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The Billing Nightmare…

May 18, 2015

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This article highlights the disaster in the medical billing world for patients on the receiving end but no one talks about the difficulties a medical practitioner has with billing or the ridiculous economic forces now set against doctors in the process.

For example, just coding the reason for the visit uses a set of numeric codes, ICD-9 to describe the diagnosis, and for procedures, there is another code set. For diagnosis, ICD-9 has 13,000 codes and for procedures, CPT has over 7000. Yet with both code sets there are many situations that are not described and we pick the closest code. This is actually more common than one might think especially in the subspecialty and micro specialty world such as reproductive endocrinology. Now the proposed ICD-10 uses nearly 70,000 codes to describe diagnoses and each code has 3-7 digits. So with an encounter the physician has to find one of hundreds of codes that might apply to the diagnosis and then choose from 100’s of codes for the procedures performed if any and then send a bill. Each insurance company has different rules about billing and coding and payment. Some insurance companies have many “plans” that may have different rules so when the bill goes in, it may not get paid based on these rules and codes. The service was provided but due to technical and often “computer problems” the bill doesn’t get paid. This represents about 30-40% of our billing and overall is incredibly complicated.

When denied, our office then calls the insurance company and usually we are placed on hold for an average of 25 minutes until we get someone who usually has limited knowledge of medicine and may or may not give us the right answer. Later we may find that their recommendation or information was wrong triggering more phone calls and follow up. The patient responsibility aspects often call for follow up to get this side of the equation paid. This could be for a $75 visit where $20 is patient responsibility and $50 is the insurance company responsibility. It is not uncommon for the insurance company to give a precert number verifying service but later saying the service was a non-covered service. In some situations we can bill the patient and in others we are prevented from doing so and are forced to provide the service for free?? So in many cases I’m paying a billing person $20/hr to collect 20 – 75$. The system is unbelievable.

In the case of procedures, insurance companies routinely just deny surgical procedural codes in an arbitrary way without any consistency from bill to bill. We then go into an appeal process that requires up to 3 reviews and may require me talking to the insurance company directly. We send 1000’s of individual coding events each month and are dealing with this nightmare day in and day out. We have to hire 6 billing people in our office and 4 people in our front office just to keep up with all this. On the other side, the insurance companies have 100’s of people fielding these billing “problems.” All this salary money in the healthcare system that is not going to the patient or their healthcare just to back room accounting and billing. This is just a small example of the waste in the medical system.

With the electronic medical record, doctors lose about 30% of their efficiency. The doctor is slower in seeing patients and sees fewer patients each day. The EMR, as it’s referred to, is generating mountains of worthless information, clogging the system even further. The new ICD-10 with it’s 70,000 codes is proposed as a way of making healthcare better to trend outcomes and study patterns. As in research, it is well known that with meta-analysis (combining multiple studies into one) there are multiple problems with different sites of care, different patient selection and approach to the same problem. The data is suspect at best but offers clues to the correct approach. The data that will go into the “master healthcare” system using icd-whatever will be much more problematic due to individual differences in the way things are coded and treated. Data mining in hospital care over the last 15 years with critical care indicators has contributed very little to improving healthcare for the patient. What it has done is create incredible expense, frustration for healthcare workers diverting their attention from you as the patient and toward data and stats, and complicate the system further.

The new ICD-10 is just another example of this process. Your doctor is now saddled with the task of sorting thru hundreds of potential codes for each visit, adding yet another few minutes to the visit. Doctor’s who now are 30% less efficient now will be 35-40% less efficient. In an already stacked economic environment, where costs are going up and reimbursements going down, these loses of efficiency will result in the demise of medicine as we know it. More and more doctors are giving up their autonomy and selling to hospitals and other groups and becoming simply employees, punching a time card like everyone else. Those doctors have little incentive to be the best they can be because there is no reward in doing so. Do you wonder why doctors have their face in a computer screen typing madly while you are talking about your problems, rarely even looking up?? Lawmakers think YOU, the patient want this new fancy technology and this new “face” of medicine. If you want to preserve the doctor patient relationship, you need to speak out now because there is not much time left. Nearly every doctor I know tells smart young people including their kids not to go into medicine. The quality of medical students in the pipeline has been declining over the last 20-30 years.

The inefficiencies described above are dramatically diminishing the productivity of US physicians. It is as if we suddenly lost 30% of our doctors. This comes at a time when Obamacare hopes to bring another 50 million patients into the system. The ER’s are bulging at the seams because doctors can’t see patients in the office. We are facing an enormous manpower shortage.

The government and insurers currently are auditing doctors and hospitals and using the coding and billing guidelines that are so extremely complicated to find small errors, errors that all humans make, to extract large amounts of money in the form of “paybacks.” The services are performed but due to technical rules, payers can refuse to pay. They review a small number of billing and if they find a 6% error rate, they multiply this by all the billing for several years to figure the payback. There is never a provision for the provider to argue all the failed payments and ignored services from the payor. This is the way insurers and the government are struggling to keep this huge bureaucracy running a little longer before the whole system collapses. Doctors, already facing incredible cuts in reimbursement and increased operating costs including dramatic increases in regulatory costs, can not tolerate much more intrusion into the business of medical practice before they give up en mass and quit practicing good quality medicine.

Over time, the professionalism will progressively decline. There is only so much abuse a profession can take. To add insult to injury, if any bad outcome occurs, lawyers jump in and extract millions from the malpractice insurance system. The public has no idea how much this costs the system. Listed as 1% of healthcare costs, the trickle down cover yourself ordering of expensive tests and procedures to be sure your care would not be open to attack from the Monday morning quarterback legal system, are responsible for 20-30% or more of healthcare costs. These legal attacks are extremely emotional and traumatic for physicians who have dedicated their lives to caring for patients.

So imagine a time…. when a patient came to their doctor for a problem and the doctor patient relationship solved the problem in a cost effective way. The patient paid for the service and carried major medical insurance that was cheaper to cover high costs for hospitalization and surgeries etc. The doctor wrote notes quickly with a pen that he could understand representing the needs of the visit, wasn’t fearful of lawsuits nor did he have to have a billing department in his office to continually fight and negotiate the complexities of medical billing, lack of ridiculous regulation, and therefore charged proportionally much less for the service. The visits were shorter because of less intrusion into the doctor patient relationship by billing, insurance concerns and computer issues. Doctors are not perfect but we are the only people in the system who truly care about our outcomes for you as the patient and want you to succeed with a healthy life. If government run healthcare is the outcome all of the doctor patient relationship will be lost. All you have to do is step into a Canadian, English, or Italian hospital and you will see what medicine will look like…

These are just some of the major issues, there are more. We feel for patients trying to negotiate this system because those of us in the business have a hard time figuring it out.

Michael D. Fox, MD
Jacksonville Center
Reproductive Medicine

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