A Three-Ring Circus in the Medical Care Arena

In medical care these days, the insurance companies seem involved in everything. They often call the tune, and doctors usually are looking over their shoulders as they conduct their practices.

While the insurers’ concerns with keeping costs down and stemming improper billing sound reasonable enough, many doctors suggest the frequent outcome is that they get paid less and spend less time with their patients. As a consequence, physicians say, the care the patients receive is diminished. The paperwork, meanwhile, goes up enormously.

All this seems to be at issue in the dispute between the husband-and-wife doctor team of Charles and Joan Marie King in North Hollywood and Transamerica Occidental Life Insurance Co., administrator in Southern California for the federal Medicare system.

Several months ago, the Kings, who have been practicing for 30 years, saw reimbursements mostly cut off to them for the 70% of their clientele who are under Medicare. Transamerica was rejecting their claims as excessive.

The Kings borrowed money to keep their practice afloat, and sought a conference with Transamerica representatives.

The meeting took place at Transamerica’s offices downtown on Aug. 4, with Dr. Arthur N. Lurvey, medical director for Transamerica’s Medicare oversight, and Kimberly Rowe, a company specialist, representing the insurer.

At the Kings’ initiation, the meeting was taped on both sides, and the Kings later provided me their copy of the recording.

Lurvey, while saying he understood “the frustrations that you have,” was also insistent that the Kings were billing Medicare for too much time with patients.

He particularly objected to examinations for what he described as “chronic conditions” that lasted three hours. (The Kings’ office manager says many were just two hours.)

“The documentation didn’t justify the amount of time you spent,” Lurvey said at the meeting. “We’re suggesting that under our rules you didn’t meet [Medicare] standards.”

“How much time do you spend with [such patients]?” asked Dr. Joan King.

“Fifteen to 20 minutes, sometimes a little more,” responded Lurvey, who practices privately one day a week in Beverly Hills.

“With an 82-year-old who has multiple complaints?” Joan King asked.

“Absolutely, because I’m efficient,” Lurvey responded.

Later on, Joan King insisted that such restrictions in what Transamerica will pay for have led to many specialists cutting exam times and failing to explain their diagnoses to the patients.

“I’m seeing more and more patients whose specialists . . . don’t talk to their patients at all,” she said. The patients “come to me and ask that I interpret everything . . . and that’s why these visits are so long.

“I don’t care what anybody says. When you cut the visits too short in an older person, that person wants the answers just as much as anybody else. . . .

“If you can tell me you can go over a person in 20 minutes . . . and talk to them about what’s happening and listen to them, take care of a real person and call it medicine . . . this is very, very insulting.”

Lurvey responded, “We’re not suggesting that you’re not a fine doctor. You are a fine doctor. . . . No way did I suggest that the caring was inappropriate. All we said was that the documentation in some areas didn’t support the level that you quoted, and that the community standard wasn’t met.”

When Charles King told of seeing a 69-year-old woman for two hours beginning at 1 a.m. before she underwent surgery for a strangulated hernia, and then questioned why, under Medicare rules, he couldn’t get paid for seeing her in the same 24-hour period as follow-up after the surgery, Lurvey answered, “There are federal rules I don’t have any choice on.”

Rowe, the insurer’s representative, noted that the Kings seemed “quite proficient in the law field,” and said they could go “to the code of federal regulations and it will tell you what we’re supposed to do and how we’re supposed to operate. We’re trying to administer the program as the law has been written.”

“Well, what about quality?” Joan King interjected. “Where’s quality built into this?”

Lurvey said, “The answer to that is most doctors are performing in a quality way.” He vowed that all the King claims would be “reviewed, looking at the issues as we’ve described them.”

Since the Aug. 4 meeting, the Kings said that Transamerica has been approving payments at about a 30-cents-on-the-dollar level, and rejecting their appeals.

Transamerica’s chief Medicare director, George Garcia, acknowledged in a later interview that the amount of oversight by the insurer has increased.

He said this was triggered by a government report two years ago that found Medicare was paying $23 billion annually, or 14% of total claims, that were not accurately documented.

Since then, according to two further government reports, the amount not accurately documented has declined to $12.6 billion, or 7.1% of the newest total.

Chris Peacock, spokesman for the federal Health Care Financing Administration, described the decline as “welcome proof that our zero-tolerance policy for improper payments is paying off.”

Peacock said that under the law creating Medicare, 64 private insurers, like Transamerica, have been assigned to administer it in different parts of the country.

“The idea was to keep as much of the decision-making as close to the state and local level as possible,” he said. “There was concern that there not be a huge federal bureaucracy.”

Despite the claims that the percentage of excessive payments has been cut in half, the Kings say the amount of their reimbursements is down 60%. If this continues, they say, they will be forced to retire.

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Ken Reich can be contacted with your accounts of true consumer adventures at (213) 237-7060 or by e-mail at ken.reich@latimes.com.