Medicare: It's Got Me by the Throat!

Have you ever had a job that makes you feel as if you are swimming in water that is out of your depth?

Currently, I am working as a Medicare Contractor, and if you are horrified, then imagine yourself in my shoes.

When I first started, I was working for a temp agency, clerking my way through the day and eager to learn with the hope of being hired full-time. At that time, I was working for the "QIC" team (Qualified Independent Contractor) . The purpose of the QIC person is second level appeals on Medicare claims by doctors, hospitals, radiology, laboratories, and those persons over the age of 65, who qualify for Medicare. While the real QIC person was working out of another state, our office received all of the closed cases, which were sorted, filed and stored in the archives. Each case could be as little as ten pages or as many as five hundred or more.

The first level of appeal is called the "Redetermination." I have no idea who made up that word, but it is not in the dictionary. I suppose some bright young thing had a spark of genius when he came up with that one. After all, the claims are "determined" whether they are paid or not, and Medicare is "determined" to make certain its carriers follow Federal guidelines. So, as the word "appeal" evolved, it became known as the "Redetermination" rather than the simpler "appeal," which everyone understands. What was wrong with the word "Appeal?" Why mandate a made-up word?

The process goes something like this:

Mail arrives in the office. It is date-stamped and scanned into the computer system. Then, a clerk physically scans (with their eyes) to discover where each "case" should ultimately be destined to make its way. Once it arrives in the Redetermination bucket, the mail numbers in the hundreds. When I arrived, there were nine people in the department to handle all of the redeterminations. When each day's mail does not get worked, it rolls over and becomes "aged." While the goal is to complete each case in a timely manner (less than 30 days), nine people would have to work 50-75 cases a day to meet the 95% metrics that Medicare demands, and the average (depending on the complexity of the case, amount of research needed) amount worked in the department is 10-17 per day.

As I slowly learned the processes involved, curiosity got the best of me. I found out that these nine people had been working overtime (12 hour days and 6-8 hour Saturdays) for over a year in order to meet the demand. By the time I was hired, along with another two dozen or so, the department was behind by a minimum of 45 days. Most of the people in the department had been there for 15 to 30 years. They knew Medicare inside and out. Or so I thought.

My immediate concern was, "Do I know enough to pass muster?" After all, I had my degree. I had been in insurance for years. Medicine was the love of my life. Surely, I would be great at this job if given the opportunity to learn all of it.

Training came as a reality I was not prepared to meet. The software we used was as ancient and as inappropriate for our use as an ancient dinosaur of the computer age. The CMS website a hopeless dead zone where search engines could not search, resulting in hopeless frustration. Changes and updates not announced on the website, updates that changed little within the manual. Even the articles often read "Updated in 1999." I could only wonder where they put the updates from 2000-2008, because I sure could not find them. When I did find what I needed, I was appalled at the error rate, the misspelled words, the run on sentences, the dangling adverbs, and I wondered, "Is this what was approved by our government as language to use in letters?" Where did these people go to school? Or did they even finish school?

Perhaps, as a result of what was seen, and in spite of company updates to the multi-carrier's system. whole sections of the intranet were devoted to translating how and where to reference codes, information updated daily for the needy (like me) to perform a particular function due to the fact that no one could find anything on the CMS website. It was practically a disaster waiting to happen. With zillions of codes to enter to reach the sections we needed, trainees were stunned to learn that the "Menu" did not list most of the codes needed to access information! Instead, we'd find them hidden in audits!

In addition, every piece of information was "in code," requiring one to "look up" every itsy, bitsy, teeny bit of information in each case. As a result, my "training" began with the claim handling long before I began training for redeterminations. Naturally, the training was done on the internet with instructions for each line in the system and what to do with each line. No one types "real" information anymore. They type numbers and letters. The information, alone, would fill a million volume set of books. Then, what we learn dissolves into a, "Once I find what I need, what do I do with it?" Reality bites.

Every company seems to have its own intranet these days, accessible only from the work site. Not only do we have one intranet, we have a dozen!!! Not only is there one internet address to find, there are more than I can count. Plus, someone decided approval and denial codes must be preceded (or succeeded) by a letter of the alphabet. Suffixes galore. Edits, audits, codes and more codes in the hundreds. Numbers and letters combined in the instructions that make no sense. Even the instructions require instructions! For example, in the training manual, there are pages upon pages of columns to explain what the denial code relates to (without mentioning the code) as in "UA denial" written by CK, in JB, from AK, reference this manual, that chapter, this section and that paragraph. How can trainees learn when even the training manual is written in code?

The sheer volume of instructions for one procedure-claim handling-is mind boggling. I cannot even begin to describe the feeling of diving into an ocean of information in cyberspace. It's like drowning with no lifeguard in sight. Needless to say, it's only 8 am, and already I have a headache from reading about "if X happens, deny with JA, but if F occurs, deny with PU."

Remembering when I used to file claims, I thanked God on bended knee for paper.

Now that I am well into training in redeterminations, my trainer returns my letters with comments like, "Incorrect. This is a 576 denial." What is that supposed to mean?

I'd like to have some instruction, please!

No wonder doctors, hospitals, laboratories and radiologists send us request after request on denied claims. The billing and coding department has given up hope. They need a translator! If they are frustrated, just imagine how we feel! In every case, we know the average billing clerk is reading a CPT manual (current procedural terminology) and writing down what they see. Most of them have no idea there is a website that will help them code their claims to be certain their employers receive payment. The industry is all too willing to blame the carriers, never realizing what they read in letter format is CMS mandated. They also blame Medicare for their own failure to read the fine print.

Granted, the forms are not user friendly. The column that reads "You May Be Billed" with a dollar amount to pay the provider often has either numbers or zeroes. Simply put, the zeroes mean you do not owe anything. The decision is out of your hands. Medicare has denied payment, and only the doctor can make the correction, not the billing and coding department. Then, the claim has to be resent as a new claim. If the correct information has not been completed in the space it was created for, it will deny again. Even the instructions to ask for an appeal tell the person or company to "circle" what they question.

No carrier has the right to change the way claims are billed. The billing department does not have the right to change the diagnosis. Many claims come into the office with no documents. No operative reports. No medical records. It's a wonder anyone gets paid anything!

Medicare was not designed to be simple. It was designed to solve a problem in our country, and that problem is insurance coverage when one needs it most.

Medicare is not insurance. Remember that. Medicare is a Trust Fund. It is designed to help the elderly save money, not to make doctors rich. Surgeries are "bundled," meaning that all of the procedures concerned with the surgery are included in the surgery code. There are no separate fees for office visits of the same specialty physicians because it falls under "global" guidelines. Major surgeries have 90 day global period where no doctor will be paid separately for performing work related to the surgery. . . and so forth and so on, ad infinitum. These differences mean that specialized training in Medicare should be mandatory for all billing and coding enthusiasts.

Being a member of this elite society of "Redeterminations" is like volunteering to be tortured, day in and day out. I do not yet know if my "training" will ever end. Every time I learn something, it changes. New information is released. Updates from CMS are emailed. Codes get a closer look by medical directors. It is a world of rules, regulations, law and pure grit. We expect change to happen just as farmers expect rain. It's called progress, and no progress is ever made without effort. Yet, as tortuous as my job is, it is thoroughly absorbing. I live, breathe and sleep Medicare. It goes beyond traditional medicine, and it's a lifesaver to many.

Perhaps, it is past time for Medicare to put some money into its coffers and update their own website so everyone can find what they need without wanting to pull out their hair, or else their name might be changed. Medicare will finally become what it really is: "Medihair."