In my spare time, I’m a sucker for black and white slapstick comedy. If challenged, I could probably recite every line and verbally recreate every scene from the Marx Brothers’ 1933 comedy classic Duck Soup, complete with Harpo’s pantomimes and horn honks. I also do a mean imitation of Curly Howard of the Three Stooges running on his side if prodded, just not right now.

What makes slapstick comedy gratifying is the belief that it exists strictly in the realm of entertainment. In real life, we tend not to see pie fights at society parties, wars won because the leader of the enemy country is being pelted into submission with fruit or adults getting hit square in the face while playing dodgeball. We tend to think that institutions can’t descend into complete and utter chaos due to one bad decision, yet the process looks really easy to accomplish with the right script, the right actors and a skill for setting up a humorous situation.

In the absence of an abundance of banana peals and squirt bottles full of seltzer water, the closest parallel we have to slapstick comedy in our daily lives is the decision-making process of our federal government, particularly in relation to its unctuous administrative giveaways to large American businesses. As an illustrative example, I present Palmetto GBA, which in the past two years has quickly risen to the top of the list as a California physician’s least favorite wholly owned subsidiary of Blue Cross & Blue Shield of South Carolina.

During the last presidential administration, someone in government decided that it would be a wonderful idea to take the assignment of Medicare contractors for some states and shift them to other contractors. As part of that decision, Palmetto GBA, who until 2008 had been responsible for some of the smaller states in this country, was given oversight of the state of California, which by itself is the 7th largest economy in the world. Simultaneously, the decision was made to move every provider to a National Provider Identifier (NPI). 

What was planned was a smooth transition from one carrier to another with an accompanying, long-awaited transition to a single provider ID number. What resulted in mid-2008 was comparable to Lucy and Ethel at the candy factory, with too little staff assigned to too big a task. This would be the perfect situation for high comedy were it not for the fact that it sent tens of thousands of medical practices in America’s largest state to the brink of bankruptcy due to long-delayed NPI enrollment applications and lack of staff to answer basic questions leading to resolution.

In the fall of 2008, a flurry of press releases emanated from Palmetto GBA in typical corporate style stating that the problems were being addressed, additional staff was being added post-transition and that everything was going to suddenly metamorphose into a fantasy land of fairies, elves, candy buttons, marshmallow clouds and rivers of pure chocolate.  In the roughly 18 months since, it can be successfully argued that the same problems still exist, only instead of NPI, Palmetto GBA has now demonstrated their lack of readiness a second time with their approach to the PECOS/referring physician database issue.

As an illustrative example, one of our California providers, was having a problem with his Provider Transaction Account Number (PTAN). When our credentialing specialist contacted Palmetto GBA, the person answering the phone stated that the physician did not have an individual PTAN. It was shortly after this that the physician received a letter stating that the same supposedly non-existing individual PTAN was being deactivated. Further investigation revealed that this stemmed from a suite number in the correspondence address being entered incorrectly in Palmetto’s system, which in turn caused a conflict with the PECOS system, hence the threatened deactivation.

Mercifully, CMS has now delayed Phase II of the PECOS project until January 3, 2011, which gives Palmetto GBA roughly 10 months to discover another integral process for which they lack either competent staff or updated information. The lesson of California’s painful transition is still playing out, as the last 14 states in the five jurisdictions yet to go through administrative carrier transition are being delayed due to protests being lodged with CMS. This affects the four additional states that will be under Palmetto GBA after final transition. Spare a little pity for the provider communities in the Carolinas, Virginia and West Virginia after all is said and done.

All of this provides an abject lesson in governmental process. It is hoped in the future that legislative changes with profound financial side effects will more resemble a workable, functional business model rather than a 3-dimensional tribute to Larry, Moe and Curly.

Chalk this posting up to exhaustion.

