Thursday, June 30, 2011

A form for every purpose under heaven

For physicians, and especially those in primary care, it seems like there is a form for every purpose imaginable—often for purposes that are hard to imagine.

An ACP member in Rhode Island recently gave this example:

“I was just asked by my Medicare Advantage plan to sign a form for [a well-known pharmacy benefit manager]. This form is to be faxed to them in order for them to send me a prior authorization form for a med. So in other words, I had to complete a form in order to get another form. This is nuts!”

Or how about this, from another ACP member in a private internal medicine practice:

“The documentation that is getting to me, is that documentation that the ‘durable medical equipment people want including repetitive- recurrent documentation, whenever we see a patient to document "continued need". The list of things we have to document, sign, approve or prior authorize, I believe is what makes most physicians think they chose the wrong field. A PBM letter to me about my prescribing practices today nearly did me in! Luckily I just shredded it. If I am kicked out of this business, I am so close to retirement it would be a blessing!”

Or this:

“In 2011 we now have to complete the ‘Home Health Face to Face Encounter form, a one and a 1/2 pager that is required for every patient starting home health care, in addition to the plan of care forms. IMHO, this is getting ridiculous. Any one of these is really no big deal, but the collective volume of these forms is stifling and is taking away from time with my patients and my family. If I happen to have a med student with me, they can't help but notice the significance of the volume of paperwork in my ‘paperless office, that delays me entering the exam room.”

Wouldn’t it be great if there was a law to require insurance companies to reduce paperwork requirements on physicians and patients?

There is. A law recently passed by Congress requires the following:

--By January 1, 2012, the federal government must seek input as to whether the process by which physicians and other providers enroll to participate in a health plan can be made standard and electronic, including whether a uniform application form is viable.

--By October 1, 2012, the federal government must establish a system that provides a unique identification number for each health plan. Ensuring that each health plan has only a single identification number should improve the ability of physician practices to manage their administration interactions with health plans.

--By January 1, 2013, insurance companies will be require to abide by a standard set of rules to facilitate electronic transactions, including use of machine readable identification cards, to enable physician practices to verify patient health insurance coverage eligibility and obtain the status of claims submitted to bill for services. Physicians will be able to determine the insurance product that covers the patient, whether a specific service is covered, any patient financial responsibility, prior to or at the time of the patient encounter; whether the insurer received the claim submitted and the status of an accepted claim in the processing cycle, and be able to access information on how a determination is made whether to pay a claim and how to appeal adverse determinations.

--By January 1, 2014, insurers will be required to comply with standards on electronic funds transfers (EFTs) and claims remittance/payment. They must allow for automated reconciliation of the electronic payment the physician receives and the corresponding remittance advice that the health plan provides.

--By January 1, 2016, the federal government will implement a standard set of rules for the administrative transactions: health claims; referral; certification; and authorization. Standardization related to these transactions is intended to decrease the burden on physicians and patient that comes with required use of different forms for different payers. Also, insurers will have to comply with a standard and associated set of operating rules that pertain to health claim attachments.

The best part is all insurers will be required to comply—and will be fined if they don’t.

Do you know what this new law is called? The Affordable Care Act (ACA)--yes, the same health reform law derided by some as putting more “bureaucracy” into the doctor-patient relationship. (To learn more about the ACA’s administrative simplification requirements, go to ACP's Practical Guide to Health System Reform, and under the table of contents organized by topic and year, click on the heading Simplifying Administrative Requirements the Health Care System Imposes on Physicians.) Link
The ACA may not entirely solve the paperwork problem, and it undoubtedly will create some of its own paperwork, some of which will have to be challenged. But it will put in motion the most comprehensive and systematic federal effort ever to streamline, standardize, automate, and reduce paperwork associated with health insurance transactions.

That is, to reduce the kind of paperwork that causes internists to pull out their hair and scream “This is Nuts!”

Today’s questions: What do you think about the federal government requiring insurance companies to streamline, standardize, automate, and reduce paperwork associated with health insurance transactions? And were you aware that the ACA requires this?

Update: CMS today issued an interim proposed rule to make it easier for physicians to check patient eligibility and status of claims.


Robert J. Sobel, M.D. said...

The form topic is not good for my blood pressure. You can page through the ACA and find edicts, but you can also find new bureaucracies. We are at the mercy of too many entities and it is absolutely impossible to practice medicine without their coercive effect.

The PBM's have gotten more aggressive with the passing of more drugs onto generic status. This shift in the cost dynamic occurs abruptly. It basically leaves us hand-tied if we have any desire to leave a steady therapeutic regimen in place.

