Courtroom Chaos and Cash

By Insurance Guru

I recently accompanied a friend to a court appearance. The background story as to why she was there isn't really relevant to the goings-on that I witnessed that day. First of all, the court room was jam packed. Apparently, a recent holiday had led to some "over-booking". What the heck - even the airport couldn't beat this place for high, quality people-watching.

First person up to bat was an lady from Armenia. She spoke broken English but declined a translator. Accused of shoplifting, she was given the "misdemeanor speech" by the judge... "up to a year in jail or probation, a fine and other costs, blah, blah, blah. She plead guilty, got 10 days in jail to be served if she didn't complete the year's probation. She also had to pay a $500.00 fine and complete a shop-lifting diversion class provided to the city by Wescalpem Enterprises. Wait a minute....who doesn't know shoplifting is bad? How much of a kickback does the city get for this $250.00 class that my dogs could teach?

Batting second was a young man reappearing for a curfew violation back in 2002. No - that is not a typo. I would've apologized for wasting this young man's time, but no - the judge said he "hoped the young man was staying out of trouble". Excuse me? ...If all I had to show for my mis-spent youth was a curfew violation?

Batting third, fourth and fifth was a trio of Hispanic shoplifters that needed a translator. See same result as batter number one.

Number six was a DUI. This fellow had to pay $1500.00 in fines, serve 30 days in jail with work release allowed for twenty of those days. For the remaining ten days of the sentence he's on house arrest. Of course he had to pay 25 bucks a day for the ankle bracelet and pay for the DUI diversion classes provided to the city by Nobucksforu Inc. I'm pretty sure there were other fines and assorted costs in there, but I couldn't keep up.

Number seven was a young man accused of assault. The funny thing about this is that it had previously been dismissed... twice. According to the judge, the city had a year to continue to bring this up. So they did. There's probably some big bucks to be had from the Hitting/Yelling is Bad diversion classes.

The entire afternoon parade went on in the same manner and my friend's case wasn't heard. It was a standing room only day at court, but what an education in our judicial system.

After watching all this money grabbing going on, my friend "lawyered-up" the very next day. It was expensive, but let's give the bucks to someone doing their job. In less than two weeks time, all charges against her have been dropped without another visit to the cash court. We still have to wait a year to see if they've developed a "Fines are Cheaper than a Lawyer" diversion class.

Michael Jackson RIP

by Insurance Guru

I'm going to miss Michael Jackson. He was part of the sound track of my life for the past 35 years. You have to respect his talent and drive while acknowledging the maelstrom of his life.

I was in Barnes and Noble today, the store music was all Michael Jackson and a bit louder than usual. It was interesting to see shoppers, in their 60's, tapping their toes, the teenagers singing along with "Black and White" and the employees all humming along. I'll admit to my share of toe tapping as well. I would've moon walked, if I could.

I hope he is at peace now and his suffering at an end.

Beware the Office Staff

By Insurance Guru

I'm not the only one that has trouble with the office staff at my medical provider.

The Computer Says, "No".

A Yard Sale - You Meet the Best People!

by Insurance Guru

The Guru had a Yard Sale Last week, not for economic necessity, thank goodness, but to get rid of some stuff that was a little too big to haul to Goodwill and I've been feeling pretty cheeky this past month so it sounded like some fun.

My plan was to start at 7 am but as soon as the garage door rolled up, the hard core negotiators pulled up. These folks are serious! I mean they go yard "sailing", towing trailers and tie-downs at the ready.

By the end of the day, my garage full of another man's treasures was reduced to two cardboard boxes on their way to Goodwill. I met and chatted with so many neighbors... the very ones who before were just a wave and a nod as they drove by. Kids left with giant smiles holding books, toys or a gift for Mom after parting with a quarter. I was able to make an elderly woman's day with a bargain priced stove she desperately needed and we included delivery and set up.

The extra cash this project generated was appreciated but the day-long enjoyment was priceless!

