Thursday, July 20, 2006

Medicare Claims: A Tale of Two Headaches (Maybe More)

[posted by dinah]

You know, it's the damnedest thing. A patient came in today and told me she'd called Medicare to ask why she hadn't been reimbursed for her care and they told her they'd never received a claim from the physician. I could swear I filed one. Actually, I could swear I filed the this exact same claim for this exact same patient three times, because that's how many times she's told me that Medicare hasn't received the claim. What I haven't figure out is why they get some of the claims, but not others, when I send them all in the same envelope. It's like the phenomena of the dryer and the missing single sock.

Okay, sometimes they get the claims, they just reject them. There are columns and rows and codes. The language of these things is a mystery to me: I was ranting at a patient recently (much as I love to rant, there are a limited number of things I can rant to patients about and I've decided that Medicare claims are one of them) about how I couldn't even understand the forms they send me and "I don't even know what coins is!" referring to the name of one of the columns. It was the patient who told me he imagined it stood for Co-Insurance. Wow, I thought, assuming he could be right, it was this Eureka moment where I got an answer after years of subconsciously wondering, only to have my bubble burst when it occurred to me that I didn't know what Co-insurance meant any more than I knew what Coins meant.

Some of the codes are subscripted with sentences that approach English. Some of my claims are returned with "PR-42", PR means "Patient Responsibility. Amount that maybe billed to a patient or another party." 42 means "Charges exceed our fee schedule or maximum allowable amount. Only the fee I charge is the fee determined by Medicare as the limiting fee for a non-participating physician in a non-facility; as a psychiatrist, I only bill for a few codes (mostly 50 minute psychotherapy session with medication management), so what is it sometimes deemed wrong and not other times? And then there's MA130: "Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocesssable. Please submit a new claim with the complete/correct information." It would be so nice if they told me What information is incomplete or invalid. And of course, there's MA28: "Receipt of this notice by a physician or supplier who did not accept assignment is for information only and does naot make he physician or supplier a party to the determination. No additional rights to appeal this decision, above those rights already provided for by regulation/instruction, are conferred by receipt of this notice." There's nothing like being succinct.

My favorite Medicare form story: a couple of years ago, Medicare announced that the physician's name, address, & phone number-- information which I have on a handy little rubber stamp designed to make it fit in the space-- needed to be placed in box #32. Before that, the information needed to be placed in box #33. They put this in a bulletin and somehow I didn't see it. A patient complained he couldn't get reimbursed, and since this pre-dated the time when a significant portion of my claims were 'not received,' I called for the patient. After sitting on hold for 25 minutes, I was told I hadn't placed my info in box #32. I pointed out that the exact same information was available to anyone who wanted to look in the immediately adjacent Box #33, but I suppose it's hard to shift one's eyes those few millimeters (please forgive my sarcasm here...). Funny, but not a single psychiatrist I asked had seen the bulletin, some had simply been wondering why they or their institution hadn't been paid in months.


Sarebear said...


I worked as a temp for two weeks at Primary Children's Hospital in SLC, Utah, 10 years ago (just about the last job I ever worked, by then I was lasting only weeks or days at things). I would call up insurance companies on claims that were getting old, to find out what the holdup was, and stuff. And work out solutions to it and things. Dang, I used to be good at problem solving, except when I was falling apart, and that I couldn't keep it up, or be consistent. (I once worked 3 years as the secretary to the Underwriting Department Head for a health insurance co., so I know all the jargon and how the insurance system works (rather, DOESN'T work . . . . )

ARGH. It's amazing all the snafu's that crop up; beaurocracy sucks.

NeoNurseChic said...
This comment has been removed by the author.
ClinkShrink said...

Hearing the insurance horror stories helps me make it through correctional life. It's like when I go to the grocery story and see a shrieking kid in a grocery cart, and think: "There's one headache (sorry Carrie) I'll never have to deal with."

I'm sorry about your bureaucracy. It's pretty sad when it's easier to understand what your dog wants than what your government wants.

Steve & Barb said...

This is what's fucked up about the whole insurance gig. Can you imagine signing a check below that "do not write below this line" line, and then it never showing up in your account? You call them, and they say, "Sorry, never received it." And then, if they own up to finding it, they say, "I'm sorry, but you didn't sign it in the right place... you'll have to send us another one."

This just does not happen in the banking industry. It's not that they don't have incentive to "lose" your money so that they have several extra months to invest it before they have to give it back. It's just that people have a choice. If my bank routinely lost my check, I'd have a new bank pretty quickly.

But this is accepted behavior in the insurance industry. Why is that? I'd like to know.

Medicaid tends to pay poorly in many states, and it is often hard to get docs to participate. I believe it is not solely because of the low rates. It is mostly due to the red tape. See if you can figure all this out.

Or Medicare. Here you go. This Medicare manual has 16 volumes. One of the volumes has 30 chapters. Chapter 22 has 31 pages.

You want to have more docs accept insurance? Make it simple. Patient goes to doctor. Doctor swipes insurance card and punches in some codes. Three days later, payment shows up in doctors bank account, with full accounting available to patient and doctor on secure website, in addition to patient's copay from their bank. Doctors are willing to accept less money to cut the hassle factor. I guarantee it. Of course, this is how it works if one pays out of pocket. Umm, remind me why health insurance companies are still in business.

Anonymous said...

"Umm, remind me why health insurance companies are still in business."

Health insurance companies are still in business because that's all people have. You could have a national health service as in some countries such as the UK, but in the UK, the bureaucracy of form-filling and targets is increasing all the time. It's the world we live in, sadly.

Sarebear said...

Here's something for that headache of yours:

Rubber Ducky Cupcake

Now they are invading our foodstuffs . . .