Stuart E. Mirvis, MD, FACR
Sitting in on any meeting with your medical management team
reviewing the practice's reimbursement procedures for medical
services is a truly bewildering, if not frightening, experience.
Several things are apparent. The vocabulary is not designed to be
understood by either a physician or a patient. A brief primer of
acronyms: EOB--explanation of benefits; FSC--financial status
classification; CCI--correct coding initiative; CAC--carrier
advisory committee.
The reimbursement for medical procedures seems fairly arbitrary
and capricious and, on the whole, moves inexorably only in a
downward direction. The exact services that are covered depend on
the third-party payer, usually one of a multitude of different
companies or governmental entities, each with different rules and
regulations that change frequently. The name of the third-party
payer and its ownership, management, and coverage benefits seem to
shift constantly. The specific diagnoses that are covered vary from
one provider to another, and, in many cases, the provider does not
reimburse well-established, highly accurate procedures, such as
computed tomography angiography for pulmonary embolism, because the
procedure is not deemed "medically necessary" in the locality.
There are myriad reasons for which payments for medical services
are denied retrospectively. Some of my favorites are:
* the procedure is not deemed medically necessary (typically
decided by people with no medical training and no detailed
knowledge of a given patient's circumstances)
* the procedure is duplicated (not actual dual dictations of a
study, but multiple studies of the same type, such as chest
radiographs, performed on the same day: the first is covered, but
the rest may not be, unless, perhaps, on appeal)
* bundled/mutually exclusive (don't even ask)
* the patient may, possibly, have other health insurance
* an incorrect Alpha prefix was used
* the patient was not eligible on the date of service
* only full-time students over age 19 years are covered
...and so on. At one medical reimbursement meeting I attended,
31 different reasons for rejection--in only three of the numerous
major categories--were cited by the medical management group. It is
often very difficult to determine under which category--for
example, "outpatient" or "inpatient"--someone is covered or whether
he/she is covered at all for a given procedure, and if so, in what
type of facility. Obtaining all the information needed for the
"insurer" from the patient is frequently difficult or impossible,
as they often do not understand all that is required.
These problems exist despite a large, competent billing company
that does its utmost to comply with and stay on top of the
frequently changing and often arcane rules controlling medical
reimbursement. In many ways, the ever-increasing requirements for
information needed to generate the "perfect claim" require the
physician to spend much more time than in the past providing
"administrative information" about the patient and allowing less
time to perform the medical service. Consider the time spent
addressing these administrative needs for routine radiographic
interpretations.
Perhaps one of the bright spots in all of this is that radiology
practices and hospitals have been compelled to purchase elaborate
hospital information systems, PACS, direct voice-dictation systems,
and the like to improve delivery of service, to facilitate
communication, and, in part, to deal with reimbursement
problems.
Today, most radiology practices are performing more procedures,
doing more hours of work, carrying more personal and medical legal
responsibility, and deriving less compensation for their efforts.
This continuing trend is an anomaly in a free-enterprise economy. A
massive amount of work is currently, and has always been, provided
by most physicians without payment, but there should be limits.
It is sad that such a huge cadre of people is required to
generate the bill or claim and to run the payer gauntlet. Many
resources are devoted to the bureaucracy that has evolved around
the reimbursement process. Some of that bureaucracy is, at least in
part, dedicated to business growth or stockholder enrichment. Every
dollar spent on servicing the bureaucracy is one less dollar being
spent on
real healthcare.
Most patients will probably tell you that in many ways our
nation's healthcare system is badly broken. As both users and
providers, we see that every day. Physicians should take the
initiative locally and nationally to promote changes that will
create a streamlined reimbursement system with uniform and fair
policies easily comprehended by both physicians and patients. Care
providers and recipients should have a much a louder voice in the
discussion. The vying special interests within the health care
labyrinth won't make improving the system an easy task, but if all
participants thought of themselves as potentially extremely ill
people in need of available, high-quality medical care, it just
might lubricate the process of achieving a more reasonable
reimbursement system.