The telephone encounter: the cast of characters encountered by the physician executive.

The encounter between the attending physician and the medical director is compounded by the "physician personality," which is egocentered and individualistic. The majority of physicians are honest and sincerely concerned with the welfare of their patients. However, there is a small minority who diverge from this pattern. From years in practice, we know that a small minority of patients takes the majority of the physician's time. This admonition is also true for the medical director, who negotiates with providers rather than patients.

Strategy

The medical director must prepare for the telephone encounter by knowing facts about the procedure, anticipating the physician's defensive moves (they will usually follow a predictable path), and quickly identifying the physician's personality mix. The first and second items are done before the call is placed. Identification of the personality or "mind track" must be done in the first moment of the phone call.

In that first moment, the medical director will determine whether the physician is an antagonist, a protagonist, and one who wishes to be heard above all else. Certain phraseology or maneuvers to control anticipated behavior may then be implemented. The intent is not to control the decision out-come, but to guide the discussion so that a fair decision is rendered. If the medical director can anticipate the mindset of the attending physician from the phone response pattern, the call will be shortened and more productive.

The Cast of Characters

The cast of characters encountered by the medical director are shown in the table on page 34. Friends may be divided into the helper, who can make the life of the medical director very pleasant; the educator, who sincerely wishes to dialogue and teach all with whom he comes in contact; and the praiser, who believes the medical director has a purpose in the medical ecosystem. This group comprises the majority of providers. The remainder could be classified as foes.

The combative one might be called a protagonist. He will argue each and every point raised. He will prolong the conversation indefinitely if allowed. You cannot engage in a lengthy encounter, as you will neglect other calls and duties. Your best defense is "to control the agenda" and stick to the facts. Do not volunteer any information other than that necessary to complete the transaction.

Do not allow this provider to draw the conversation into peripheral issues. He or she will take your statements out of context, rephrase them, and relay the modified statements to the patient, insurance commissioner, etc. Generally, you can sense this behavior early by the tonal quality, the initial pause, and the deep sigh at the beginning of the conversation that translates as "my time is more important than your time."

The skyrocket starts out the dialogue in a calm and collected manner until you announce that you cannot certify the request on the basis of the information provided. He or she then immediately challenges, attacking everything. While usually this person uses a sequential pattern, the skyrocket may stay on one point, becoming progressively angry; talking faster and faster, in a progressively high-pitched voice, and then hanging up in frustration after a few choice words. The skyrocket is a frustrated person. Your best defense is to "control the agenda." Do not respond to any innuendo that is thrown at you. Most important, do not respond in kind. This is what the provider is subconsciously trying to do. This character is the friendly pup that turns into the junk yard dog. There is not much you can do other than listen.

The authoritarian group can be divided into the true authority and those who are self-made. They cannot cope with anyone challenging their decisions. They must be right and you must be wrong. Your best defense is your knowledge of the procedure and the facts. If you feel that you are right, deny the procedure or request. The authoritarian has the right to appeal the decision. Do not be drawn into peripheral issues, as the authoritarian type will try to invoke any recommendations that he or she feels might change your mind. Usually, this a set of standards heard at the last meeting of a favorite society. The issue in question is, Are his or her interests being confused with facts?

The clever ones are more problematic, as they are actively trying to outwit the medical director. They have experience and have manipulated the system before. Their behavior is repetitive.

The gamers are the most difficult foes. They are usually clever and use a number of mechanisms to see if they can win over the system. The gamer is a cat that is playing with the mouse and enjoys the challenge of beating the odds. This may be one more day in the hospital, or an expensive procedure, or stretching the fee or number of visits per diagnosis. The defenses are not clear. I would insist that the provider fax key reports before a decision is made. The provider knows that the medical director is busy and does not have time to obtain specifics in every case. One approach is to assign the provider in question to one medical director so that the pattern can be identified.

The unbundler is a creative person who divides the procedure into parts and initiates a code for each part so that he can generate a charge for each component part. If the physician is caught in this behavior, he should be intensively reviewed. The best defense is eternal vigilance and a very sensitive ear to the community. Other physicians within the medical community will be aware of the problem.

The prober wants to know what the medical director wants to hear. His or her first remark might be, "What do you want to know?" The conversation proceeds with short questions and short responses. If you feel that you have a prober, you might counter with "I need to know the history, physical examination, and your logic for requesting this procedure". Once the provider recites this information, the medical director can control the conversation. If you have the feeling that the "molasses will not come out of the jar," you probably have a prober. The hidden agenda of this provider is to probe the review system to find out how they can gain key pieces of information to receive approval.

The splitter exists within the multispecialty referral system and tries to include the referring provider in the procedure. If he or she can create a companion procedure, both will share. Look for multiple surgical codes on the same day. Some of these are justified and some are not.

