you are able to get insurance reimbursement or not. IF so you need his number. If not, that should have been disclosed right up front.
His nurse has told me repeatedly that they have patients that get reimbursed. She says that I need to emphasize that it is "not in my contract" with my insurance company that I need to provide the Tax ID #. She says that their patients usually get reimbursed once they threaten to "tell their senators," and that one patient did have to actually do this to get reimbursed.
I plan to do this, first threaten and then report my insurance, but I haven't received an official denial. I think they are waiting on the Tax ID # and trying to avoid denying it (despite the fact that I've spoken to them and told them repeatedly that I can't get that number).
quote:You do need it to get reimbursed. Is he covered under your plan? Is he willing to have you submit his bill?
My plan should cover him, because my insurance will pay 80% of out-of-network costs.
quote:If so, he HAS to give you his number, or he is treading into malpractice territory.
This is exactly what I've been wondering. I don't want to be the reason that a perfectly good LLMD gets into major trouble. I don't want to threaten him with this because I want to continue to see him.
I have considered going elsewhere because of this issue but the wait lists are so long for the other doctors I considered (6-9 months). I would continue treatment with him during that wait period. He expects me to be doing fairly well by that point in time so I don't know that it makes a lot of sense to switch to a pricy NYC-area LLMD (which are the next-nearest LLMDs to me) at that point.
Thanks for your comment, though. It's good to know that he shouldn't be withholding this information. I just need to figure out what I'm going to do now.
Posts: 25 | From PA | Registered: Sep 2011
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randibear
Honored Contributor (10K+ posts)
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I do not know but I think if you report him to anyone and start claiming Lyme you are opening up yourself because other doctors then won't see you and he may loose his license. Jus saying...
-------------------- do not look back when the only course is forward Posts: 12262 | From texas | Registered: Mar 2007
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I wasn't planning on reporting him but this is a good point to keep in mind. I wasn't going to report him just because I don't want to be the cause of a LLMD losing his license.
But the point you raised means that I really don't even have a choice. It's messed up that the political climate surrounding Lyme means that LLMDs can get away with minor infractions that other doctors wouldn't.
Posts: 25 | From PA | Registered: Sep 2011
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randibear
Honored Contributor (10K+ posts)
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if you really think that this doctor is practicing illegally or using deceptive practices then by all means file a formal complaint with the AMA or your insurance company. All I am saying is to be prepared for a landslide of inquiries into your medical history, your life in general, etc. Personally I would just find another doctor. The stress of reporting somebody and the ensuing problems might possibly kill me.
-------------------- do not look back when the only course is forward Posts: 12262 | From texas | Registered: Mar 2007
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Rumigirl
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Hmmm. I think I know who your LLMD is, I had a similar problem with this office, but did get the number (this was a while ago).
It sounds to me like they are getting more protective of the dr, or he is getting more protective. Unfortunately, from what my insurance co has told me about THIS SPECIFIC dr, with good reason (meaning the insurance co is trying to bring this dr down one way or another).
YOu could PM me about this, but give me a chance to clear out my mail box first---it may be full right now, or close to it.
This stuff is horrible beyond words. This was one dr who WAS NOT paranoid, but now may be, because the insur co's are making life so difficult for him and his patients. Grrrrrrr!! They don't like dr's who diagnose and treat Lyme, you know---it costs too much! Grrr some more.
And my insur co refuses to reimburse me for visits to this office---even with the number. Or they pay hardly anything. It's crookery on their part. I've fought it and fought it to no avail.
Posts: 3771 | From around | Registered: Mar 2008
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Tracy9
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As a mental health practitioner, I can tell you what they do with the Tax ID number is provide you with a 1099 at the end of the year and report your earnings to the IRS.
There is no other reason for them to need this that I know of. With all due respect, and I am sure this is a great physician, he/she is playing with fire by refusing to provide that number. It equates to hiding income from the IRS, possibly. This is the kind of stuff that gives LLDs a bad name!
All insurance companies report every penny they pay provider with our Tax ID numbers (EIN) numbers. I can't think of any other reason not to provide it. They already have all the information they would need on this provider were they to file a complaint. This number is strictly for IRS reasons. It is provided by the IRS and used for tax filing.