It turns out that the annoying cough I’ve been fighting for the last week is actually bronchitis. For this, my urgent care physician prescribed a Z-Pack and $50 cough syrup that makes you drowsy. To spare the reader, I skipped the cough syrup for this post, as it’s a fine line between an industry blog posting and William Burroughs’ Naked Lunch. I’ll be brief, and hopefully effective.

Two updates of note came to light this week. First, on January 4th, Medicare was to implement a rule clarifying date of service and place of service rules for interpretation of diagnostic tests. These rules stated that the date of service and place of service of the interpretation of diagnostic tests should be when and where the interpretation was performed, and not the date and place of the performance of the test. Thankfully, on February 5th, this new rule was postponed indefinitely due to mass provider confusion. The policy could be reviewed at a later date for future implementation.

The second update follows up on my last posting here regarding the 2010 Medicare Physician Fee Schedule. Thanks to the snowstorms that pounded the East Coast this week, which led to a federal government

Being a person who renders opinion and advice regarding medical billing and coding issues, I have done my level best in this space to remain neutral as the political infighting continues in our nation’s capital with regard to health care reform in general, and physician reimbursement specifically. A glance at the calendar is changing my mind.

Today is February 5th, and being that this is the shortest month of the year (think of February as Tattoo and the calendar as Fantasy Island), I count that there are 23 days left until Medicare will begin instituting a 21.3% pay cut across the board for all physicians. Seeing as a cut of this magnitude immediately places countless medical providers is dire straits, and by extension our clinic-based medical infrastructure in jeopardy, one would think that this issue would be at the top of the list for a country that embraced “promote the general welfare” as a founding ideal of the nation. So it is with surprise that upon looking at the Congressional calendar for February that Congress is giving themselves a break for the entire week beginning February 15th. This drops the actual days to fix the problem to roughly 18, but anyone who has ever tortured themselves watching C-SPAN can tell you, U. S. Congressional work must be judged on quality of time spent, and not quantity.

Physicians are already taking a financial hit in 2010 with the Medicare’s elimination of reimbursement for consultation codes. As specialty organizations urgently lobby their members to contact Congress to issue a fix, Congress is snapping into action by taking 5 days off.

I spend my work days being a physician advocate. While it is not the place in life that I pictured for myself in my childhood, I think of myself as a very important part of our healthcare system as it is currently configured. Physicians spend 10+ years being trained to solve the myriad issues involved with the inner workings of the human body. We don’t contact a physician when we’re feeling great. A doctor is called when something is wrong. I object to this being  referred to as “A God complex” as so many do, as this is not a preordained royal imprimatur, but rather an outcropping of the decade or more of training necessary to understand and positively restore human beings to maximum function. I feel I owe it to a physician to take financial worries off the table and let them concentrate on what they have been trained to do.

I had five doctors in my family ranging across four different medical specialties. I find the scientific healing of the sick to be a fascinating world, not only for what is known about the human body, but what remains unknown as well. Had I been a better student (a FAR better student), it’s very possible that I could have ended up on the clinical side of health care rather than the administrative. As it is, my mind is geared more for appreciation of physicians rather than the occupation itself. Having said that, with the current insurance landscape, the work I and others on this side of the healthcare industry explore through on a daily basis (when exactly this became an “industry” rather than a noble trade, is long forgotten), from tracking down every possible dollar of reimbursement to helping design defensible documentation for medical services, takes on increased importance. None of us should gain any joy from knowing that our doctor is up in the middle of the night not solving the problems of a sick patient, but rather contemplating their financial future.

If you’ve been in this industry for any length of time, you become desensitized to the annual rite of Congress reversing a well-publicized physician payment cut. It is analogous to a long-term hostage-taking, where after a while being chained to an oil heater in a basement, being beaten and tortured and living on bread and water becomes a new standard by which to measure “normal”. If no one else is going to stand up and say it, I will. This latest deadline to end all deadlines isn’t business as usual, and it’s not something we should just get used to and coexist alongside, awaiting the usual temporary solution. It’s sick, it’s depraved and it has to stop.