My Credit Card is What?

by Insurance Guru

Image via Wikipedia

I've been a credit card holder for longer than some of you, Gentle Readers, have been alive. While sadly, I have more than my share of credit card debt, I am fortunate in that I am able to pay more than the minimum. So why are the evil Credit Card Empires cutting my credit limits and increasing my interest rates? On the big, corporate, balance sheet you would think that I look like the golden goose... I'm never late, pay a bit more than the minimum required and have been a customer for years. OFF WITH 'ER HEAD! Oops, I mean, credit limit.

Yesterday's mail brought me the latest from a company to remain nameless... Okay, initials only... BoA. Glossy brochures trumpeting my privacy policies and what-not on cheap paper. It's the "what-not" that they hope you toss. Interest rate increases, penalty increases, poke your eye out with a spoon rate increases. Now I can decline all of that and here, the instructions get a little fuzzy. I think it involves a GPS scavenger hunt, plasma donation and sperm count?

Never fear Gentle Readers, I shall foil their evil machinations and return my interest rates to the now arbitrary rate I signed up for. I can't help feeling a little cranky about all of this, though. Following the rules I signed up for just isn't good enough any more. So what should the honest folks do now?

Doctors in the Poor House

by Insurance Guru

I was reading some letters to the Editor in a recent AARP magazine. Hey, it's my Dad's. Really! The letters were discussing "Disappearing Doctors" and laid the blame at the feet of Medicare reimbursement and byzantine insurance rules. Boy, that makes me cranky. Yes, I know about rising malpractice insurance, increased office costs, lower reimbursements, rules, regulations, paper work, etc, etc, etc...

What I don't understand is why these letter writers believe their profession should be immune to the life the rest of us are facing. I'm an average Jane out here in the world trying to get by. I face rising insurance rates, stagnant paychecks, increased costs, rules, regulations and paper work. I'm still trying to get it all together for the tax man.

Being in the Insurance Industry, I get daily e-mails telling me how to "Increase My Medical Office Accounts Receivables!" or "Avoid OIG Billing Audits!" or "Best Billing Practices for Diabetic Patients!". The subjects and e-mails are endless. There is an entire industry out there that is devoted to "show me the money" for physicians. Add to that the American Medical Association which has a yearly 18 million dollar budget to lobby Capitol Hill. That's just one group, there's another for Chiropractors, Hospitals and on and on.

I guess a lot of physicians aren't just like me. I drive a 2004 Ford, live in a small house, my kids go to public schools and we shop at Wal-mart and Target with coupons. In order to further economize, I got rid of the cable movie channels, magazine subscriptions and weekday newspaper. I take care of my own yard, house repairs and dog grooming. My 401K plan now literally means 401 dollars. I haven't checked yet, but I don't think there's a lobbyist out there on my behalf.

Physicians are highly trained and a valued part of our communities, but it can't be just about the cash and status. If it is, than maybe we are better off without the physicians that have chosen to leave. I want my doctor to want to help me and is willing to work as hard as the rest of us to pay the bills by doing the best we can with what we have.

My Aching Knee

by Insurance Guru

The planets aligned, the Angels sang and my knee surgery happened! All those things seriously had to happen first. I have never had to work so hard to get 30 minutes of surgery.

Two years ago, I had the same exact procedure done to the other knee. A couple of X-rays, an MRI, an ortho appointment, a couple of phone calls and boom... done deal. Then it was a couple of post-op days on pain pills, a post-op visit a few weeks later and on with my life.

This time around it has taken me 7 months of calls, visits, calls and more calls to get this done. Even when the paperwork was going where it was supposed to, I still needed a pre-op physical, labs, CXR, & EKG... that equals four more appointments. I just had a physical last August (with lab and CXR). Another pre-op visit to make sure my crutches were sized and another visit to discuss the surgery. It's a flap of knee cartiledge people... not a liver transplant. I wasn't even under general anesthesia.

24 hours before the surgery, my surgeon's office called to say my PCP had not faxed over all the pre-op paperwork and they needed it in the next 45 minutes or we would need to reschedule. Perfect.

I drive to my PCP's office and tell them I will hand carry the paperwork to the surgeon. I was informed in very haughty tones that they were taking care of it and would fax them over. In haughty-to-infinity tones I told them I wasn't leaving until this was resolved. It became a bit of a shouting match once they informed me my EKG results weren't there, I merely pointed out that they couldn't have been working on it if they just now realized that.

