Why not a Museum of Bureaucratic Legalism, so future generations can study
the juridicial workings of American minds at the millenium? We have museums
of rock and roll, of baseball, of space travel — this one will round out the
collection. The political wing will display chads and butterfly ballots, with
small-print legends that explain our fascination with rules (and interactive
exhibits where children can punch their own chads). The health care wing will
divide into themes.
The Denials Wall will feature legal strategies to deny care. Here are a few
archival treasures from that Wall:
The ABN Notice.
Medicare prints ABNs (Advanced Beneficiary Notices). The title only hints at
the intent — but ambiguity marks the archetypic bureaucratic legalism, so the
exhibit works well. Briefly, the “ABN” tells the patient that Medicare may not
pay for a specific laboratory test, even though the patient’s physician ordered
the test. Minutes before the patient sits down and rolls up his sleeve, the
laboratory asks the patient to sign the ABN. Does Medicare’s denial mean that
the patient does not need the test? Medicare concedes no. Medicare doesn’t say
what the denial means. Medicare has zillions of these forms piled up somewhere
— every enrollee is supposed to sign one before having the questioned test,
though failure-to-sign has no consequences.
The “Pre-existing” Condition Denial Letters.
Health insurers at this millenium don’t want to pay for treatment. So most
private plans will not cover treatment for diabetes, cancer, arthritis, asthma
— whatever made a new enrollee need insurance in the first place — until the
enrollee has suffered for a set period of time, from six months to longer.
Definitions of “Home-bound.”
How do you drop a benefit legally, without seeming arbitrary? or cruel? When
Congress wanted to cut Medicare home health benefits in 1997, Medicare figured
out a solution: re-define “home-bound.” New definitions pared the rolls of people
eligible for service (without paring the rolls of people needing service). The
Spinal Cord Injury Association took the government to court. More papers. More
rulings. More exhibits for the Denials Wall.
Picture a vast map of computer codes. Every disease, every illness, every treatment
has a numerical code. That code in turn connects with a payment. The challenge
for the “coder” is to place the patient in the code that will yield the highest
payment – without triggering a “false claims” alarm that will set off a stream
of lawyers and accountants to descend on the hapless coder. Onlookers can struggle
through the babble of acronym-codes: ICDs, RUGs, DRGs. This too yields a wonderful
interactive exhibit, letting everybody “play” the codes. Millenia from now,
a more advanced species — maybe Klingons — will wonder why wealthy, technocratically-advanced
Americans on the eve of the 21st century were not healthier. In the Museum of
Bureaucratic Legalism, they may find some answers.
Joan Retsinas is former executive director of the R.I. Health Care Policy and
Planning Consortium. Her column appears frequently.
