I recently had my 50+ physical with all the blood work that goes with it. While I have a high-deductible health plan with a health savings account, the labs are supposed to be fully paid by my insurer as preventive care.  But the lab order wasn't properly coded and I was billed for about $400.

My regional hospital where the labs were done told me to call my physician and ask her to resubmit the order coded to indicate preventive care. I asked why the hospital doesn't just call its affiliated provider and was told they don't do that. So I called my physician's office, explained which codes had to go where and asked to resubmit the order. The office did so, incorrectly, again.

My hospital called again and insisted it was my obligation to make sure the paperwork was properly submitted. Another request that someone at the hospital pick up the phone and call an affiliated physician was refused.

I went to the hospital to ask for a note--which I would deliver to my physician--explaining what was needed to properly code and resubmit the order for the third time. I was directed to the cashier, who called the patient accounts and coding departments, explained the issue and was told no one was available to talk to me. The cashier flagged down someone walking by, who turned out to be an ex-coder now in a different role. She wrote down instructions and gave her fax number for my physician to resubmit the order, which she would deliver to the right place. I returned to my physician's office, they coded the order correctly and resubmitted.

A few days later the hospital called again. I explained the order had been faxed back and was told they never got it. I gave the fax number it was sent to. I also was lectured again about my obligation to do the hospital's work. I shot back, explaining my obligation was done, I would do no more--if they sued me for nonpayment we would tell our stories to the district judge and we both knew who would win. It's been a couple of weeks and no one has called, so maybe the matter is settled.

The point of this story--which plays out all day every day across the nation--is that it demonstrates how unready the industry is for accountable care organizations, shared savings programs, value-based purchasing and every other health care reform provision that actually requires provider organizations to cooperate to any appreciable degree.

If patient account staff at hospitals and physician offices won't talk to each other to get PAID, are clinicians going to communicate any better to ensure safe, effective and efficient treatment across the care continuum? Of course not.

Chances are very good that hospital-physician relationships in your region are just as bad as mine. So chances are very good that almost no delivery systems are remotely ready for accountable care organizations, shared savings programs, value based payments and a huge expansion of Medicaid.

The health reform law, written by "experts" who don't work in provider organizations, won't succeed. Aside from curbing some insurance abuses and tightening the HIPAA transaction sets, I can't see any provision that will work when rose-colored glasses come off. Can you?

Joe Goedert is News Editor at Health Data Management

 

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