How the College is working to reduce the hassle factor
For a printable version of this column, click here
By Sara E. Walker, MACP
Over the last 15 years, physicians have seen an unprecedented level of office hassles invade their day-to-day routines. In this month's article, I'd like to take a look at some typical hassles internists face and review some of the ways the College is helping.
To learn how practices are affected by ever-changing—and growing—rules and regulations, I talked to physicians and staff at Austin Internal Medicine Associates, a four-physician primary care practice in Austin, Texas, with a patient panel of 7,000.
Every day, nearly 125 patients check in at the front desk and receive a stack of forms to complete. New patients sign a "consent to care" form that gives the practice permission to provide medical treatment, among other things. New patients must also sign a form acknowledging that they have read the office's payment policy and giving staff permission to file insurance claims.
All patients must regularly update their addresses and insurance information. If they are new to Medicare Part B, they must review an 18-item questionnaire to determine if Medicare is the primary or secondary payer. By signing the form, they acknowledge that their physician has made a good faith effort to designate the primary carrier.
The practice uses still more forms to notify patients that Medicare will not cover preventive health examinations. If patients will need laboratory tests or procedures for most screening purposes, they must sign a Medicare advance beneficiary notice.
In April, the practice will add yet another form to the stack. Patients will have to read and sign a new privacy form so the practice can comply with the Health Insurance Portability and Accountability Act.
Help from the College
Insurers often implement procedures in a way that makes sense to them, but many of these rules and regulations waste doctors' time and create gaping discontinuities in patient care.
Bureaucratic requirements take their toll on the morale of physicians and their employees, adding to the cost and complexity of running a practice. Just as importantly, filling out the same form over and over exasperates patients.
Onerous check-in procedures are just the tip of the iceberg when it comes to hassles. Physicians must also grapple with complex government regulations and navigate a labyrinth of insurer policies to get needed medications, procedures or specialist care approved for their patients.
Recognizing that practice hassles hurt both physicians and patients, the College formed the Medical Services Committee in 1998 to deal with practice rules and regulations, as well as relations with third-party payers. The Committee, which is currently chaired by ACP-ASIM Regent C. Anderson Hedberg, FACP, develops recommendations to improve third-party payment, coverage, coding, documentation and medical review policies that act as barriers to providing high quality patient care.
Unlike other ACP-ASIM committees that primarily develop policy, the Medical Services Committee works to identify the major hassle factors for internists. Committee members and College staff then meet with representatives of regulatory bodies and private and public insurers to reduce internists' regulatory burdens.
In its five years of existence, the Medical Services Committee has been very active in bringing various hassle problems to the attention of key third-party payers. The Committee, for example, initiated regular meetings with policy-making representatives from the Blue Cross Blue Shield Association, the Health Insurance Association of America and the American Association of Health Plans to help craft initiatives to reduce hassles affecting physicians.
Staff in the College's Washington office work year round on other activities to reduce office hassles. Internists have benefited from the following accomplishments:
Fraud and abuse. ACP-ASIM successfully encouraged the Office of Inspector General (OIG) to remove offending language from its "Who Pays? You Pay" campaign, which encouraged seniors to look for—and report—instances of fraud.
The College feared that the campaign's literature could taint legitimate providers in the eyes of their patients. Patients with questions about their bills have been directed to resolve billing issues with their physicians first instead of calling the OIG's fraud hotline.
(For more information, click here.)
Billing. ACP-ASIM helped develop standard Medicare policies for 23 frequently ordered clinical laboratory tests.
Before this change, laboratory test policies varied throughout the country, and Medicare carriers had used local medical review policies to limit coverage of certain tests to specific diagnosis codes. Because carriers didn't follow a national standard, physicians and staff had to spend a great deal of time trying to determine which diagnoses justified which tests in order to be covered by Medicare.
(For more on this issue, click here.)
Claims processing and credentialing. The College convinced the American Accreditation Healthcare Commission to develop claims processing accreditation standards for insurers. The standards will address timeliness, protocols, appeals and communication in the claims process. The Commission voted to establish such standards after consulting with ACP-ASIM and other organizations.
(For more on this issue, click here.)
E/M documentation for teaching physicians. ACP-ASIM has worked with Medicare for the last eight years to simplify and clarify the documentation requirements for evaluation and management (E/M) services. One victory came late last year, when the government ruled that physicians in teaching settings did not have to repeat documentation already provided by a resident.
The College was directly involved in developing documentation instructions and common scenarios that were included with the ruling's instructions. These scenarios illustrate the language that teaching physicians should include when documenting the performance and medical necessity of services.
(For more information, click here.)
How can you get involved in reducing regulatory and administrative hassles? First, you can tell us your stories. The most powerful ammunition the Medical Services Committee can use in its meetings with regulators and payers is concrete examples from physicians.
If you have specific complaints about a commercial insurer, you can fill out a complaint form on the AMA's Web site. The AMA created this form as the result of an ACP-ASIM resolution, and the information is used in discussions with insurers to resolve the common hassles physicians encounter.
Finally, you can make your voice heard in Washington by joining the College's Key Contact Program. Key Contacts communicate with their members of Congress on important issues that affect internists and their patients-like hassles that impede quality care. The Key Contact Program provides tools members can use to develop and maintain relationships with legislators. For more information on the Key Contact Program, click here or call Kathy Heabel at 800-338-2746, ext. 4532.
Finally, I'd like to thank our fearless office managers who serve on the front lines in the battle to operate our practices within the limits imposed by legislators, payers and countless regulatory bodies. Thank you for helping us maintain our patients' trust, as you explain why they must sign the same forms every time they come to see the doctor.
And thank you for explaining that a specific carrier will pay for some preventive services but not for others, and why certain tests they read about in the paper won't be covered by their current insurance. Without your help, our practices would fail.
Isabel Hoverman, FACP, and Jan Ream, office manager for Austin Internal Medicine Associates, contributed information used to write this article.
The College offers many educational resources to help you navigate federal regulations and administrative procedures that can be onerous for physicians. For more information, see "Hassle factor resources from the College."
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