Thursday, April 20, 2006

Medical Billing -- The Lucid Nightmare

Rarely, but in most people's experience, there is a special state of mind between dreaming and wakefulness called lucid dreaming. Even though the details may be lost to memory a few hours later, at the time of the lucid dream they are as vivid as reality. The interesting part is that during a lucid dream we are aware that it is a dream, and sometimes have some measure of control over the momentum and results of these imaginary events. I'm not much interested in the subject but it makes an interesting diversion if you do a Google search, including a Wikipedia entry. I use the term this morning to describe Doctor Bob's series on medical billing, now in it's fifth installment. Reading through this series, however, is more a lucid nightmare than a lucid dream. You know it is happening, and you want very much to bend the rails a bit...but all your efforts are in vain. The best you can expect, given the now well-established thicket of weeds in the garden, is that you might get one more tomato off the vine before weeds, worms, and wild animals beat you to the prize.

I have been copying this series to a Word document which now runs to about fourteen pages. I'm not sure what I aim to do with it, but it makes a pretty complicated subject more understandable if I can tote it around and study it a little at a time. Doctors, you know, tend to be very smart people. They assume that other people are as bright as they are, so saying things over and over is not one of their strong suits.

If you think you can absorb it all from a monitor, go read it. If not, do as I have and put it together in one piece, print it out, and take it to the john. This most recent installment describes what can happen if the Federal Rottweiler goes after a medical practice or individual suspected of fraud...

And, of course, as a physician or health care facility, in such an investigation, you will be treated with the utmost respect and deference to your mission and profession … or maybe not:

***In August 1999, Dr. Robert Gervais, a cataract surgeon practicing in Arizona, was invited to a public meeting on a HCFA project. Federal agents were hiding behind a one-way mirror at this public meeting to see which doctors were making negative comments about HCFA and the project. Dr. Gervais was critical. A little more than a month later, Dr. Gervais’ clinic was subjected to a “surprise” inspection, where federal authorities found “deficiencies” in his documentation. Dr. Gervais’ plans to
remedy the “deficiencies” in the time HCFA required (6 days) were deemed unacceptable, and his clinic was then “de-listed” by Medicare.

***In another case, in February of 1999, 37 armed, flak-jacketed agents carried out a Medicare raid on East Tennessee Woods Memorial Hospital, a 72-bed hospital in Eastern Tennessee. The invading army of armed federal agents stomped into the hospital, trampling through sterile areas, forced employees into a small room and held them.

***In another case, at Dr. Danny Westmoreland’s office in West Virginia, three armed federal agents invaded and held everyone at gunpoint, including the physician, his wife, patients, and children.

So, if you’re wondering why doctors are feeling a bit under the gun of late, I hope this helps you get some insight. But I do have some good news (and no, it’s not about my car insurance): the Feds make even the malpractice attorneys seem warm and fuzzy by comparison.

My interest is underscored by a piece of mail I received two days ago. "This is not a bill" it said at the bottom. Well, no, it wasn't. It was more like a warning that a train was on the track, your car is stalled at a crossing, and if something doesn't soon change you are about to start employing some of your most important legal your will or critical conditions directives.

I am amazed that the system has need to even mail me such a notice, uephemistically called an "Explanation of Benefits" which in this case is an explanation of NON-benefits.

Significantly, at the end of this document is a bold-face line or two instructing the reader how to argue against the content of what it delivers. This seems to be part of the form, which indicates that it is more apt to be delivering bad news than good. Or in the event that the news is not good (meaning Claim is Denied for one reason or another...see the little numbers up there and pick the one that applies in your case) the insured (who in this case is the UNinsured) can do the equivalent of going to court as his own council.

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