While, "don't worry, the evidence is that there is no real difference," is generally true, the effect of this ceded authority is too much for the psyche of a good internist to bear.

Bob, this is the root of my Regulated Royalties. The behavior of internists is fine. The price of the drugs is wrong. The forms are there to coerce us for the financial gain of others. Cost savings are illusive.

Show me a real example of how my day to day management of patients will be affected favorably by these changes.

I'm all for the mandate, increased access to private insurance, and price regulation of health care commodities.

Let's see if we can really focus on the changes that would help us in the part of the system that still works. Importing everyone into the chaotic waste of the system that must pay the premium of new technologies while hassling the professionals who are closest to the patients, leaves the key part of reform undone.

How about that recent Reglan decision? Both sides called our copy-cat system poorly designed. How about taking up my plans for a Hatch-Waxman II?

PCP said...

Want to fix this problem. simple rule. Doctors time is valuable and if you need the doctor to review/complete a form, then each page is to be compensated at 10$ a page. That will make the insurance insurance industry including Medicare figure out when the doctors time and input are most invaluable.
Then all this discussion will be moot. It is this unfunded mandates that are the problem, then tend to start with Medicare.

chediak said...

The insurance paperwork standardization provisions of the ACA are a good start. But these can and should have been passed on their own much earlier, and without the additional provisions of the ACA that make it so onerous and counterproductive.

It's like using a spoonful of sugar to help the Ipecac go down...

encdinosaur said...

Bob, I agree with Dr. Sobel.

It has gone to far, for too long, and no fiddling with a few forms here or there is going to make any difference in the interest of students in primary care, or of young doctors of staying in primary care.
We now have attorneys in our area, needing expert testimony on competency hearings, learning that these patients have been cared for by NP's and PA's for more than 5 years without ever seeing a physician!
Our health care system is collapsing more quickly as a result of the ACA and its savings predictions based on fee cuts that will close every primary care physician's office in the country.
Daily I am deluged with DME forms for lift chairs, diabetic supplies, back braces, shoes, scooters, and other devices that the government obviously pays too much for, and apparently first dollar as well. I no longer am harboring any guilt trashing them. I am well aware of the literature showing no benefit at all for Type 2 Diabetics checking their blood sugars daily, yet the government continues to pay billions for such testing.
The lobby of DME manufacturers, drug companies, and PBM's will forever control the political agenda, and find ways around it.
It is inconceivable to me that one year later we are discovering things in the ACA that result in unintended consequences (note the issue of different tax benefits of retiring at 62 "just discovered).
Unwise physicians and their managers are accepting EHR funding promising to meet "meaningful use" criteria that are yet to be established in phase 2.
The consultants will help anybody set up their ACO, if they have $11 million to spend to do so, and then take risk and not be able to manage it for more than one year, since they won't know who is in their ACO until after the end of the year!
We have enacted a "fix" to a health care system under leadership that has never met a payroll, and even now is trying to borrow more money to maintain its status quo.
Believe me when I say that the rank and file ACP members I know dont't share any rosey feelings about the ACA with you.

Steve Lucas said...

Dr. Sobel and I often have slightly different perspectives regarding medical issues. On this topic he is absolutely correct. This act really only creates a monster while claiming to streamline the process. Think of all those new IRS agents we will soon be supporting.

Regarding the prescription medicine issue; I have many older friends who are on a prescription regime that works and they can deal with both financially and physically. Changes their med and there is anxiety about effectiveness, paper work regarding the change and cost, and then just the act of dealing with a different colored pill. We need to remember; often those taking the most meds are those with limited finances and declining mental and physical abilities.

Following this debate on another blog I was struck by the lack of economic knowledge of the doctor involved. Their solution was to have the patient come in for an office visit. If a person needs to be taken to the doctor and it takes an hour to get to the doctors office, including time to get ready, an hour in the office with wait time, and an hour to return, we have six man hours involved, with mileage and parking. I will let the doctors do the math on a per hour bases, based on their business model.

Doctors are professionals and need to be paid for their time. We have a system wide problem that needs to be addressed. Building more cost or complexity into the system is not the solution.

Changing 1/6th of our economy based on acceptance of the ACA paperwork reduction is a false economy.

Steve Lucas

ryanjo said...

Ironically, the ACP Internist has a story today (July 7th) about electronic prescribing providing no improvement in medication errors compared to handwritten prescriptions (

After several years of physician eRx incentives, and now looming payments cuts for non-eRx users, this is a bitter wake-up call about the heavy-handed government approach of top-down reform efforts.

What other unpleasant and costly failures await us as the ACA rolls out?