I grew up watching what would now be horribly politically incorrect cartoons as a child--probably scarred me for life. Some of you might know the ones I'm talking about--original Warner Brothers "B" list cartoons from the 1930s and 1940s as well as some of their "A" list cartoons. There was nothing politically correct about Bugs Bunny, except maybe dressing in drag on more occasions than one would think was normal--at that time.

I remember a few of the black and white "B listers" where at one point the main character was going to do something he knew was wrong. He looked at the audience and said, "If I does it, I gets a lickin'--I does it!" and then proceeded to create cartoon mayhem and hilarity.

Some days I feel like that now "ancient" cartoon character, and it shows up in some odd places. Like at work.

I process hospital provider applications for people who don't have medical insurance. The hospital and/or a medical collections provider sends the application and I decide based upon evidence presented and state and/or federal policies if the bill gets paid by us (the Commonwealth of Pennsylvania) or if the hospital or patient has to eat it.

I tend to lean in favor of paying the bill, but that's not always altruistic--sometimes I just don't want to be bothered with going through the motions of preparing a response to a tiresome appeal that both I and the appellant know they're going to either withdraw or lose. Do it right the first time--easier for all concerned.

When I complete a case, I have to write up a case narrative. Most are pretty bland recitations of fact and policy, the sort of thing you could use to put a surgical patient to sleep. Not that anyone actually reads the case narratives--I could write them in rhyming couplets and iambic pentameter in Russian or as Japanese haikus and no one would notice.

Here's where the cartoons come in. Every now and again I get a bit frosted by some of the bovine excrement that crosses my desk on an all too regular basis and I use the case narratives as my personal vomitorium (Kids, hopefully if you forgot everything your teachers taught you about the Roman Empire you remembered those.), here are two examples:

"On 09/01/09 an MA provider application was received for Mr. **** from Methodist Hospital; the attached MA314 showed that he was treated in the ER on 06/28/09, but no bill amount was given. The application was submitted by PATHS on 08/24/09 and was received by the Federal D.O. on 08/31/09; no identification was provided with the application.

At the time of treatment Mr. **** indicated on the CAF that he was not working and had no income or resources of his own; he indicated that he lived alone, but no management verification of any sort was provided with the application. Mr. **** has no employment or criminal history in IEVS, and no medical assessment form was provided with the application, leading one to wonder why Methodist or PATHS even bothered to submit it--this did not even rise to the level of "phoning it in". A PA253 was faxed to PATHS in what was clearly a futile attempt to obtain identification, a PA1663 and verification of Mr. ****'s management.

Mr. **** signed the PA600P and a PA4. The requested verification was predictably not received by the due date, and as of 09/25/09 nothing had been scanned into Imaging for him; A#6072728 was at 28 days. The TD00 NCE was rejected to Reason Code 042 and the application was forwarded to the Closed MA File; that PATHS might choose to appeal this rejection is an absurdity that cannot be discounted."

"On 09/01/09 an MA provider application was received for Mr. **** from Methodist Hospital; the attached MA314 showed that he was treated in the ER on 06/04/09 and incurred a cost of $853.00. The application was submitted by PATHS on 08/20/09 and was received by the Federal D.O. on 08/31/09; a copy of his PA driver' license was provided as identification. This particular application was very sloppily handled by both PATHS and CCS/HCU, even by Methodist Hospital ER application standards.

At the time of treatment Mr. **** was employed part-time by Resources for Human Development and was paid biweekly; this was indicated on the CAF but no income verification was provided with the application. Per IEVS he was also employed by DLC Management Group during the second quarter of 2009, but that employment was not even mentioned on the CAF. He was married and living with his wife and children, who were listed on the CAF but were not registered by CCS/HCU despite their presence in the household; per Mr. **** she was not working and no other household income was indicated. Due to the household composition resources were not an MA eligibility factor and a medical assessment form was not needed, but Methodist Hospital provided an incomplete PA1663 with a beginning temporary disability date of 06/04/09 but no ending date; no criminal history was indicated. On 09/08/09 a PA253 was faxed to PATHS requesting at least verification of Mr. ****'s wages for 06/09.

Mr. **** signed the PA600P and a PA4. The requested verification was not received by the due date and as of 09/25/09 nothing had been scanned into Imaging for him; A#6073076 was at 28 days. The TD00 NCE was rejected to Reason Code 042 and the application was forwarded to the Closed MA File; an appeal for this rejection would be the new dictionary definition of "chutzpah"."

Sometime in 2050 an auditor will review one of those cases, read the narrative, and blow a major blood vessel in his head--I'll be long dead by then, but it's nice to know I'll get a laugh from the grave....

All those coders and billers who take (in your two cases---my insurance forms often indicate a similar lag) 56 and 75 days to request payment...one with no payment amount.,,

I now see the opposition to single-payer systems like Canada has with only one small form to complete to trigger payment.

We could never afford to pay the unemployment to the masses of incompetent coders and billers jamming the payment system today.

If the auditor gets past the time lag and the missing information and the lack of documentation...

Nah. Don't lose any sleep over the possibility of discovery in your narratives.

Nothing broke there.