Manipulators try to seize the initiative and place themselves in a superior position. Their goal is to project that they are right and you are wrong." Your best protection is simply to not assume a defensive posture. If you do, they will be waiting with a set of well-thought-out responses.

Don't let providers draw you into a position you cannot defend. An appropriate response might be; "I am sorry that you feel that way, but I still cannot certify your request." If you are challenged with a threat of legal action, state, "You have that option, but it will not change my decision." You might state, "I understand your logic, however I still cannot certify your request, as our logic (guidelines, protocol, system) does not recognize your request."

The shame-er feels sorry for you because you are such a pathetic person that you must resort to this form of prostitution. This provider starts with "I feel sorry for you" or "Shame on you, what you are doing is wrong and against the oath you took when you graduated from medical school." Do not respond to this person; you cannot change his or her mind. State, "I am sorry you feel that way, but I cannot certify your request."

The challenger argues for the fun of it. This call usually comes at the busiest time of the day. This person continues to argue with you even though you have approved the procedure. If you have already told the provider that you will approve the request and he or she continues to talk, I have found the following works well. "If you are unhappy with my approval of your request, I can fail to certify it."

The self-righteous hold themselves in high esteem. They will state that they have developed the procedure, designed the prosthesis, written the book, or presented a new paper that changed the course of medical history. This provider is convinced that only he or she is right, being the authority. If you feel that you are correct, stick with your original decision. The medical director should not be drawn into an indefensible position, as the self-righteous provider is an expert on the nuances of the procedure.

The protagonist is an argumentative wanderer who will sequentially argue about one topic after another. This provider is much like the challenger, but skips from one topic to another. The protagonist can be extremely time-consuming. I utilize the following approach to terminate the conversation: "This discussion is not germane to the issue of certifying your request, and I am sure you must have patients waiting to see you. Thank you for your time."

Obfuscators try to confuse the medical director with behavior that is not constructive or productive. Usually, they feel they too important to be bothered with such trivia. They are performing a great service to consent to speak with a medical director. These are not humble people. These providers need to be watched, because they use such behavior to cover up other transgressions. They usually are trying to confuse the medical director in an effort to get a procedure or hospitalization approved. They should be made to clarify issues and provide faxed information to back up requests. If they are required to document requests on initial encounter, they will be less likely to repeat this behavior.

The fast talker gives a sigh that translates to "I don't have time for this." Then there is a pause, which translates to "I am going to control this conversation." Then there is a staccato of verbiage that is far too rapid to understand, much less to try to take notes to document the conversation. This behavior pattern is aimed at control of the encounter. The best defense is to request that they repeat the information. If you have listened carefully, you will find there are discrepancies between the first and second conversations and that you have placed the attending physician on the defensive. If the provider does not give you the information in an intelligible manner, the request should not be approved.

The creator creates a new entity to justify a previous procedure that did not attain the desired result. Some of the requests are justified and correct and some are intentionally repetitious. Be cautious of providers who file for two codes so that they may bill for both. This person is a very creative "chartsman." Again, the best defense is to encourage dialogue with these providers and ask them to repeat the history, physical examination, and logic for requesting the procedure. Often, you will find that there are discrepancies in the first and second versions of the request. The creator is thus placed in a defensive position.

The uncouth is an unhappy and frustrated person who can do nothing but curse at you. Four-letter words have no place in any profession. My response is to listen or to state that, if the behavior doesn't stop, I will hang up. This behavior must be documented for the medical director's protection.

Quiet ones express their denial of the process by silence. The silent talker quickly appears on the phone and is bewildered about such a call. They protest that they never talk to insurance companies, even though they know that they are talking to one. Office personnel will not put a call through to their physician without some information about the reason for the call. Usually, this person is trying to evaluate your purpose for the call. If unsure, the provider will state, "I cannot talk to you without a written records release," even though there is a records release on record. Usually, these providers will not call back until the request has been turned down for lack of information. At this point they realize that the medical director controls disposition of the case.

The recluse will never return calls to anyone except the patient. If there is insufficient information to make a reasonable judgment, the request cannot be approved. This provider is not in the competitive market and has no reason to respond. The days of communication between the attending physician and the patient without recognizing a third party are passed. The lack of a timely response must be documented.

RELATED ARTICLE: The Cast of Characters Encountered by the Medical Director

Friends

The helper

The educator

The praiser

Foes

The angry ones

The combative one

The skyrocket

The authoritarian

The clever ones

The gamer

The unbundler

The prober

The splitter

The manipulators

The shame-er

The challenger

The self-righteous

The protagonist

The obfuscators

The fast talker

The uncouth

The rambler 

The quiet ones

The silent talker

The recluse