Well, the surgery happened, I think the knee is fixed. Although, for a simple bit of cartilage removal, I have a leg that is black and blue from the knee down. Were there some helper gorillas in there? Was I leg wrestling in my sleep? I dunno, but my lesson in all of this is beware the office staff.

The Art of Making Popcorn

Image by jmacphoto.com via Flickr

by Insurance Guru

There's an entire generation out there that believes popcorn comes from the microwave. As long as you have the right side up and hit the "popcorn" button on your microwave, a tasty treat is just seconds away.

My dad was a popcorn connoisseur when I was growing up in the '60's. He was always after the perfect combination of chilled popcorn kernels, oil temperature, pan size and the Zen of being one with the kernels. We experimented with Jiffy Pop and all the latest corn poppers that came out one by one. Did you know there was an early version of a microwave popper that used water instead of oil? An absolutely sub-par product came out of that contraption.

Sad to admit, but I've lost the art of making popcorn from the stove. In the spirit of "Economic Hunkering Down" I bought a Stir Crazy Corn Popper. Now I can control the amount of oil, salt and butter in my tasty snack and there's a warm, fuzzy memory in every bite.

Uncertain Times and Knitting

by Insurance Guru

The Guru has taken up knitting, kind of. I'm one of those Type-A get it done kinda folks. You'll never catch me in a quiet meditative pose. I do my best thinking while moving. Still, one always needs some "zen" down time so I've started knitting with a knitting loom. Perfect for me since I don't have to "knit one - purl two", count my stitches, count my rows or any other annoying knitting-type task. True, my finished product is a square or a rectangle of material - yup, scarves and blankets.

All my little dogs have new blankets, the kids have scarves whether they want them or not and now I can move on to knitting baby blankets to send to third world countries. It's quite soothing work and with the all the financial and employment chaos around, it's better than a double Prozac cocktail. If it all hits the fan, I may need this new skill in some climate-challenged, post-gaziliion dollar debt world. I wonder if I can make yarn from the bounty of my shedding dogs?

Super Bowl Sunday!

Image via Wikipedia

by Insurance Guru

I admit it, I love football. I grew up with a Dad that loved to watch and taught me the rules. The future ex-Mr. Guru is a huge fan and by default so is my son. Is there anything as exciting or more American than Super Bowl Sunday!? I can hear the NFL Films music right now and the voice of John Facenda... "the frozen tundra of Lambeau Field...".

I also love an underdog, Cinderella story so I am extra excited to see the long suffering Arizona Cardinals in the mix. Sorry, Steelers - I'm not rooting for you this year.

So come on over, the Guru is having a Super Bowl party. Bring some dip and pull up a chair. The big screen will be running in high definition, the TV in the garage will be available for the smoking section, if you need a moment to yourself, the office and guest room TV's will be warmed up. Fair warning though, the Guru will skip Springsteen at half-time and we WILL be watching Puppy Bowl V on animal Planet.

Go Cards!

Behind the Velvet Rope

by Insurance Guru

I sure did have some kind of hissy fit during my efforts to get a referral to have my knee looked at before my leg fell off. However, now I feel as though I've been let behind that red velvet rope that keeps the unwashed masses away from the famous folk in L.A. clubs.

The Orthopedics office was quite posh and took up the entire floor of a medical complex. On my first visit I had my knee x-rayed a hundred different ways and within 30 minutes, I was talking with the doctor about the results. He decided I needed an MRI and their crack office staff would make all the insurance arrangements and... THEY DID! Who knew such a thing existed?

I was able to have the MRI at their offices and it was such a cute little machine. It was built just for lower extremities, so no freezing in a gown trying to keep still while your nose itches. Within a few weeks we had the results and it looks like the Guru will finally get that annoying meniscus tear fixed. The crack office staff promised to take care of all of those arrangements, too... but it's been a month now..... (sigh)

Back From the Abyss

by Insurance Guru

Whew, what a grueling couple of months this has been. Deep in the Cube Farms on Insurance Island, we have been slaving away to get the 2009 Benefit Plans loaded, the 2009 Medicare rules, rates and insanities loaded, the 2009 contracts up and running and still hoping that claims don't blow up at the other end.