DOS not provided. (Date of Service) TX and code(s) for CXR = 7010 with Modifiers. Submitted date most likely expired due to DOS in JUNE. No name? Did I get that Correct? Lacks a lot of info. A 'nightmare' in the making.. (I worked ER and Flight Nurse and OR and Med-Surg AND Billing for a Doctor too) Was DON (don't like that) So I loved being a Nursing Supervisor on second shift. (We did Admissions on second shift too ..as in DIRECT ADMIT) An RN can do the initial assessment and if 'short staffed' they have to leave their patients to go to the ""Front Office"" to input data on the Computer such as, minimally, Status of DNR and even copy Ins. Card. If NO insurance card, we admitted them anyway. But you can bet that the ER rarely sent up the paperwork. (The Paramedics get SOME information but NOT Insurance) I'm a Paramedic too (For extra training for Flight Nurse) Got out of that. A chopper went down in GeorgeTown, SC just yesterday. Just the flight crew were killed. Not the patient. Thank God. My Supervisor Role was Multi-Tasking. Guess I've seen it all. BTW ""GOOD LUCK"" with what U wrote. Geez!

TX = Treatment. Those of us on the Front Lines know so much about Health Care!! UHC is not thr way to go, JMHO. I have a Flow Chart to post. Just wait until you see how COMPLICATED the Gov't option will be. Thank You ...signed Agent 99

The requests for coverage from ER admissions to any of the Thomas Jefferson University Hospital affiliates are crapshoots at best and pure crap at worst. In July we got a boatload of those all at once as the providers wanted to clear their books for the coming fiscal year--I'm still wading through some of those rejections, since they came at a time when our beloved and mercifully soon to be gone forever governor and the state legislature were mired in a pizzing contest that resulted in "payless paydays" for a month.

I'll bite the bullet and work on my own without pay under normal circumstances in order to lighten my workload, but I was damned if I was going to work two shifts per day for free--did a lot of idle reading in July, but now I'm digging out from the backlog. At some point I'll actually see my bare desk again--just under an order from General Washington telling soldiers from the Continental Army where to fall in prior to crossing the Delaware River....

The USA will not have a 'simple' little form. Lots of Gov't Agencies to 'ramrod' through first. Good Luck with that

quote:

Originally posted by ipw533:
The requests for coverage from ER admissions to any of the Thomas Jefferson University Hospital affiliates are crapshoots at best and pure crap at worst. In July we got a boatload of those all at once as the providers wanted to clear their books for the coming fiscal year--I'm still wading through some of those rejections, since they came at a time when our beloved and mercifully soon to be gone forever governor and the state legislature were mired in a pizzing contest that resulted in "payless paydays" for a month.

I'll bite the bullet and work on my own without pay under normal circumstances in order to lighten my workload, but I was damned if I was going to work two shifts per day for free--did a lot of idle reading in July, but now I'm digging out from the backlog. At some point I'll actually see my bare desk again--just under an order from General Washington telling soldiers from the Continental Army where to fall in prior to crossing the Delaware River....

You tried. Nothing to work with really. Thank you for your work sir. Thank you.

"Simple little form"? What a joke that is. The PA600 Common Application Form is 15 pages long and requires answers to questions ranging from household composition to income, criminal history, medical disabilities and expenses, employment, income, resources, general household expenses and school attendance. Mercifully the state does not care whether you own a chihuahua or a budgie or a stuffed moose, unless you try to claim feeding them as an expense--and if you try to claim the expense of feeding a dead stuffed moose as an expense you deserve to be rejected, but I've seen statements just as inane.

Answers to those questions must be verified--this adds yet another layer of paperwork. Let's just take income, for example. An ordinary working person gets a regular paycheck from his or her employer, and we request copies of those for verification purposes. All well and good, but how many people these days actually keep their pay stubs? And what do you do with people in the "underground" economy (quite large in Philadelphia) who are paid "under the table" in cash?

I'm no virgin, and I wasn't born yesterday. Some young guy with no steady job claiming to do occasional odd jobs for cash probably isn't--he probably has a regular but illegal income that he can't verify without getting himself in trouble; we get a lot of those. Get granny to write a statement that she lets you sleep on the couch and watch reruns all afternoon before heading to the corner (leave out the last part) at no charge and you're good. But don't think that I'm not aware that that's a sham and that his payment isn't coming out of my pocket as a taxpayer or as a future hospital patient.

We like to characterize this lightly as the old childhood game of "kick the can". But what do you do when the can turns into a 55-gallon drum full of toxic waste that would frighten the bejeezus out of New Jersey...?

quote:

But don't think that I'm not aware that that's a sham and that his payment isn't coming out of my pocket as a taxpayer or as a future hospital patient.

That seems to neglect the 'pay me now or pay me even more later' nature of the health care business...or did I miscount the negatives in that statement?

quote:

But what do you do when the can turns into a 55-gallon drum full of toxic waste that would frighten the bejeezus out of New Jersey...?

That, Sir, is the question before the legislature as I understand it.

quote:

That, Sir, is the question before the legislature as I understand it.

