[NPInfo] Re: Referrals (was Physician blogs maligning NP s)

[Sue Wiers]

I recently faxed a introductory letter to a urologist before my patient arrived.  I summarized her rather complicated medical history, medications, and her preferences regarding avoiding aggressive measures.  I wrote the letter to simplify things for my patient.  However, I was surprised when I received a very nice letter from this specialist (first time ever from this group) summarizing his findings and plan of care.  While this is not feasible for each patient and wouldn't likely have the same effect on other specialists, I am hoping that I won't be treated like a second class citizen in the future by this physician.  
 
Sue



> Date: Mon, 10 Mar 2008 05:22:28 -0700> From: ljthiem at yahoo.com> To: npinfo at nurse.net> Subject: [NPInfo] Re: Referrals (was Physician blogs maligning NP s)> > Reading the article that Carla sent below from Family Practice Management, it seems that we are not the only professions who have difficulty with the consultation/referral process. It seems that some specialist ego and/or goodoleboys club behavior gets in the way for them as well as it does for us.> > What are you prepared to do? I like the idea of calling the specialist. If you can get through the office assistant, etc. I also send my business card with the patient so that the specialist knows who sent the patient and how to contact me. I follow up with a call or letter requesting info. If all of that fails, I contact the office manager, the practice owner and tell them they will be losing my business. I also tell them to be prepared to hear from the insurance investigators as billing for a consult visit without communicating with the referring provider is illegal per Medicare's guidelines. See page three of this document:> http://www.oig.hhs.gov/oei/reports/oei-09-02-00030.pdf> > Recently I received a visit from a new spine specialty group representative. Of course they want my referrals. I told the representative that the first time my patient came back to me with a statement that the specialist told them they should be "seeing a real doctor" or that I didn't receive a follow-up report that I would no longer refer to them and I would notify the board of insurance etc.. She was floored. I told her of the actions of other specialty groups under their parent umbrella with physician-centric remarks, stealing patients and refusal to communicate with me--a nurse practitioner. I told her that those specialist, while having outstanding reputations, would never receive any of my patients. She promised to get to the bottom of it. Nothing has come of it and my expectations weren't high. I will try their group. Once.> > As for the patient who finds their own specialist--I tell them "I'll send the stuff and make the referral but understand that I will likely not hear from that specialist or know what is happening with you. You will need to sign a consent so that we can send for those records with every visit." While I value every patient, I also understand that they have to make decisions for themselves. If they find someone else's care preferable then they need to be with that provider. I'm not going to scramble to keep someone who wants to be somewhere else.> > Laura, NP, CNS> > Carla Anderson <carla_rayne at yahoo.com> wrote: Hi Stephanie,> > The rules are the "unwritten" and some are "written" rules of appropriate conduct, in terms of people starting a new business, in terms of a good ol boys club, in terms of just doing the right thing... There are many articles on the "written" rules, and here is one on the AAFP website:> > http://www.aafp.org/fpm/20071100/38opti.html> > In this article, it says the docs will be so embarrassed if they get a call, but I find they are more brazen than that..so I think I WILL make a personal visit, ahead of time... There are not too many choices, as a lot of the docs that are in surgery, or gi, work in large groups together, and are affiliated with certain hospital groups, and patients dont want to travel too far out or dont have a choice because of their insurance. Regarding the "secretary part", boy the games they play. They have their true secretary call me and say " we need YOU , SINCE YOU ARE THE PCP, to call the insurance company and make this appointment that we scheduled (without your approval I might ad) retroactive, because YOU dont want the patient to suffer and pay extra....we want this to be in the best interest for the patient...dont you?" I literally have had many patients not return once they see the specialist. Or I work very hard to find a psychologist that is an "expert in the field of> ADHD/OCD/Tics in adults, for