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Behind Closed Doors

A sneak peak into the bureaucracy of claims processing

By Stephen C. Spain, MD, FAAFP, CPC
When you think about the inner workings of your Medicare Fiscal Intermediary, what images does your mind conjure? Perhaps, like some, you imagine a cadre of bespectacled auditors, working long hours in dimly lit rooms, poring over your payment requests with magnifying glasses, feverishly attempting to find the most picayune excuse to deny your claim. Others might envision a gargantuan computer, crunching mountains of digital data, arbitrarily making payment decisions and robotically communicating judgments to legions of hapless medical providers.
I realized that neither of these scenarios could be close to the truth and I decided to learn what transpired on the other end of the claims submission digital highway. Curiosity led me to contacting a medical director at Trailblazer Health, Texas Medicare Administrative Contractor (MAC). I followed the suggestion of several of my Rose County AAPC chapter officers and contacted a long-time medical director for Trailblazer Health, Debra Patterson, MD. Dr. Patterson is a frequent speaker at our chapter events, often helping our members with a variety of coding issues. True to her reputation, she embraced the opportunity for an interview, and was eager to shed some light on the role of the medical director and her interaction with the claims process.
Our discussion began with Dr. Patterson’s job path leading to medical director. She started her medical career in the private practice of internal medicine in the Dallas area. After several years of practice, she joined what was then BlueCross/BlueShield of Texas as a physician consultant for the medical review department. That job quickly grew to be a part-time associate medical director position. What started as a part-time position eventually became a full-time one and she made the difficult decision to leave private practice after 19 years of devoted patient care. She has been a full-time medical director for about nine years.
I imagined her with a primary role of reviewing claims and arbitrating payment decisions. I was surprised to learn this was actually a small portion of her responsibilities.
Dr. Patterson said, “Our primary responsibility is to develop local coverage policy,” also known as Local Carrier Determinations (LCDs). “Developing a policy is a very proscribed process, and takes about nine months to take it [policy] from concept to being effective. There are numerous steps prescribed by CMS. There are also two included waiting periods, one to allow for comment on the proposed LCD and another formal notice period about the final policy.
“Maintaining those policies is also a large part of my responsibilities,” Dr. Patterson added. She emphasized the crucial role of Trailblazer’s large support staff, which includes medical review management staff, data analysis professionals, and an educational staff. These groups are all instrumental in determining an annual medical review work plan. “We all sit down and formulate a medical review strategy every year and the rest of the year we implement that strategy.” Part of that strategy includes compiling reviews of claims data. “Every year we look at the data and prior year’s audit findings, and see what we have learned.” This information is then incorporated into the current year’s work plan.
Surprisingly, her review process involvement includes more review policy development and computerized data edits than actual hands-on individual claims review. Dr. Patterson said, “My involvement in medical review is usually at the request of the claim processing, data analysis, medical review, and appeal staff in the form of physician advice pertinent to their workloads.” When face-to-face meetings are necessary with physicians over claims issues, one of the Trailblazer medical directors attends.
Dr. Patterson emphasized that her organization’s rules are constantly changing. In an effort to simplify and centralize the claims process, CMS is in the process of winnowing the number of claims processing contractors (carriers and fiscal intermediaries) from over 30 to about 15. When we spoke, Trailblazer had recently been granted the second MAC contract by CMS, meaning that Oklahoma, Colorado, and New Mexico were just added to Trailblazer’s jurisdiction. Dr. Patterson said, “As part of this reorganization, we had to take over claims processing from the existing companies. We had to get the claims edits from the existing contractors and merge them with ours.” This meant Trailblazer “had to create a whole new set of policies. Of course, after the [merger’s] implementation is done, we’ll have to go back and clean those up. The policy consolidation was a huge undertaking, and it had to be done in under 30 days!”
We turned to the subject of EMRs, and the effect this change would have on claims processing and auditing. Dr. Patterson said, “The things that are good about an EMR are the things that are bad about an EMR. The ability to create a record by bringing forward information can create not necessarily false records, but a ‘garbage’ record. The true nature of the patient’s disease, the true nature of the ailment and its presentation, can become lost in the noise of all of the stuff that gets brought forward from other encounters.
“The other big hurdle to overcome is the fact that you have multiple users using the thing and entering data on the same record, and it’s difficult to keep a proper audit trail. It is not clear who did what. It is a problem that is really not thought of by the designers of these systems. You end up with this jumble of ‘the nurse said this’ and ‘the doctor did this,’ and ‘the medical assistant did this’ and down here is the receptionist. And it all ends up in one big document. It can be very misleading and unhelpful, especially to an auditor.”
“Where,” I asked, “do you turn for coding updates and advice?” Dr. Patterson explained that she and her associate at Trailblazer, Dr. Charles Haley, and their staff members receive drafts and updates on proposed CPT® and ICD-9-CM changes. Dr. Patterson said, “I also have friends out in the coding world who share information from their various sources and organizations.” She reported that the medical directors of all the Medicare contractors are in close contact and often use one another as a sounding board on policy questions that arise. CMS holds an annual meeting that brings together representatives of CMS and the medical directors of all the contractors. This meeting is an important opportunity to share ideas and approaches to problems, and to explore different approaches to implementation of CMS guidelines and directives.
Another large part of her job, taken on by her own initiative is to speak to various groups about coding and applying CMS payment policies. “I do about twenty speaking engagements per year.”
Impressively, she does all these for free.  I was struck by her commitment to educate health care professionals and to be a spokesperson and liaison for Trailblazer and for the Medicare program. Her initiative takes her all over Texas and beyond, and she is a featured speaker at our local chapter meetings.
As we wrapped up our meeting, I asked what Dr. Patterson enjoyed in her leisure time. “Oh,” she chuckled, “I crash when I get home at night.” When I pressed her, she admitted a fondness for gardening. “On the weekends,” she added, “I have a farm with a large number of horses, Arabian horses, and two donkeys. What I would really like to do is provide a nice place for old horses to live out their days.”
After the Dallas interview, as I drove back to Tyler, Texas, I had time to reflect upon my meeting with this dedicated professional. Being a health care provider, I am often confounded by the maze of insurance regulations and policy wonks, it was refreshing to find there was such a pleasant, approachable, and humanitarian presence in the middle of the Medicare bureaucracy. We are rapidly moving toward some of the most crucial times in Medicare’s history. As we encounter these challenging times, I find some comfort believing medical directors such as Dr. Patterson are the rule, rather than the exception.

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