Why We Need Universal Health Care and a Uniform System for Digital Record Keeping

OrangeClouds115 has generously allowed us to post her health commentary, which also appears on DKos. She has written a diary of her first-hand experience of the complicated and confusing billing-process imposed on doctors, hospitals, clinics and laboratories who have to deal with each insurers system, most of which are different. This is a passionate and informed account of one of the glaring deficiencies of the present health care system from someone who has worked with it on a daily basis. She also writes a blog on health and food.

Don't Know About Healthcare That Will Make You Mad

by OrangeClouds115.

So, what is there in the health care system that will make you mad? Oh... lots. As you might know, I just left a 5 year career in electronic medical record implementation. That means that I had my paws on all of the data that a hospital or clinic moves around during your visit - your registration info, your appointment on the schedule, your medical info, your tests, prescriptions, results... and of course... your bill. So I know an awful lot about it. Some of it's boring and mundane - but some of it will MAKE YOU MAD. 

First off, about electronic medical records - some people worry about their safety and security. I don't see this as a problem. The thing you need to ask yourself isn't "are they 100% safe?" but "are they considerably safer than paper charts?" I'd say yes. Paper charts are vulnerable to snooping just as much or more than electronic charts, and on paper you don't have an audit trail of who snooped. On the computer, you do. I've seen people fired for snooping where they shouldn't.

An electronic medical record is essentially a file of everything that used to exist on paper - your history, info about each appointment, notes about you by the doctor, test results, the meds you're on, your allergies, etc. The increase in organization of the chart and the ability of doctors to view the complete chart easily is a big bonus over a paper chart. I know one doctor who went on a vacation overseas and was able to log in and answer patient's questions while out of the country.

Some people are worried about the idea of a government-owned national patient chart. We are YEARS away from that being technically feasible so it's not something I worry about now. Right now your chart is owned privately by where you get your medical care and they (mostly) don't release it without your permission. A few exceptions exist there, like if they find evidence that a child is being abused and have to report it.

And about medical billing... how does it work? Well, there are 3 different basic systems I know about.

  1. You get a service (a doctor's visit, a test, etc), the clinic bills your insurance, they pay the claim, and most of what they don't pay falls to you (i.e. if you get a cosmetic procedure that won't be covered by your insurance).
  1. "Capitation." An insurance pays a monthly amount per patient to the health care organization no matter what services were given. This gets recalibrated occasionally based on the cost of care the patients are getting.
  1. Billing by diagnosis. I believe this is what medicare does in the hospital. Each diagnosis is worth a certain amount of money, no matter how many days the patient stayed or what services were rendered. The idea is that it should probably average out - if some pneumonia patients need more care and some need less, hopefully all of the pneumonia patients' care is paid for by the amount paid for a pneumonia diagnosis times the number of sick patients.

Now, when your clinic or hospital sends the claims over to the insurance, they use a standard set of codes to describe what was done to you and what you were sick with. The procedures are all identified by CPT codes (I remember the P for Procedure) and diagnoses are all identified by ICD-9 codes (I remember D for Diagnosis). People actually go to school to become coders - experts at knowing these codes - because for the most part, the doctors sure as fuck don't know them and don't want to either. They are doctors, not coders.

Here's the kicker: The insurance companies make all kinds of rules about these codes - what they will cover and what they won't. Let's say you were sick with something, you saw your doctor, the doctor provided the care you needed, and then accidentally sent the claim to the insurance with the wrong codes? The insurance won't pay. Even though you were REALLY sick and the doctor REALLY did a good job and deserves money.

Some codes are NEVER OK. We make those unavailable for doctors to pick. An example? 250 diabetes. Or even 250.0 diabetes. Nope, the doctor needs to pick 250.00 for diabetes. So that's the one we make available. Other times a diagnosis might be perfectly OK in general but NOT in combination with the procedure that was done.

On some level, this makes sense. If you came in with a bad cough and a fever and the doctor did a chest X-ray, that's appropriate. If you came in and your toe hurt and the doctor did a chest X-ray, well... why should the insurance company pay because your doctor can't tell the difference between your chest and your toe? But sometimes this can get tricky, where a diagnosis the doctor thinks is appropriate will not get you paid for the procedure the doctor thinks you need.

