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How Would You Resolve This Dilemma?

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Okay, I own a headache clinic. In the past 31 years of working in headache medicine, I never once admitted a patient for headache treatment, EXCEPT, for the 4 years I worked in an inpatient headache treatment center, the we admitted all of them.


But in a typical headache practice, if you do a good job, the patient would never need to be admitted. I do still send a patient or two per year to the same inpatient treatment center where I use to work out east. We have all kinds of out-patient treatment protocols (including home infusions).


Now, our number one insurer (Regence) says, that if we do not have hospital privileges, we will be dropped from their insurance. If we are dropped, we have no chance of remaining solvent and the practice would have to disappear, almost overnight, abandoning about 1500 patients.


Now I've approached three hospitals about getting privileges. Hospital #1 requires $1,000 (which is not a big deal) BUT, that if we do not admit a patient for one quarter, we will be dropped down to courtesy staff. I then talked to Regence and they said if we become courtesy, we will be dropped.


Hospital #2 sees us as a competitor (they have two neurologist on staff) and will not grant us privileges.


Hospital #3 requires my SP to have followed at least 100 inpatients in the past 3 years and he has not. They also require that 10 patients be admitted per year, or we will be dropped to courtesy staff.


This is complete nuts. I've tried many times to make sense with the insurance company. However, this is their new policy and they are not willing to bend their rules.


Sure, we could admit a patient per quarter, but in my opinion that would be fraud. They wouldn't need it. It will cost the patient money and not just the insurance company.


I have one plan in mind, but was wondering if any of your freakin geniuses have another idea. :heheh:

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admit a pt a quarter who wants to be admitted who would otherwise require extensive outpt therapy(home infusions, etc). that is legitimate and would not be fraud.

some pts LIKE to be admitted....

or admit 1 pt/quarter who needs inpt psych evaluation...I imagine you probably could come up with some candidates....

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Definitely, the deal w/ hospital #1 is the best.


You will be " on staff", and have an opportunity to demonstrate the quality of your work.


You will be able to order certain procedures which you have in the past had problems getting ( LPs).


There seems to be no downside.


If it could be a coin toss as to whether or not the patient needed to Be admitted, and -as E says-, the patient wants or certainly does not object to being admitted.. Admit them.


I admit many patients who do not absolutely need admission ( meaning that they could be taken care of as an outpatient), but who need admission for other reasons ( social, financial, convienence, better delivery of drugs, easier access to studies sleep deprived EEG in patient patients from far away who have no local sleep lab, etc)


As C says, you NOT. Admitting has as a basis saved the insurance companies big bucks.


So admit. You are not being unethical.


The cost of doing the greater good is sometimes paying a small penalty. In this case, the penalty actually is to your advantage.


But... But... I smell a rat.


Why this rule? To what advantage?


Is it a ploy on the insurer's part to undermine their relationship with you?


Play the game..

Advantages: staff membership

Hospital access

Better credentials to show patients who may ask "where do you admit if I need admission?"

Broader reputation for quality work within general medical community ( especially the ED)

Continued insurance.


None, really. Other than this strange pride in non-admission rate.


Best of luck. Your struggles and this fight for survival continue to amaze me, and admire you.



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