Insurance Cube Farmers rarely have a long Christmas or New Year's holiday. I myself worked straight through all the holidays and even through a couple of scheduled PTO days. It wasn't the best time to be told there are no raises this year and no assurances regarding future down-sizing.

However, a plane landed on the Hudson River and all survived, the Arizona Cardinals are going to the Super Bowl and a Black American is now the president of the United States. Has someone sent scarves and mittens to hell? This might just be my kind of year!

It's the Holidays which means... Open Enrollment

by Insurance Guru

Open enrollment, the bane of my December existence... While trying to budget for Christmas presents, cope with the extra workload at the office and praying I get to keep my job, I must sort through the various insurance plans being offered for the next year.

I use the term insurance with a bit of sarcasm here. You would think being employed by one of the nation's largest Insurance Companies, I would have the Cadillac Escalade of plans to pick from at a cost that would make mere mortals weep. NOT. The last 5 years have seen a steady decline in plan options and increase in cost for we cube farmers.

The plans offered to me are so hideous that I don't even use my employer's insurance. I've got the Guru's family enrolled on the Future Ex-husband's retiree plan. How absurd is that?

If I worked at Wal-Mart, I would get an employee discount, if I worked at a gym, I would get free membership, if I worked at AIG, I would get spa days. I guess I should just suck it up and count the twin blessings of employment and medical insurance.

During this joyous season of Open Enrollment, I encourage you to look at all the plan offerings and how each would cover you and your family in the year ahead. Consider if that dodgy knee or new baby is a concern. New glasses? Braces?

Most of all, if you are lucky enough to have an employer sponsored insurance plan, take advantage of it! A little insurance is better than none. Take a look at this little video that Dethmama dug up.

Patience is a Virtue? ...Not.

by Insurance Guru

Dethmama mentioned one day that some of her patients had complained of having to wait up to several months to see an oncologist. It could just be an urban legend, but regardless, they felt that they had had to wait too long to see a specialist.

If you feel that you can't see a specialist within an acceptable time frame and your PCP isn't helping, call your Insurance Company. If all the paperwork required to see a specialist is approved, you are not restricted to the specialist that your PCP chose. Your Insurance Company can provide a list of specialists for you to pick from. You may not get the closest specialist to your home, but hey - if I need an oncologist - I want one NOW!

PCPs often refer their patients only to the specialists near their offices. I won't speculate on the reasons, but your PCP should be working for your health, not toward maintaining a relationship with the specialists in their area.

So, dig out the number for your Insurance Company, and get on the phone... Now!

Finding Bigfoot 1.5

by Insurance Guru

I've been trying to get an authorization/referral/Papal blessing to see an orthopedic doctor for over two months now... see Finding a Good PCP is Like Finding Bigfoot.

I finally spoke (4th time's the charm) with someone at my PCP's office that actually SENT a fax to the Insurance Company. Within 24 hours, my Insurance Company sent me an e-mail letting me know of the approval. I printed out the referral/auth/blessing and faxed it to the orthopedic office. After two days, I called to get the elusive ortho appointment...

Office: "Do you have a referral?"

Me: "Yes, I printed it from my Insurance Company's website and faxed it myself two days ago.

Office: "Well, I only see this fax and it's not from the Insurance Company so we can't accept this. We need something with the office codes on it and saying that it's approved."

Me: "Oh, you mean like right there on the paper where it says "approved" and the approved codes for the office visits?"

Office: " Well yeah, but we need the number of visits and it has to come from the Insurance Company."

Me: "So where it says I have 4 visits and the Insurance Company name and my name and the effective dates of the auth and your office name, address and phone numbers... this won't work?"

Office: "No - we need it to come from the Insurance Company. Have a nice day."

Me: lighting my hair on fire and cursing small animals.

Well, my Insurance Company happily faxed them the auth and exactly three months after this began, I have an appointment. Don't even ask how many people I had to talk to or how long I was on hold. I'll start cursing small animals again. My hair is now too short to light.

For all of this effort, they better wave a magic wand over my knee and send me on my way!

