Is simpler medical billing possible?

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It's never gonna change

I work at a lawfirm that helps hospitals deal with accounts improperly paid by insurance companies, self-funded employer health plans, etc. I formerly worked at a lawfirm that did lawsuits against patients for unpaid accounts.

Simply put, it's never gonna change. Every time one side does one thing the other side counteracts. Medical providers have "chargemaster" rates (think "full retail") and insurers and others set up "managed care contracts" in which the provider agrees to discount charges in return for "patient steerage", i.e., either the patient must use a "network provider" or the patient's portion is higher if he uses a non-network provider. Insurers and other networks basically hand providers a "network provider agreement" and say "Here, sign this. No, we won't agree to ANY changes to our boilerplate agreement." Often they force providers to grant as much as a 50% discount.

What's worse is that once the bill is sent the payors send the bills to an "independent" audit company known for "slasher" audits. The "independent" audit company sends the bill back with all sorts of "above reasonable and customary" reductions. The payor then uses the unilaterally reduced amount as the BASELINE and then takes the DISCOUNT on the REDUCED amount. Small providers such as solo practitioners just "take the hit" because it's too complicated to fight. Hospitals send the accounts out to lawyers or companies that start arguing back and forth.

Almost all managed-care network contracts require binding arbitration. The payors know that for an individual account it simply isn't cost-effective for the provider to pay for arbitration. Unlike a court, arbitrators charge by the hour, generally at least $250 per hour, including travel time and refamiliarization time. At a trial the case is called for trial and keeps going day after day until it's done. If a case is not concluded after the first arbitration setting all the parties, lawyers, necessary witnesses, arbitrators, etc., have to schedule the next hearing date, which can be months later. So, of course, each time the various people have to get reacquainted with the case, all of which is billable time. Payors know this is not cost-effective for providers and therefore providers almost never arbitrate. As a result, payors' attitudes frequently are, "You're right, we're wrong, we're not paying. Tough. You can't sue and you won't arbitrate and we know it."

On top of that, medical providers generally pay non-competitive wages. Hence, they get clerical staff of below-average competence, and then they overload them too. If a claim is denied, routine practice is to simply attach a copy of the medical records with a form cover letter labeled "Appeal", regardless of what the actual basis is for the dispute.

As stated, the fact is nothing is going to change. Every time someone comes up with a way to simplify things someone else comes up with a new type of dispute and, of course, charges to do so. Then the provider either has to give up or pay to have people continue the dispute. Any saving or additional payment winds up being offset by the additional expense of hiring an outside expert to fight.

On top of that, there are SO many variations and SO many regulations and each payor/network has its own specialized Provider Manuals, etc. The fact is that NO ONE is an expert OVERALL because there are so many different programs, they vary from state to state, etc.

Posted by: Rick_R   Posted on: 08/08/07 You are currently: a Guest | Members login | Terms of Use

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