a guy that has been dealing with it for YEARS. So I tell him how important it is to get the right person (he has waited this long). I get an appointment scheduled, do all the referral paperwork, call the patient. Then two days later, the patient says he looked on line and found "someone" that can see him in two days rather than two weeks, so he will just go there... The list goes on and on.. > > Yes it goes to educating the patients, but there are so many unique and individual cases... I had one woman who I set up with a nationally renowned breast surgeon for a biopsy, and her plastic surgeon boss who always threatens to fire her, got his ego inolved and said to her "you should go to the doc I refer you to..., we like her better"... so then I have to cancel, and my credibility goes down with this doc I initially set up..> > So it is a problem on both the patient and the specialist end, they both need a lot of education.. I think I am going to really educate, prior to the consult. The patients may think they can shop around, but in my neighborhood there are not a lot of providers that go out of their way for house calls, answering calls on a Sunday , etc..> > It comes down to being like Parenting. If the specialists will form a united front with me, then the patients have structure and are not confused. But if they play the patient back and forth, then it creates confusion. > > I just never used to see this before, where the ortho doc refers to Rheumatology, instead of back to me, no letter, nothing. And the only way I found out is because I called the patient. I also am in practice by myself, no doctors to back me either. > > The letter/form I send is very clear. It says I am sending this patient to you for a consult and/or a procedure. Please send me a written explanation of your findings, and your recommendations..." something like that..and I send copies of all notes, labs, insurance. And then they ignore me. I had one doc a colorectal surgeon who was great.> He gave a personal call right after his visit, then sent a great letter, of his procedure, and referred the patient. > > But I will fix the problem, and keep you informed. Carla > Stephanie Walker wrote:> Hi Carla,> > What a difficult situation you have, but I agree with AnnMarie that > you may have some leverage. Although you gave a lot of information, > there are some details that only you are aware of.> > In your area, is there more than one specialist office for each > specialty, so you can boycott the more troublesome offices if it > comes to that, and only send patients to the ones who are cooperative?> > If so, I think it is worth the trouble to contact these specialists > personally. Obviously with 2 jobs, you have little time to make a > personal visit, but I think it's more effective than a phone > conversation. It's harder for the doc to brush you off. I would just > walk in like a drug rep and ask for 15 minutes of their time. Why not > bring a box of candy for the office staff with your business card on > it, or something, just like the drug reps do.> > To the doctor, you could say that for some reason you are not getting > any written reports from them after you have referred a patient, and > do they have any suggestions, since you would like to continue > referring patients to them.> > When you say the specialist office will tell you to play secretary > and do all the paperwork for them--what paperwork do you mean? And, > when you mention that they are breaking the rules, whose rules are > you referring to--is it the insurance contract? If so, then you could > speak with the insurance company.> > Best of luck,> > Stephanie> > > On Mar 9, 2008, at 5:32 PM, Carla Anderson wrote:> > > I also wish to join the ACC. I mentioned it before, and am working > > at my second job today, but will get back to it right away. I have > > a question for the list. I did not see the original blog, of > > malignment, but along those lines..I have my own practice. I do > > not know if it has anything to do with me being an NP PCP rather > > than an MD but here is what is happening.