How About Both Sides of This Table?

@msuster is a steady source of good info in my Twitter feed. His recent tweet with reference to a blog post about the purchase of Health Data Insights is fantastic news for him and his firm, http://t.co/Z0UJMdwl. I wasn't familiar with HDI so I read a little about them. It's fantastic that technology is rooting out fraud. As a taxpayer I couldn't be more happy. But there is another side to this coin. I don't know what the data is but I know there is a percentage of "fraud" cases in medicare and medicaid that are simply because providers, or their staff, incorrectly code or bill for the services actually rendered. The billing codes for procedures are very precise but procedures are not always very precise. Additionally, there are many other points at which a claim could be labeled fraudulent. If, for instance, an incorrect time, date, patient demographic, diagnosis code (there are about 30K diagnosis codes, soon to be over 130K codes with the implementation of ICD-10) or other important information is incorrectly entered into a claim form it could be considered fraud. The process to resubmit, sometimes multiple times, in order to correct a denied claim takes a lot of time from staff and adds cost to the system when in fact services to a patient were actually rendered correctly. I know there are two different things I am referencing here, incorrectly filed claims and fraud, but there is some overlap as I alluded to and admit that I don't have that data at hand.

In the private insurance world the billing process takes on some interesting twists and turns. The group with which I work was not paid for a single claim for months until each claim was resubmitted.. This was from the main insurance company we deal with (and with whom we have a contract). And the claims were submitted as our office staff has always done, for the last 20 or so years that the group and office manager have been in existence. My theory, pessimistic, is that insurance companies know a certain number of claims will disappear in this submission and re-submission process. It helps their bottom line while it hurts my groups' bottom line in two ways. First, we may forget to refile some of those claims and second, it takes more staff or hours of paid time from that staff to resubmit al those claims. You all can come up with a number of reasons from a non-pessimistic perspective why these kind of things occur. Maybe the truth is somewhere between.

Suffice to say though, the medical claim process is a huge pain point and ripe for innovation. There are some companies getting into this on the periphery (Simplee Health comes to mind) and of course HDI on the payer side. But few technological advancements are being made that help providers. Sure there are EMR and medical practice software providers who provide and electronic platform to enter the same data. But more is needed than a simple digital version of what we have always done.

Here are few questions for the tech folks brighter than me to help and answer/solve. Where are the algorithms on the provider side that recognize trends or at the very least gives cues for complex billing situations, or just cues to include all the pertinent data? Why doesn't billing software submit claims automatically to payers instead of having to go through a clearing house. Clearing houses are these entities which have grown up because billing software providers can't/won't integrate the idiosyncrasies of claim forms from all 1100 or so payers that exist in the U.S. and I don't think anyone in this industry has ever heard of and API. I contacted our practice management/billing software provider so our group could build its own app to get case and care data to our office via that app. Me: "Can I have your API?" them: "We don't have an API." Me: "So can I send digital data about anesthetic cases to our billing software?" Them: "config.sis, MS-DOS, $$$$$, archaic, re-invent the wheel, blah blah blah" (I paraphrased them).

Once again, I admittedly lack data, but extrapolate from the huge dollar amounts in @msusters post and know that the correlary situation occurs on the provider side. It is a maddening source of frustration for providers (good ones, not the tools that are really bilking the Feds) and our staff members. This is a pandemic across the U.S. so anyone who would like to solve some of these issues will probably get bought up for multitude millions! Good luck!