So in order to make sure the right codes get picked and the wrong ones don't, hospitals and clinics have to jump through a LOT of hoops. When we say that Medicare has less overhead costs compared to private insurance, this is where some of those savings would come in.

For a software geek like me, Medicare is easy to deal with. Why? Because it's universal. There's 1 set of diagnoses that are OK for each procedure. Pick those diagnoses and you'll get paid. Pick something else and we pop up a screen that says "Hey! This won't get you paid." Then you can either change your diagnosis if there's a correct one that WILL get you paid - or you have the patient sign a waiver saying they'll pay out of pocket.

We get the data files for that from a third party and it's pretty efficient because it's the same file of data that the entire country uses. And there are a lot of patients on Medicare. It gives you GREAT bang for your buck. But what about all of the other payors and plans out there? Is a geek going to program in EVERY single diagnosis that gets reimbursed for EVERY single procedure? And even if someone DID do that... they change! Like, MONTHLY! It's impossible.

So if you're on private insurance, your doctor is basically crossing his or her fingers and hoping that the insurance will pick up the tab based on the diagnosis and the tests ordered. And for the hospitals and clinics, well... crossing fingers isn't a good strategy because they NEED to get paid. (Typically a doctor gets a professional fee for the visit or they get paid for performing a procedure and then all of the lab tests or imaging studies ordered are billed by the hospital. Sometimes the clinic charges a "facility fee" too for your visit based on the level of care given.)

So... your doctor places orders, diagnoses you, and sends you home. What happens next? Your charges go to a billing system and step one might be that they run them through something that checks them based on rules that are programmed in. For example, if we don't have the name of the doctor who you saw, that's obviously a problem that will make the claim get denied. If there's a common mistake doctors make while ordering, they might electronically fix it. Otherwise they might send it to an error queue for a human to take a look at and fix.

Now... voila! Off the claims go to the insurance. Some get paid, some get denied, and some come back with a request for more info. So the health care organization has a team of people in the billing department - often each devoted to a particular insurance company - who goes through the denials and the more info requests. They do the research, and send it back to the insurance.

I don't have my notes with the full process that takes place (it's long and complicated and I'm leaving steps out) but the basic take away I had was that health care organizations are wasting TONS of effort and money trying to get paid. It would be far more efficient if they could just work with one payor. Why? Because we'd rely on those pop-up warnings on the computer UP FRONT to let the patient and doctor know in advance if they are going to get paid or not.

All of the extra effort it takes for hospitals and clinics to get paid trickles down to us when we pay premiums and pay the costs of our care. Obviously I'm mostly referring to outpatient care because that's what I know best but I bet it applies to the hospital too.

Now... why is medical billing so complex in the first place? Because the insurance companies don't want to pay the claims. They will do ANYTHING to avoid paying the claims. So they come up with all kinds of goofy rules. Stuff like "If you get a tetanus shot, you need a diagnosis that basically equates to 'needs a tetanus shot' or else we won't reimburse that claim." Or they say that certain diagnosis can be used but not as a primary diagnosis. Or a diagnosis can be used to describe an accident where you got whatever injury you're being seen for but only if they include details about the injury.

Usually these confusing and complex coding systems make their way to doctors as forms to fill out that present them with the information in the most straightforward way and let them know what the requirements are in order to get paid. Like "If you order this test, you need to add a modifier." But on the whole, the coding systems were not made for doctors' use - they were made for billing use - and they aren't necessarily useful or straightforward for the doctors. And as a patient, do you want to pay for your doctor's time while he or she looks up codes in a book instead of caring for you? Especially if they bill hundreds of dollars an hour!!! I don't!

The digital age gives us some tools to make medical billing more efficient and more accurate, but it also allows the insurance companies to set up more freaking rules. In my opinion, we'd save a lot of money by having medicare for all. Geeks like me don't come cheap ($1500/day... and no, I didn't see most of that money) so if you are improving your billing system by streamlining it with a great electronic medical record set-up, that means paying someone like me to program all this stuff in. So now you know - when they talk about reducing overhead costs by going single payor - just what they are talking about.

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