13 years Lyme & Co.; Small Fiber Neuropathy; Myasthenia Gravis, Adrenal Insufficiency. On chemo for 2 1/2 years as experimental treatment for MG. Posts: 4480 | From Northeastern Connecticut | Registered: Jun 2005
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poppy
Frequent Contributor (1K+ posts)
Member # 5355
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Could you contact a support group that is likely to know something about this situation, like whether there is reason for paranoia? If there isn't, then maybe someone else, like a support group leader who is tactful and informed, needs to explain the tax ID situation to the doctor's office so you and others can get reimbursed for out of network visits.
If there is reason for paranoia, then this needs to be known by support group leaders anyway, so they can start thinking about what kind of actions to consider taking.
Posts: 2888 | From USA | Registered: Mar 2004
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Rumigirl
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PM sent. I'm aware of this particular situation.
Posts: 3771 | From around | Registered: Mar 2008
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randibear
Honored Contributor (10K+ posts)
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well with all the trolls I bet they find out now
-------------------- do not look back when the only course is forward Posts: 12262 | From texas | Registered: Mar 2007
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-------------------- aperture Posts: 551 | From Louisville, KY | Registered: Nov 2011
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randibear
Honored Contributor (10K+ posts)
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I lost a great llmd just because some jerk didn't like his wife getting treated. He complained to the medical board and the doctor was penalized. He went out of practice ......'sad
it doesn't take much to get them to stop practicing. just a little sanction and they're gone.
quote:Originally posted by poppy: Could you contact a support group that is likely to know something about this situation, like whether there is reason for paranoia?
I guess that's why I was coming here! There aren't any support groups near me, it would be a few hours' drive. I haven't felt the need so far to bother.
quote:Originally posted by aperture: I don't file
out-of-network claims, even though Lyme has made
me completely broke, because I want as few
external entities to be aware of my Lyme
diagnosis as possible, to avoid any future
denials (ex. prescriptions). For me it's not
worth losing my LLMD in the future over a $80
payment from the insurance company.
I suppose I am just very concerned over my financial situation. I am taking a medical leave from grad school and the job that accompanies that because of Lyme. I am going to eat through the money I have pretty quickly. It may be getting pretty scary here in a few months.
But this isn't about one payment, it's about on-going monthly costs of visits. I see my doctor every four weeks. I'm going to be paying for COBRA, which costs a lot more than what I'm paying for insurance now, and then paying for visits on top of that.
So far my insurance has covered prescriptions, fortunately, including Mepron. I am so thankful for that.
quote:Originally posted by randibear: it doesn't take much to get them to stop practicing. just a little sanction and they're gone.
it's often too much for them so they just quit.
Yeah I don't want to make his life difficult. I am in a difficult position but I realize that he helps a lot of people other than just me.
Thanks for all the replies, everyone. I was really just trying to get an idea if I would have the same problem if I went to another LLMD. I don't really want to switch but it was a possibility on the table.
Posts: 25 | From PA | Registered: Sep 2011
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Keebler
Honored Contributor (25K+ posts)
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posted
- I always go back to communication with the immediate source.
I know the office manager told you a couple of basic things, like that number should not be needed.
You might call at a time not likely to be busy and ask if she has time to help you better understand all the nuances of this situation.
Also feel free to ask your doctor at your next visit. Then you have details straight from the source and you'll be better able to assess the situation.
The office manager said that they've had other patients who received insurance reimbursements (even partial). I hope she is referring to current times, not just in the past.
I also hope some of the others have the same insurance company as you.
So, if you can also navigate this, it can certainly make the difference in the degree of care you can access. I hope your communication with the doctor and his staff helps. -
Posts: 48021 | From Tree House | Registered: Jul 2007
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Keebler
Honored Contributor (25K+ posts)
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- You noted that there is no lyme support group near you. You might try going through Lyme Disease.org, an excellent group.
The Lyme Disease Network is a non-profit organization funded by individual donations. If you would like to support the Network and the LymeNet system of Web services, please send your donations to:
The
Lyme Disease Network of New Jersey 907 Pebble Creek Court,
Pennington,
NJ08534USA http://www.lymenet.org/
UBBFriend: Email this page to someone!
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