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Medicare’s satanic process

I sent the required e-mail. Two forms were returned in order to begin all over, with many boxes to check. None had the proper CPT codes.

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The elderly patient cannot come to me. After an application process lasting almost 6 months, I was approved for an out-of-network Single Case Agreement contract with her insurance company, allowing me to go to her weekly. According to 2022 Medicare CPT billing codes, our numerical contact was a 99335 (“Level 2 established patient domiciliary, rest home or custodial care visit”). She would have said there was more to it than that.

Several months ago, she began to hear satanic voices and understood herself to be haunted. She took to bed, stopped eating, and prepared to die; not physically sick enough for a medical admission, but too sick medically for most psychiatric units. I changed her medications and changed them again.


2023 arrived, and — for reasons unknown to most of us — Medicare revised its CPT codes. We are the same providers, and the patients are the same patients. But suddenly billing code 99335 no longer exists.

Visiting her is now a different code, 99348; not covered in the Single Case Agreement contract. I called her insurance company. In fact, over the course of days and hours, I called four departments within her insurance company: Provider Relations, Customer Assistance, Claims, and Clinical Services. Each call came with a long hold because, a pleasant voice apologetically explained, caller volume had increased. Those voices that eventually answered in real time — unlike the voices my patient heard — tried hard to be helpful, though not one of them asked how the patient was.

Customer Assistance, sounding far away or maybe in the tub, told me to contact Provider Relations. Provider Relations, in deep, foreign tones, told me to contact Claims and insist new billing codes be “loaded into the plan file.” A voice that broke now and then on the Claims hotline spent almost an hour trying to understand why the new codes weren’t in the system, then spoke in an aside to a supervisor and suggested I call a national Medicare number to clear it up. The voice of Clinical Services, youngest of all, informed me that my contract had now expired and there was no way to add the new codes into the patient’s account. He gave me an e-mail address to start a new out-of-network Single Case Agreement application. He apologized for the inconvenience. I believed him.


I sent the required e-mail. Two forms were returned in order to begin all over, with many boxes to check. None had the proper CPT codes.

I continue to meet with the patient. How could anyone not? On a cross-taper and high doses of two new medications, she is doing better: reconsidering the advantages of life, dressing herself, eating doughnuts. She has improved, while the insurance system is beyond repair. I am glad she didn’t have to make these calls. There is something satanic about this process, and the world has disturbed her enough.

Elissa Ely is a psychiatrist.