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Robert B. Edmiston MD, Vice President
Pennsylvania Ble Shield
Camp Hill, Pa. 17011-0062
September 29, 1988
I really do hate to be a pest about the explanation of benefits matter, but I'm afraid the EOB recently has been so difficult to manage on my end of things that I really think it's going to have to be changed. For the purpose of conducting this conversation, please look at the claim I've just received with check #32711005. I've attempted to xerox this although it's a little too big for my machine.
The first of these two patients have Medicare, or at least she is over 65, the second doesn't have Medicare. On other claims, I believe I have noticed a difference in the way Blue Shield 65 Special is handled from the regular business EOB. In this case, it's the Major Medical coverage which is being reported. It is particularly vexing to me that I have made so much of an issue of piggybacking actually occurs.
The problem which I as participating physicians am faced with, is that I have no way of telling from this EOB how much I'm entitled to balance bill this patient and how much I should write off as a discount. I do realize that this printing is on a form where the pre-printed columns don't correspond to the output, and I presume that there will be a forms change soon. However, even making allowance for this, I have absolutely no way of judging what the original charges were, what the allowance is, therefore what the discount or billable balance might be. The message codes in the far right-hand column are entirely mysterious to me and the reverse side of the form has no explanation for them. Even if it did, it would be far better for the computer to print out an expanded legend at the bottom rather than trust the recipient to be able to match the front of the paper with the reverse.
I'd like to propose that Blue Shield form a committee, with me as a member and preferably as chairman, to analyze the interface between Blue Shield and the providers. Might also include the claims form, although it's true that the EOB alone would be quite a lot of agenda material for quite some time.
You should also know that I'm beginning to feel that a separate corporation should be created to interface between Blue Shield (plus all other carriers) and the providers. I'm familiar with the limitations which Medicare imposes on intermediaries to maintain an arms-length relationship between the payment process and the billing process. At the same time, the providers are working with a certain amount of antitrust concern about banding together. It is beginning to seem to me that the creation of an intermediary corporation is going to be the only way out of this since the construction of workable protocols will be mandatory for any sort of electronic interface.
I really have a serious concern that the whole payment mechanism is in danger of breaking down. If I've got this much trouble with it, I can scarcely imagine what most of my colleagues are doing. If Blue Shield of Pennsylvania is having this much trouble, I can scarcely image what the smaller carrier is struggling with. Both sides of this equation have built up jerry-rigged systems by patching together a succession of colleges. When the House Ways and Means Committee issues new policy directives toward the end of each year, the programming community finds itself with no time to make radical adjustments; understandably, they look for quick and dirty solutions. Stir in a little Ralph Nader and a little bit of sensational newspaper reporting, and you have the making of a humongous mess when the subscribers start to howl.
I'm serious about both the committee and the separate corporation. I'd like to discuss this with you further at the PMS annual meeting, and with Sam Ross, if he is willing to talk.
With very best personal regards,
George R. Fisher, MD
Originally published: Friday, November 02, 2018; most-recently modified: Thursday, May 23, 2019