Doctors drowning in insurance paperwork

Robert Bennett's father is a doctor - a longtime practitioner who cannot get his head around all the computerized medical recordkeeping.

Robert Bennett's brother is also a doctor - part of a younger generation that grew up with computers and cannot imagine practicing medicine without them.

Bennett is a Washington lobbyist who represents the beleaguered - the medical administrators who work for doctors like his father and brother. Administrators, he said, are drowning in insurance paperwork that is costing the nation's health-care system hundreds of billions of dollars a year.

"There's a ton of frustration among our members," said Bennett, who is with the Medical Group Management Association, a national trade group based in Colorado.

In fact, James G. Kahn, a health-policy professor at the University of California in San Francisco, who has studied administrative expenses, estimates that billing costs the nation's health system up to $400 billion a year, although, obviously, some of that expense is necessary.

"The biggest part is the burden on doctors and hospitals, because they have to deal with literally dozens of health-care plans," each with its own system, Kahn said.

No one disagrees.

Even as politicians continue to hash out health-care legislation, there is no argument over the need for administrative simplicity, a shared provision in the Senate and House bills.

"Considering the computer age we're in, a lot of the administrative burden should be made a lot easier," said U.S. Rep. Allyson Y. Schwartz (D., Pa.), who pushed to include the measure in the House bill.

Some envision a day when a patient would scan a plastic card into a machine in a doctor's office. That action would flood the office's computers with information, including the person's prescription-drug history, the date of her last mammogram, the co-pay due, and insurance eligibility for certain procedures.

With that kind of information, doctors would not prescribe drugs that work at cross-purposes, nurses could schedule overdue mammograms, eligibility requests would not molder in the insurers' computer systems, and duplicate claims would be flagged on the spot.

Not only that, but an easy-to-understand claims form would be generated, one that did not take a four-inch-thick training manual to decipher.

"But that would be running," Bennett said. We're just trying to crawl now."

What irks Bennett is that a doctor's clerk will collect a patient's insurance card and driver's license, photocopy both, then enter (or mis-enter) the information onto the computerized form that begins the payment process.

Crawling, he said, would consist of a government-imposed system so the card reader would load in the basics - name, address, and policy number - the same way on every form. That alone would save $22.2 billion over 10 years, he estimated.

Toddling, Bennett said, would be a standardized numeric-identification system and the requirement that every insurer use it to assign a unique number to each type of plan it offers. Insurance companies sell hundreds of kinds of plans, varied by state or benefit level.

Why hasn't this happened earlier?

Some say it is fragmentation of enforcement, with each state having its own rules. Schwartz said health-care legislation would allow the federal government to set standards the states can enforce.

Susan Pisano, a communications vice president for America's Health Insurance Plans, an industry trade group, said there were four main barriers:

"You need the technology to exist - computers with the capability to handle it. You need widespread adoption of the technology. Until recently, a lot of physicians continued to rely on paper.

"You need someone to convene the stakeholders, so they can agree to do something in a consistent way. And you need a common set of rules and standards."

Groups such as Bennett's wonder if insurers intentionally make the claims and appeal process difficult so providers give up and accept less, lowering costs for the insurers.

"I don't know whether the process is complex to foster that kind of thing, or whether that is just the way it turns out," Kahn said, citing comments he has heard in his research.

Pisano disagreed.

"Frankly, if it is more efficient for doctors, it's more efficient for us."

In Ohio, Pisano's group has organized the insurers and doctors into an efficiency experiment launched in November. A similar program will begin next month in New Jersey.

Jason Koma, spokesman for the Ohio State Medical Association, a physicians' trade group, described the change. Before, a doctor's clerk had to log onto each individual insurer's Web site and then click around the site to determine eligibility and co-pays for each patient. It takes time and training to learn how to navigate each site.

Under the program now being phased in, the clerk simply logs into one Web site, powered by Availity L.L.C., a Florida software company. That one portal links to all the insurers.

"So far," Koma said, "we've had positive feedback."

The New Jersey effort will be powered by NaviNet Inc., a Massachusetts software company. NaviNet's founder, Tom Morrison, worries that the push to simplify will create problems if new systems are too crude to cope with the myriad variations in people's health and insurance situations.

"Health care is a really complex business," he said. More important than creating standard forms is creating standard workflow processes that manage complexity simply.

Kahn thinks there is too much experimentation. Thirty other developed nations already have solved many of these problems.

"We should just be looking at these successful systems and using what works."