What do you do when you're faced with a ticking time bomb? The first thing you do is find someone brave enough to go in and defuse the damn thing. But we're dealing with politicians here and bravery is some nine-tentacled creature from Alpha Centauri to that sort. So politically you wait for the fuse to fizzle out. Fortunatelty we have a President and Congress unable to take bold steps--I'm hopeful that by the time they get back to actually playing with the bomb the fuse will be dead....

So despite my retired status and inability to remain coherent after lunch I can get a job with the gummint reviewing health-care claims under the new Obamacare program?
Cool, where do I sign?

ipw533 Yooper seems to think the NEW Politically Run UHC will be 'like Canada' as in a SIMPLE LITTLE FORM Take a look at the Chart. Wow, it's even more complicated than "usual" Gives me a Headache just thinking about it. LOL! Medicare/Medicaid Forms are kinda like H3LL on wheels. Miss one little Modifier or a misplaced Code (say 71010 vs 71020) and well, you won't get a dime. You can appeal. Good luck with that! MODIFIERS are the Code for WHY a CXR was order as in R/O Pneumonia. Or CHF. Politicians should NOT run HC! JMHO!

quote:

Originally posted by Agent991:

Such a simple procedure

Thank You Phil! Ran that FlowChart through Picassa and yet it still is difficult to see. So did you see enough to look at what I perceive as RED TAPE?? What do you see?? Same "Simplicity" ?? Politicians should be runnning Health Care..

quote:

Originally posted by Agent991:
ipw533 Yooper seems to think the NEW Politically Run UHC will be 'like Canada' as in a SIMPLE LITTLE FORM Take a look at the Chart. Wow, it's even more complicated than "usual" Gives me a Headache just thinking about it. LOL! Medicare/Medicaid Forms are kinda like H3LL on wheels. Miss one little Modifier or a misplaced Code (say 71010 vs 71020) and well, you won't get a dime. You can appeal. Good luck with that! MODIFIERS are the Code for WHY a CXR was order as in R/O Pneumonia. Or CHF. Politicians should NOT run HC! JMHO!

No ma'am. Yooper doesn't think any such thing. The fear of a single-payer system (even among those who already use one) won't allow such a sensible thing to come to fruition.

What I said was:

quote:

I now see the opposition to single-payer systems like Canada has with only one small form to complete to trigger payment.

We could never afford to pay the unemployment to the masses of incompetent coders and billers jamming the payment system today.

My hospital billing includes a very large margin to cover the cost of people after people reviewing, rewriting, restating, recoding---throw in the guy who writes the whacky narratives---and each gets a chance to screw up the coding, the routing, and the color of ink used to fill out all the various and sundry forms.

Dig this here:

I took the better half to have a sonogram to check blood flow in one leg. An hour later, we walk out with a CD. The cd contains the entire scan---real moving pictures and stuff---, the prelim evaluation, a list of the procedures with their codes, and the presenting complaint, rationale for the test, known allergies...

Doing things the way we've always done them simply because that's the way we've always done them would have us treating syphillis with mercury and burying a third of all women who give birth.

I've been treated myself at a Canadian Hospital--we didn't used to have an orthopod for a hundred miles here. The doctor over there accepted BC/BS, but his staff hated the forms upon forms it took to get paid.

They showed me the billing form---yeah, that's one form, not forms---that a Canadian covered by OHIP required.

It can be done, but I suspect you're right that it won't.

Yooper Thank You!! I see you have experienced the 'dreaded' BC/BS Forms (my words) Yes they are difficult to even SEE sometimes. I too have CDs of tests via MRI and others. One was for TBI! (Traumatic Brain Injury) Yooper, I am not even 'old' yet even so, I am s/p TBI. It was a horrible experience to be sure. I stand corrected as to your post. Forgive me for surely I misunderstood. BTW I am cured now and yet I get severe headaches. Stay safe and keep an eye out for your wife too. I have done billing/coding. I am a 'softie' for sure. I did not see, in my Billing/Coding Insurance 'kick-backs' or denials for 'pre-existing' conditions but ONLY BECAUSE I did strict Billing. And NOT Case Studies. Yes, there is Insurance abuses. An idiot could see that. But, as for me, I just fear Gov't Run Programs. No more or less. I see the Gov't as Red Tape. My view. Others see it differently ofcourse. God bless you Yooper!!

Agent99 I like your style but...the old butt : )...BC/BS I have it yes and I am a disabled vet...yes and have VA... and I have had traumatic brain injury (long ago)and yet I have an MRI coming up at the VA soon. They asked me about metal in my body... right leg, right foot and head (my head heated up last time they gave me on on top of my head...I must still have dust particals of shrapnel still there.

So I think public option is a good "safety net" if planned correctly just like VA for vets. BC/BS denys proceedures, etc and VA does them if you need it. So I think we are caught up in a lot of bs that the insurance companies have foisted on us and the Congress. The healthcare bill sucks and should not be passed. But, a public option safety net for those layed off from work without healthcare, or with "pre-exhisting conditions" or chronic needs, should be included in the safety net concept. Unfortunately the legislation is full of garbage that both sides threw in to kill the oppositions complaints...and that is all we have left the garbage.