American College of Physicians: Internal Medicine — Doctors for Adults ®

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Friday, February 10, 2012

Broken system #1: The distance between work and pay

I think people missed my point. Let me say again to those who misunderstood my last post: I am talking about the health care system being broken, not health care itself. Our system is broken, which means that the money put into it is being wasted in staggering amounts. Yes, we are getting some amazing results in regards to the care itself, but those happen despite the system, not because of it (most of the time, at least). My first item of broken-ness will make the point.

Labyrinth here by cogdogblog via Flickr and a Creative Commons licenseOur office is not getting paid this year. We used our credit line to fund my last paycheck.

Bad business? Not at all! We have worked very hard, seeing lots of patients in the usual surge that happens at this time of year. So, one would expect, more work means more pay, right? Not in our system. While we do collect some money from patients up front, most of our billing goes to a third-party (insurance or government), and in many cases a fourth party (supplemental insurance). The most important bill we send for our work goes to the "carriers," not to the patient. We have all accepted this as the norm, and it may be the only way to do health care in some circumstances. But this year there is a major glitch in the system.

I was actually not 100% truthful in my statement about who we bill. The truth is, we don't actually send our bills to insurance companies. Since there are a gazillion insurance companies, all with different contracts with different doctors, we actually send them to a clearinghouse. These companies (not to be confused with those who present giant checks at people's doorsteps) take electronic submissions from doctors' billing systems and re-route them to the appropriate insurance vendor. This saves us the hassle of remembering where to send each bill, which would be nearly impossible. They do take a little bit of our money in the process, but the time it saves us is worth it.

Assuming the clearinghouse gets it right and sends the bill to the proper place, the insurance company then either pays on the claim, or denies it. The news of their decision then goes back through the clearinghouse and to us. If it is denied (which it often is), we figure out why that happened, and whose fault it was. Sometimes the insurance company made a "mistake" and denied it in error. Sometimes the clearinghouse sent it to the wrong branch of Blue Cross or got our identifiers wrong. Sometimes we submitted it using a bad diagnosis or other technical error. Sometimes the patient forgot to tell us their insurance changed or lapsed.

This is the day-to-day complexity of medical billing in our system.

But things aren't working this year. The problem is in the clearinghouse part of the equation. As of Jan. 1 there was a new standard that clearinghouses had to comply with, called the "5010 of the x12 HIPAA transaction and code set standards." It puts me into a dazed stupor when I read the explanation of just what this is, but the HIPAA part has to do with patient privacy, so I suspect this is a patch to some privacy leaks in the billing system.

This also has to do with the change to ICD-10 (another broken thing I'll hit on in future posts), which is the code we have to use to submit our bills to the clearinghouses and ultimately to the insurers. The problem is, many of these clearinghouses are not compliant with the 5010 rule. Since it was a government rule dealing with HIPAA and since these clearinghouses are not paid if they do not run through transactions, I assume it was a highly complex and confusion standard. In other words, they had a hard time doing all the things the government required.

But the upshot of this for us: Nothing is going through. Nothing. And that means that we don't get paid.

Word on the street is that this is a nationwide problem, and we aren't the only practice not getting paid. The insurance companies have no problem with this, as they are hanging on to "their money" a little longer. The clearinghouses are frantically trying to fix this, but we're not sure when that will happen. When it does, the queue for submission will be enormous, and so the payments will undoubtedly be more delayed.

All of the complexities in our system add cost, and the billing/payment system is mind-boggling in its complexity. The bottom line is that there is always a long separation between the work I do and the payment I get. There are many steps requiring many people and giving room for many problems. These problems, of course, give more people work to do (all of whom get paid faster than I do) cleaning up the mess made by the confusingly complex system.

It reminds me of the game I played when I was a kid, where one person whispers "Llamas hygiene is next to godlessness" to the person next to them, and that person in turn whispers what they heard to the next person. When it gets to the end of the line of people, the last person tells what they heard, usually something like "the elevator spins in an ornate bathtub."

This translation is often similar to what happens in our payment system, with payments not quite resembling the bill that was sent. It is, of course, our responsibility to find any errors in the payment, re-submitting them through the chain to get the payment we should get from the billing. It is our responsibility because everyone else got paid. We used to have multiple employees to do this, but now have a company that specializes in this to do the job (they get a cut of what they collect).

This gives a glimpse into a reason the cost of care is so high. I have to negotiate a higher bill than I need because of all of the other people earning money off of the transaction. I have to count in the cost of the complexity of the system. This happens everywhere a medical transaction is made, with a very large percentage of people working in health care only doing so because of the onerous complexity of the system. All of those people between those who work and those who pay them will get more work to do if that distance gets further.

It's just like that game, except: "I worked hard" translates to: "Error. Please resubmit with proper documentation and coding."

It's crazy folks.

It's broken. It's also #1 out of 53 so far.

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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