> >> >> > I have noticed over and over again, that I refer to Ortho, or > > General Surgery, or wherever, and rather than them writing me a > > nice letter of Consult and sending the paient back to me, they > > either continue seeing the patient for weeks or months (if they > > have good insurance) and they are doing primary care visits, not > > needed for their specialty services, (billing the patients > > insurance at their specialty rates) , or they are referring > > patients to another specialist. They are breaking the rules. They > > upset the patient and confuse them. I do not know if they tell the > > patient negative things about NPs, and they do not really know me > > personally, this is not a personal thing. But one patient had > > severe swelling, pain, feeling cold, and numbness to her left > > wrist with positve phalens and tinels, and does a lot of repetitive > > computer work...so I sent her for an u/s to r/o dvt, then emg/nct, > > to eval for Carpal tunnel synrome. Initial labs including ana, rf > > were negative,> > but sed rate was slightly elevated. I put her on a steroid taper, > > ice (after dvt was ruled out), splinting, off work, and sent her to > > ortho. After I referred her to one ortho, the patient called me, > > and said she called another one on her own, and got in sooner, so > > now could I send all thepaper work there. So I had to send another > > letter to the first ortho doc, apologizing, and cancelling the > > referral, and then sent another referral letter to the ortho doc > > that the patient wished to see now.> >> > Anyway, this ortho doc did not write me any type of letter > > thanking me for the consult, or did not write me any letter > > regarding his exam or findings. He just referred the patient on > > his own to rheumatologist to r/o lupus... and then tells the > > patient to come back to him.. I had to find this out, by calling > > the patient. This has happened several times, and then the > > specialist gets a letter from the next specialist, as they were the > > referring doc, and I get pushed out of the loop.> >> > UNLESS OF COURSE, INSURANCE REQUIRES I AS PCP DO THE PAPERWORK. > > Then the specialist office will call me and tell me to play > > secretary and do all the paperwork for them.. I really feel that > > maligning is going on behind the scenes. I thought about having > > lunch with these docs, which I will, but there are so many, > > especially when the patient later tells you, of a certain doc she > > has seen since childhood..> >> > I have the American Academy of Family Physicians website Consult > > Form, including the rules.. They are clearly breaking the rules, > > and it is clearly disrespectful.. The problem is the patient is put > > in the middle.. and I do feel that being an NP in private practice > > is part of this passive agressive move that is occuring.. I will > > continue to remain positive. I think I am going to answer part of > > my own question right now... PRIOR to any referral, I will call > > the doctor's office and ask to speak to the doctor directly. This > > is when i have the most power. At that time BEFORE THE REFERRAL, > > I will let the doc know that I need to be in charge of all > > referrals as PCP, kept in the loop, and referred back to with > > findings if specialty care is not needed. I ALSO am going to tell > > the patient BEFORE the referral they are NOT TO CALL on their own > > and set up with a different provider as it causes a lot of > > confusion and fragmentation...The patient clearly can be in charge, > > and tell> > the specialist what needs to be done, as if they have good > > insurance they are very powerful. And the patietns that have gone > > to private NP practices know, and are very loyal, but the brand new > > ones are easily influenced if no bond has developed. But these docs > > MUST REALIZE I AM A GREAT REFERRAL SOURCE and I will not use them > > again if they abuse this.> >> > Just for this one patient I had to fill out several work excuses, > > medication rxs, the referral letters, the different imaging > > studies, and the 6 pages of Family Medical leave act that had to be > > faxed to both her employer and he employers insurance company. The > > primary care provider (whether doc or NP or PA, needs to be the hub > > of the wheel, and the specalists are the spokes). They are not the > > one that coordinates the annual exams, all of the meds, the > > testings, and making sure that all providers associated with the > > patient are on the same page. Carla Anderson, FNP-Healing Presence > > Family Practice, Oregon> >> > jlambertrn at comcast.net wrote:> > Karen,> > I echo your thanks to Stephen and David. I agree whole heartedly > > with you and your thoughts and the fact that much of our knowledge/ > > training is similar to the apprentice concept that has been working > > for centuries. (Sorry about the run-on sentence; my high school > > english teacher is probably rolling over in her grave!) As you, I > > too remain humbled by the amazing amount of knowledge that is out > > there that we (including docs) need to be on top of. I treat people > > with respect, and expect the same in return, docs included. For the > > most part, I enjoy a very collegial relationship with the other > > docs in the ED where I work. Occasionally, I have to call a > > specialist for a consult. Most are receptive to me as a NP, however > > you still run across the arrogant jerk every now and then. I always > > remember who they are when I am moonlighting in primary care as I > > frequently do. Does a doc really think I am ever going to refer a > > patient to him/her after being disrespectful or unprofession!