By Nichole Aksamit, Omaha World-Herald, Neb. Knight Ridder/Tribune Business News
Mar. 9--Just when you thought health insurance couldn't get more confusing, new federal regulations intended to speed payments and protect your privacy may be indirectly messing up your bill.
As medical and billing companies upgrade their computers to meet the regulations, some Omaha-area patients have been getting bills for seeing the wrong doctors. And some physicians' groups haven't been getting paid.
Because the changes are driven by federal requirements, such problems have the potential to affect hundreds of thousands of patients and health providers nationwide.
At least one Omaha provider that made the switch in October is dealing with billing mix-ups now, and several others report glitches.
'We recognize this in health care as a bigger problem than the Y2K problem,' said Kevin Conway, vice president of health information for the Nebraska Hospital Association.
So what's the problem?
Under the Health Information Portability and Accountability Act of 1996, or HIPAA, health-care providers are to use a standard format when submitting claims electronically to insurers or to Medicare.
The format uses standard fields and codes to refer to doctors, patients, diagnoses and procedures -- to protect patients' privacy, cut paperwork and speed the processing and payment of medical bills.
But providers, insurers and third-party billing companies are struggling to get their computer programs all speaking the same language.
Providers were to make the switch by mid-October or risk not getting timely payments from Medicare. But because so few were ready, the federal government agreed to continue accepting and quickly processing noncompliant claims until July.
Conway said the conversion requires changes in antiquated and highly customized billing systems. Mistakes at any point along the way -- the health-care provider, the billing company or the insurer -- can cause chaos.
Creighton Medical Associates, a group of physicians practicing at Creighton University Medical Center, recently sent letters to 2,500 patients to explain and apologize for problems.
Robert Glow, the group's chief operating officer, said software used by the group's new billing company randomly changed the provider on claims for some Mutual of Omaha customers.
That meant some patients were billed for seeing more costly specialists or out-of-network doctors, when they actually saw less costly providers.
Glow said the group learned of the errors when patients reported being billed for visits to doctors they didn't see and when claims went unpaid.
A review of claims and patient records found errors on 7,900 Mutual claims from October, November and early December. Additionally, Glow said, some claims the billing company was to send to Medicare and another insurer never made it through.
Glow said his group has switched billing companies and is working with Mutual to reprocess claims that led to incorrect patient bills.
'Due to the large volume of claims that were impacted, the goal is to have this completed within the next 60 days,' said the letters, which arrived in mailboxes in the Omaha area the last week in February.
University Medical Associates -- a group of about 400 University of Nebraska Medical Center faculty doctors -- has hit a few snags, too.
None of the glitches have resulted in erroneous bills to patients, though they have delayed payments to UMA, said Cory Shaw, the group's chief administrative officer.
Two weeks' worth of claims 'vanished' after submittal in December when one insurer began using part of the new format. The medical group had to re-create and resubmit those claims -- hundreds of thousands of dollars' worth.
Shaw said provider cash-flow problems resulting from such glitches eventually could put patients on the spot.
'For the most part, patients aren't going to feel the impact of this unless, as a provider, I'm waiting two, three months for a claim to be paid and I turn to the patient and say, 'It's time for you to pay me, and you can worry about getting the money from the insurance company,'' he said. 'It's a last resort, but it's possible.'
Nebraska Methodist Health System, which includes Methodist and Jennie Edmundson Hospitals and Physicians Clinic, also has encountered problems. The problems were similar to Creighton's in that they appear to have occurred at a clearinghouse that takes information from the hospitals or physicians and forwards it to insurers, said Kathy Zeitz, corporate compliance officer for the system.
Zeitz said the health system has switched vendors and worked to fix the problem.
'It would be a rare system that hasn't had issues,' she said. 'This is a colossal change.'
Of nine Omaha-area hospitals and physicians groups that use the new format and returned calls for this story, only Alegent Health's four metro-area hospitals reported no known problems.
Nearly five months after the October conversion deadline, roughly one-third of the nation's Medicare claims still aren't being filed in the new format. Ronald Bryan, manager of the Midwest Consortium for the federal Centers for Medicare & Medicaid Services, said compliance rates for Medicare claims from Nebraska and Iowa range from 19 percent to 91 percent.
For patients worried about their bills, Bryan offered the same advice the federal centers give for fraud prevention: 'We generally tell people to be aware of the statements they receive, to make sure they are for services they received and to call if there's some difference.'
WHAT TO WATCH FOR: After visiting the doctor, you should receive a mailed explanation of benefits from your insurer or Medicare and a bill or statement from the doctor's office.
Examine the documents carefully, compare them and check them against your health insurance policy. Do they differ? Does either list the wrong doctor, procedure, co-payment or amount due? Do they indicate you owe for procedures that should be covered? If so, you may be the victim of a billing error or even fraud.
To sort it out, start by contacting your insurer and your doctor's office. Enlist the help of the benefits manager at your workplace if things aren't resolved. Don't send a check until it all makes sense.
Patients are urged to report medical bill errors to insurers.
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(c) 2004, Omaha World-Herald, Neb. Distributed by Knight Ridder/Tribune Business News.
