As I sit on a delayed plane attempting to fight my way back home, I have the difficult task of attempting to clarify what it is I do. When I was a kid, I never, ever, thought, “When I grow up, I want to be a Healthcare Reimbursement Attorney!” How did an NFL-dreaming Midwestern boy end up living in Charleston, South Carolina, with a niche, national practice and more than $100,000,000 dollars of healthcare reimbursement to defend? Well, I’m a former English teacher and an analytics geek, so let’s speak well and be precise.
First, I am compelled to weigh in on the “Health Care” versus “Healthcare” debate to frame our conversation. Let’s break it down, because even the dictionaries conflict. The two-word phrase implies that “Health” is an adjective of “Care.” Now, I’m all good with doctors caring about patients’ health, but my line of work is definitely not touchy-feely and has concrete rules, bricks and mortar, and tremendous monetary consequences. “Healthcare” is defined as a noun, with capitalization to denote a proper noun – a specific subject matter. That is the world in which I work – an extraordinarily complex, vastly personal, and societally impacting, with many hard lines and bottomless rabbit holes of regulatory quagmire.
If the intricacy or polarities of that last paragraph threw you a little, please fasten your seat belt as we dive in. “Reimbursement” is a noun used to define something that is given as repayment for a prior expense or to restore a loss. In my field, that breaks down to health insurance companies (payors) repaying doctors (providers) for their prior provision of services and incurred expenses in caring for patients (beneficiaries). The law surrounding and twisting its way through the financial relationship between payors and providers is my arena – the healthcare revenue cycle.
Now we’re ready to start pulling back the layers. Let’s examine the relationship for federal payors (e.g. Medicare) to start. When a doctor enrolls with The Centers for Medicare and Medicaid Services (CMS) to provide covered services (medical treatment that CMS will pay for) as a participating provider, the doctor is subscribing herself/himself to performance under a statutory and regulatory framework in order to be reimbursed from Medicare Trust Funds (citizens’ money). As you might have guessed, this is not an arms-length transaction between equally bargaining parties and messing with taxpayer dollars carries heavy consequences. Most importantly, CMS is the flagship of all payors in the establishment of policies and rules governing reimbursable claims and a constant default for voids in the relationship between private payors (e.g. Blue Cross Blue Shield).
Private payors, unlike federal or state payors, fall under contract law, with a very strong overlay of federal law mandates and buttresses of state statutory and regulatory law. Let’s compress an example – one doctor’s participating provider agreement (contract) with one private payor has express, written terms in the language of the document itself, incorporates the terms of an ever-evolving provider manual that averages 600 to 1,000 pages, that includes federal and state law statutory and regulatory mandated compliance in order to achieve adherence. When all of that is silent on the rules for coverage of a particular service, we go off the cliff into CMS Medicare Administrative Contractor (MAC) National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs) by jurisdiction, American Medical Association (AMA) guidelines, and the enigma of the sufficient professional evidence to establish sound clinical decision making. Take a deep breath.
As you can imagine, something is bound to go wrong in all that conglomeration! In steps the Healthcare Reimbursement Attorney. No, I may not slay dragons or score winning touchdowns. But, there is great reward in saving a practice from financial ruin and providers from the death-knell of the Office of the Inspector General (OIG) exclusion when defending against a Unified Integrity Program Contractor (fraud auditor) that gets paid based on how many problems they uncover and the amount of money they squeeze out of the last six years of services provided to Medicare beneficiaries. A great, satisfying peace accompanies educating private payor Special Investigations Units (SIUs) that negligence and human error on both the payor and practice sides abounds, that knowledge kills the most venomous assumptions, and a manageable path to compliance and continued participation is possible.
So, is a Healthcare Reimbursement Attorney the guy you call when you get a records request or an audit notice? Yes. Although, I far more enjoy being the guy that gets a Christmas card with a picture of a smiling former client playing with his little girls that was wrongfully accused of healthcare fraud, retained his practice and license, and now quietly treats elderly and impoverished in the Low Country. It’s not a bad gig.