So, I've addressed briefly, the issue of prescription drug coverage and the associated hidden costs by dint of wasted time on terminal hold waiting in voice-address hell.
This week, I want to explore the personal cost of working in healthcare for a small clinic that serves the neediest of the local population by way of Medicare and Medicaid - the poor and old. Our clinic cares (over 97%) mostly for Medicare and Medicaid patients.
By the by, you'd be astounded to learn just how many people don't know what kind of healthcare insurance they have. Our patient base is over 800, and has risen by about 500 in the past year. Of that number, I'd guesstimate that over 50% of those new patients were either unsure or just didn't know what kind of coverage they had. Mostly this means that they don't understand the difference between Medicare and MedicareAdvantage Plans or even the difference between Medicare and Medicaid.
FYI - Medicare is healthcare insurance that is Federally funded and managed. Medicaid is healthcare insurance that is funded and managed by the individual States.
So, for the most part, our payments for patient billing come from NoridianMedicare and the WA State Department of Social and Health Services (DSHS).
Now, I don't have the skinny on how it works in other states or other regions of the country, but I can tell you, our state program (Medicaid) is run by much smarter people making much smarter decisions than those deciding how to run the federal program (Medicare).
On what grounds am I making this judgement? My paycheck.
Oh, no, not the actual dollars that are going into my paycheck (although, now that I think of it, it's them too), but when I receive my paycheck.
Just after returning from our Holiday break (the Doc closes the clinic for two weeks at Christmas and a week for Independence Day), I noticed that the Doc began saying, "why are you wasting my paper"? I have learned that this is the initial phase of his worrying about finances. He nit-picks about wasting paper copying instead of scanning the original directly into the data system. With so few of us, sometimes speed is of the essence, and it is soooooo much faster to photocopy than it is to scan. At least on our poor old Epson sheetfed scanner.
Background: The Doc lost his home to foreclosure this past year. He managed to keep it when he got divorced a few years ago, but he had to move out of his lovely, secluded, wetlands-facing condo into an apartment in July. While the other three of us were enjoying our historic Vancouver 4th of July fireworks display and tossing down BBQ and Borscht (some of us are naturalized US citizens from the old USSR), the poor (and I mean that literally) doctor was schlepping his household goods to his new digs. He actually took two weeks off at that time, but he spent all of it moving and settling in to his new place. So the rest of us returned to work all happy and glowing from the misty summer sun available here in SW WA (we're sort of infamous for the rain), while the Doc came back looking like last week's used kleenex. Rumpled, soggy and a bit icky.
This was the direct result of NoridianMedicare not making timely payments to our clinic. It started in February of 2007. The payments sort of trickled off. Then they stopped. Then we got a few, small checks. This went on all year, until July. By this time, the Doc had lost his home, because he was paying salaries and other clinic related bills, but not his own mortage payments. For six months. So they foreclosed on his home.
Then, we just stopped getting any checks. For three months.
Three months. Did I mention it was three whole, entire months?
Imagine getting up, every day, going to work, and not getting a paycheck for more than three months. I dare you.
Meanwhile, there were staff salaries, office lease, medical supplies for our infusion room, utilities, long-term finance debt payments, insurance, licensing renewal, and dozens of other payments due.
So, while we worker bees got our paychecks, by the end of the three months it was obvious that we might have to close the clinic doors and go out and find another job. Seriously. The stress was palpable in the final days before we finally got a check. The Biller was about to have a nervous breakdown from the Doc badgering her incessantly to find out when we were going to get paid. I was fielding collection agency calls for the Doc on a daily basis. While our building owner was more than solicitous in waiting for over three months to get a lease payment for our office space, some of the clinic's other suppliers were not so kind or understanding of our financial dilemma. Things looked bleak in River City.
I've worked in a number of other industries since 1995: real estate, contractor to a federal government agency in data services, telecommunications, broadband internet networks and a number of general clerical service positions. I have never worked in any industry where you could not contact the accounts payable department of someone who owed you money and find out just when you would be getting paid for a certain service performed on a certain date. Never. Ever. Anywhere.
Welcome to the crazytown that is Medicare.
We send medical claims to NoridianMedicare. It should be a big hint that they don't call them bills. They are medical claims.