> > al towa> > rds me? If the offender treats a colleague in that manner, how will > > he treat my patient? Nope, no referrals for you!> > As far as Panda Bear is concerned, I feel he has way too much time > > on his hands. His post was long, rambling and most of all B-O-R-I-N- > > G. One of the AMA's beefs with us has always been "they take > > patients away from us, and it will affect my ability to earn a > > living". Does Panda Bear have any clue to the difficulty a patient > > encounters when he/she calls their PCP on a day when they truly ill > > and are told that the next available appt. is in two weeks? We see > > these patients in the ED every day, so there goes the theory of > > "us" stealing "their" patients. Paaaaallleeeeeze! There are plenty > > of patients to go around and that is an unfounded, tired, mundane > > talking point put forth by the AMA and other groups. That argument > > impacts patients in a very negative manner. Yep, reading that blog, > > made me get the same feeling in my gut that I get when I have to > > call that arrogant ENT or surgeon, or whatever. The positive point > > in all of this is that I LOVE WHAT I DO, and like Peg Fitzgera!> > ld alwa> > ys says "Being a NP is the BEST job on the planet". So what next? > > We all go on doing what we always do- providing quality, evidence- > > based care to our patients who put their faith and trust in us > > every day. One patient at a time. I think it's time to join the > > ACC- Dave Mittman, are you listening? I have my credit card in > > hand. LOL.> > Julie Lambert, FNP> > Ocean County NJ> > -------------- Original message --------------> > From: karenfnp at comcast.net> >> >> Stephen and David,> >>> >> Thanks for your comments and the sample blog. As a champion, > >> especially for> >> NPs, I like to hear what others say about us in order to facilitate> >> bridgebuilding. One aspect of health care provider training I like > >> to stress> >> with docs and advanced practice clinician students is that so much > >> of what we> >> learn in the medical aspect of what we do is apprentice based. We > >> all have to> >> learn the same new info when new diagnoses, treatments and meds > >> emerge on the> >> health care scene via CME and OJT to maintain quality evidence > >> based practices.> >> ( To have more residency programs for PAs and NPs in speciality > >> areas would give> >> us more credibility in specific content areas.) I like to maintain > >> a posture> >> of humility in terms of all that we need to know these days and > >> respect docs who> >> do the same. It looks like this "panda bear physician", per the > >> content in this> >> blog blurb, chooses to spend energy putting NPs PAs down and > >> reminds me how we> >> have to choose where to spend our energy in !> >> buildin> >> g our allies in the physician community and not waste it a la > >> "casting pearls> >> to swine" as Jesus said once.> >>> >> Karen Riesinger FNP> >> Portland, OR> >>> >> _______________________________________________> >> NPInfo mailing list> >> NPInfo at nurse.net> >> http://lists.nurse.net/mailman/listinfo/npinfo> >> *****************************> > _______________________________________________> > NPInfo mailing list> > NPInfo at nurse.net> > http://lists.nurse.net/mailman/listinfo/npinfo> > *****************************> >> >> >> > Carla R. Anderson, FNP-C> > Healing Presence Family Practice, PC> > carla_rayne at yahoo.com> > 503 819 9726> > _______________________________________________> > NPInfo mailing list> > NPInfo at nurse.net> > http://lists.nurse.net/mailman/listinfo/npinfo> > *****************************> > _______________________________________________> NPInfo mailing list> NPInfo at nurse.net> http://lists.nurse.net/mailman/listinfo/npinfo> *****************************> > > > Carla R. Anderson, FNP-C> Healing Presence Family Practice, PC > carla_rayne at yahoo.com> 503 819 9726> _______________________________________________> NPInfo mailing list> NPInfo at nurse.net> http://lists.nurse.net/mailman/listinfo/npinfo> *****************************> > _______________________________________________> NPInfo mailing list> NPInfo at nurse.net> http://lists.nurse.net/mailman/listinfo/npinfo> *****************************
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