The Biller "Du Jour"

by Insurance Guru

Biller "du jour" -- I've been using this term for nearly 20 years to describe a phenomena that faces all claims examiners. You know how you ask for the "soup du jour"? Well, medical billers tend to stay just as long on the menu. They've got a tough job with low pay... so chances are that the biller you're dealing with is new on the job and under-trained. Since Insurance Companies and Providers interact in a kind of "delicate dance", a lightly trained rear behind the biller's desk could be courting catastrophe.

Here's an example: Biller Du Jour sends us a bill for an established patient visit for a yearly physical. Fine -- the diagnosis and office codes all check out, but then they tell us that these services happened at a surgery center. We have to deny that and send it back. A claim is a legal document -- we can't just have a chuckle and fix it. Well, we do chuckle.

The claim that still cracks me up is a physician inpatient visit. No problemo -- everything checks out except for the hemocult that was billed. Inpatient? Really, a hemocult is a card with some circles on it. You take it home and put some of your poo on the circles and mail it to the lab. My brain had a really good time trying to figure out what the doctor could possibly do in a hospital to get paid for that. (Insert Mission Impossible theme here) -- Dr. No stealthily visits patient X in the hospital, gloves up, checks for spies and quickly gets a poo sample. Dr. No slides the hemocult card out of his pocket, expertly applies poo to the circles, zips up the sample and it's back into his pocket and off he goes for a shaken, not stirred martini. Not. Gonna. Happen.

We all run into a Mr. or Ms. Du Jour -- probably on a daily basis ... The customer service rep on the phone, the "expert" computer person at Best Buy or the "top-notch" office staff at your PCP's office. Unfortunately ,in the insurance industry, it just creates denied claims and very unhappy patients. Your Insurance Company can't do anything about it short of telling the biller how to bill. Which is... Not. Gonna. Happen.

My apologies to past, current and future medical billers.... it's a tough way to earn a living.

Finding a Good PCP is Like Finding Bigfoot

by Insurance Guru

If you have health insurance, I bet you have a PCP (Primary Care Physician). A good doctor is hard to find. If you have one, bless you, but I am very jealous. The problem is - it isn't enough to have a doctor you that will listen to you, but the office staff has to have a brain, too.

Think about it... your wonderful doctor has given you a thorough physical, but for a complete picture, you need some labs and maybe a chest x-ray. Insurance Companies usually don't let PCPs provide those services in their offices even if they have the equipment. They get a much better discount with a big radiology office or lab company. So off you go with your lab and radiology slips... What? The staff sent you to the place that doesn't accept your insurance? What? The paper work isn't filled out correctly? You want to take a sample from where? What?

I'm currently in a battle to get an authorization to see an orthopedic doc. I've been waging this war for two months-- and I "speak insurance"! I've talked to my PCP's office (when I can get them to pick up the phone) and the ortho's office (when I can get them to pick up a phone) and my insurance company (weird, they do pick up the phone). I just need my PCP's office to tell my insurance company that I have a bad knee and could someone pretty please look at it before my leg falls off.

It worries me that I cannot get this simple problem resolved with all my insurance experience. What happens to the folks that just give up because they can't navigate the system? "Press 1 for a black hole; press 2 if it makes you feel better."

You should be able to have confidence knowing that your doctor's office can handle all of your health care needs. They should speak insurance... how else are they getting paid?

I like my doctor, but hate the office staff and as I get older and need more services that can't be done by my PCP, this issue will become critical. So -- put as much research into finding a good doctor as you do buying a car. Check the internet, ask your friends, kick the tires and take a test drive. You don't like what you see? Open up that provider directory and see if you can find your perfectmatchPCP.dot.com.... and beware the office staff.

A Day in the Life of a Claims Examiner-- Part One

Insurance Guru

I've had this rant bouncing about my brain for many years. I processed health insurance claims for several years and trained examiners for a couple more.

There seems to be a perception out there that examiners are routinely told to deny, delay or otherwise hinder paying claims so that the Company can hang onto its bucks for some nefarious world domination scheme.

I've worked for four, very large insurance companies and this has NEVER been a policy. Who wants to work a claim more than once? A claims shop is all about inventory and days on hand. A claim that's been in the shop over 10 days will have someone stopping by your desk and tapping a toe until it's processed.