We can send our medical claims either by paper (only because we employ less than 25 people), or electronically. We now send them electronically, because it is astonomically cheaper to send them via secure internet file exchange than to mail them (picture mailing four manilla envelopes stuffed with about an inch thick of paper, each, up to four times a week). It was costing hundreds of dollars each month just to mail the claims. Once. Many claims have to re-submitted multiple times before they are ever paid.
Once the medical claims are sent, our Biller (in medical offices, the accounts receivable clerk has to take special training in medical biling codes and is called a Biller) can track them, at least somewhat.
The Biller electronically signs into our Clearinghouse Portal to check the status of the submitted claims. Clearinghouse is what they call the company that we send our files to electronically, which in turn formats the data in a way that is acceptable to NoridianMedicare. We could do this in-house, but we would have to get another workstation and dedicate it to acting as the interface with NoridianMedicare, using a dial-up modem for data transmission.
Are you kidding me? Dial-up data transmission? Have these people been living in a cave? I don't understand why they can't use a secure portal and let us upload the fracking claims directly to NoridianMedicare, using a broadband connection. NoridianMedicare would have to climb up into the 21st Century to do that. Fat chance.
So, the Clearinghouse portal allows the Biller to see the submitted claim or claim batch (a batch is a bundled bunch of medical claims) status. Whoopie. What information does it tell us? If the claim has been accepted as complete and accurate or rejected. This doesn't mean that charges on the claim have been accepted as accurate and will be paid. Oh no.
An accepted claim meets the following criteria: it has data that is in the correct format in the correct boxes on the electronic version of the HICCA 1500 form. The data might represent absolutely incorrect information, but if it is in the correct format, according to NoridianMedicare it is acceptable.
Where can we look to find out the date the claim will be paid? Nowhere. No kidding. There is nowhere we can look online, nor is there any phone number available to call to find out when the claims will be paid.
We can call NoridianMedicare, but we are first required, by Medicare defined rules, to call the automated voice-address system first for information. If, and only if, we have done so, are we allowed to call and speak to a human representative.
What can this person tell me? If the claim has been accepted (see above for the definition of accepted), if it processing or if it is payable.
HA! You think, "they can tell you if it's payable, well, that means they can tell you when the check should show up for that claim, right"?
HA! Nope. Payable, for the purposes of NoridianMedicare, means that the claim has completely processed. Sometimes, a completely acceptable, processed claim results in Zero dollars of payment amounts.
WTF???
Like I said, welcome to crazytown.
How long do you think that you would continue to work under these circumstances? Never knowing when your accounts receivable would just stop for a while, with no advance notice, no explanations and no way to get any help with discovering just what the heck the problem is.
What caused the Doc to lose his house last year? NoridianMedicare got backed up in processing because their computer systems crashed for while (no one at NoridianMedicare would ever admit just how long it was down). Their answer to repeated, desperate requests for some timeline on when payments would be issued was, and I quote, "I'm sorry, our supervisors have told us to tell providers that we will be paying interest on late payments. We have no other information at this time".
And by the by, the way that they tabulate interest for late fees? To start with, once a claim is accepted (haha) and processed, it sits on the 'payment floor' for electronic submission claims, for a minimum of 14 days before it can be released for payment. For paper claim submissions, that timeframe jumps up to 28 days. When does the 'interest tabulation' start? One would think, that like every other industry, it would start the day that the claim (or bill) was received. Nope. It starts the day after the end of the 'floor hold' date. So, for electronic claims, from the day that you submit the claim, no interest starts to accrue until the claim is completely processed and has sat on the payment floor for a minimum of 14 days. Then it starts to accrue interest. How long is that processing time? Your guess is as good as anybody's. Literally. No one knows or will, so far as I have been able to ascertain, ever know how long it takes to process a Medicare claim. You see, Medicare doesn't have any rules or regulations covering how much time NoridianMedicare can or should spend on processing. They only regulate when NoridianMedicare should start paying interest on a late payment.
So those small clinics, with less than 25 employees, who are the only ones still allowed to submit paper claims, and which are usually less financially stable, get to wait an extra two weeks for their money.
Don't you wish NoridianMedicare wrote your paychecks?
Oh, and we finally got a check on Friday, January 25th. Our first check since December 21st.
It never ends.
