Bad forms.

• Author: Georges, Christopher
• Position: Health care reform

You didn't have to be a brain surgeon, or a surgeon at all, to have suspected that Phillip (not his real name), a 34-year old man with size-C cup breasts, might have had a medical problem. So when a New York-based doctor--who is a surgeon (one with 15 years' experience and a faculty post at a major New York medical school)---diagnosed Phillip in the summer of 1992, he recommended surgery. The operation, which took place last September, was relatively simple and painless. Getting reimbursed was not.

Phillip is not one of the nation's 37 million uninsured, but he might as well be, considering the treatment he's received from his insurer. Prior to surgery, both Phillip and his doctor painstakingly submitted an air drop of charts, photographs, and medical repons. The insurer signed off on the procedure, agreeing to $6,250 in coverage. But when it came time to shell out the money after the September operation, the insurer balked. During the next three months, again and again, the insurance company called or wrote asking for additional information. By January, Phillip along with his doctor had spent countless hours forwarding at least two copies of every X-ray, medical chart, invoice, and piece of medical history in the patient's file. At one point, the insurer even demanded a second accounting of Phillip's height. In January, the insurer matter-of-factly reversed its decision, ruling that the operation was "100 percent cosmetic in nature." Phillip, although much trimmer, is now $8,000 poorer, and is filing yet more forms in an appeal to New York State's insurance commission. "The patient is distressed; I'm distressed," says the surgeon. "And it's not just this case. I get one nonsensical request after another from insurance companies."

And it's not just the volume of data insurers demand that's got doctors and patients in a lather, but the questions themselves. There's no telling what the claim form wizards over at Medicare were thinking when they came up with the possible responses for "Patient Status"--not just your standard "Single" or "Married" but an option for "Other." Curious, I followed the advice on the form instructing those with queries to contact the Office of Financial Management at the Health Care Financing Administration in Baltimore. (The fine print also assured me that the form was designed to be completed in 15 minutes or less.) The machine on the other end--my "automated receptionist"--offered nine push-button options, including one that would help me with details on the "Clinical Laboratory Improvement Act," but none for marital status. I told the live receptionist I was having trouble filling out the form. "They sure don't make it easy, do they?" she said empathetically. "Unfortunately," she went on, "the Office of Financial Management no longer exists." I was soon on the phone tour of the agency (by now my 15 minutes were up), finally being connected to a friendly form administrator. So, what about that "Other" option? "Maybe," she offered, admittedly unsure, "it's for people who have more than one spouse?" And what exactly is that "FECA code" the form asks for? "To be honest, I still haven't learned all the acronyms," she said, "and there's no reference to that one in our instructions." But she did promise to check and find out. "This thing's a mess," she sighed--referring to the Medicare form--a few questions later. "You know, there's a 20-page book that explains it. It's so complicated." You're telling me.

Chances are that even if your only contact with your doctor is for the occasional check-up, you too have run up against the medical-form frenzy-- perhaps filling out multiple claim forms for a single procedure, battling insurance company clerks over how much they owe you, attempting to prove that your claim is valid, or waiting months for a reimbursement if it comes at all. Now multiply that headache by, say, 20--the number of patients a doctor might see in an average day...