We are also people. The claims that create the most difficulties to process are, of course, the ones for the most catastrophic cases. The last thing we want to do is add stress to patients and families by not doing everything in our power to get that claim paid. We had an informal rule that if a claim came in for a patient now deceased, it got paid. Now. We would run it up the food chain until it got released by whomever had the security to get it past whatever edits we were facing.

The average claims shop is not run by Scrooge McDuck nor is it full of claims processing Gremlins with popcorn bags on their ears. They are just like me and want nothing more than to process your claim timely, accurately and only once.

Insurance Guru: Sending Hospice Visit Data to the Big Bad Wolf (Part 2)

So Medicare is insisting on all sorts of visit data from Hospices...

This brings to mind the sweeping coding changes that Medicare launched several years ago for Skilled Nursing Facilities. They moved from 6 simple revenue codes to 50+ "RUGS" rates. RUGS stands for Resource Utilization Groups and the codes are things like RUX, SE3 and RMC. Sounds like we've stepped into a Dilbert cartoon or found a new rap star!

I've yet to work for an insurance company that could automate the payment mechanism for the RUGS calculations. To start with - it's system suicide to replace numeric codes with alpha characters. Thankfully, we didn't have many contracts based on Medicare reimbursements. We still use the simple 6 revenue codes in the contracts offered to our providers. Check out this article for an exercise in "quantum RUGS mathematics".

Take the approaching Hospice funding cuts, add the data scavenger hunt and you will see Medicare revamping all Hospice billing in an attempt to save money. Of course, Medicare in their perverse, logical fashion will attempt to convice the Hospices that all their number crunching and new, magic codes will get the hospices more money.

I think it will look something like this:

Code VC98.^*347 - Respite care in the home not to exceed 3 hours for ambulatory patients that like to dress in blue. For patients in other colors see code VC98.^*348 and above. For non-ambulatory patients see coding that begins with nine million and above. For more than 3 hours, too bad.

Code ZB.,;) - Inpatient care per day. Anywhere. This is it - all you get. Don't care what services you provide.

Code JUS24?& - Routine home care - per 15 minutes for patients with dentures.

Code JUS25?& - Routine home care - per 15 minutes for patients with houseplants.

Code JUS26?& - Routine home care - per 15 minutes for patients that live less than 10 miles away.

Insurance Guru: Sending Hospice Visit Data to the Big Bad Wolf (Part 1)

While I was doing some research on Hospice budget cuts and funding for my previous post, I ran across all sorts of FAQ's on the Centers for Medicare and Medicaid Services (CMS) website regarding new Hospice reporting rules. The reason given for this data mining effort?...

"The Medicare hospice benefit was implemented in 1983. Since that time, the benefit has grown considerably. Unlike other payment systems, hospice providers have had to provide minimal information on the hospice claim. The Office of the Inspector General (OIG), the General Accounting Office (GAO) and the Medicare Payment Advisory Commission (MedPAC) all recommended that CMS collect more comprehensive data in order to better evaluate trens in utilization of the Medicare hospice benefit. This additional information will help to provide a better understanding of the types and frequency of hospice services provided during a day of hospice care."

I've worked with provider contracts and their coding for years and in that time, four simple codes have been used for all Hospice billings:

651 - Routine Home Care
652 - Continuous Home Care
655 - Inpatient Respite Care
656 - General Inpatient Care

Remember, Medicare develops the coding and updates happen every year. If they've been getting minimal coding, it's because they've provided minimal coding choices.

Medicare now requires Hospices to provide additional coding to indicate where the patient is being cared for (in the home, in a SNF, etc.) as well as the visits the patients is receiving. Interestingly, they are only requesting data on physicians, nurses, home health aides and social workers. Why? And the answer is:

"We selected the physician, nurse, home health aide and social worker because we have existing revenue codes available to capture this information on the claims. We recognize that this does not represent all care or the items provided under the hospice benefit."

Wait - "we recognize that this does not represent all care or the items provided under the hospice benefit"? Is this some weird alternative universe where it only counts if you can give it a code? Oh yeah... it's Medicare, so it is an alternative universe.