In the first installment of my three-part series on healthcare, I covered the insanity of trying to get things covered by the private insurers. Today I’m going to examine the second half of the problem: getting things paid. If you are a healthcare consumer, you are likely at least a little familiar with the former, but not so much the latter. I know I’m spending a lot of time describing the problems with the system. But the thing is, we cannot adequately discuss solutions, or what proposed solutions will and will not work, and WHY, without having a very thorough understanding of just what the problems are from both the patient and the provider end.
I’ll first have to give a quick, VERY simplified primer on how medical services are billed. Providers do not send a bill to an insurance company saying “20-minute office visit for diabetes and jock itch, $74.” They use a system called CPT, or Current Procedural Terminology, that assigns a specific numerical code to everything a doctor does, from office visits to counseling to procedures. Office visits are rated from 1-5, depending on how complex the presentation, and how many medical problems were dealt with that visit. There’s a lot of these codes – the current CPT book is a good 4 inches thick. The codes are then fed into a computer, and the insurance pays accordingly, by a contracted fee schedule. Diagnoses are entered via a separate set of codes, ICD, that must match up with and “justify” the CPT codes used. Got it?
I mentioned in part one the “perpetual adversarial chess game”, and it comes into play here. The providers are always trying to figure out how to “correctly code” what they did, and the insurance companies are always trying to figure out ways to have the computer reject any given code combination. Please keep in mind that because there are so many similar codes, the “game” gets interesting. There may be 5 different diagnosis codes for a single illness, and THIS insurance company decides that they require you to use the second one, while THAT one kicks it out unless you use the 3rd one in conjunction with certain CPT codes. Oh, and they change what will “kick out” all the time, so the code that resulted in your getting paid last month will not necessarily go through this month. Confused yet?
Filed under: General, Health Care Reform, healthcare | 66 Comments »