Published - November 2003

By Dave Jakielo

Thoughts, Questions, and Ideas

This past September I celebrated my 32nd anniversary of working in the healthcare field. I got my start as a cashier in a hospital in Pittsburgh, Pennsylvania. Little did I know that I would spend my entire working life (and my entire life working) in the wonderful world of healthcare reimbursement.

In honor of my longevity in the industry, I've decide to share some of my insights about the system, raise some questions I still have, and propose some ideas to help ensure we'll continue to enjoy the best healthcare money can buy.

THOUGHTS TO PONDER (These may be too profound)

  • The medical reimbursement system in this country is so complex that millions-no, let's make that billions-of dollars are wasted just trying to move money from one bank account to another. If we redeployed all the dollars we currently spend on the administration of the reimbursement system and invested them in research and development, we probably would cure many of the diseases that plague us today. Our current system is made up of employers, insurers, actuaries, and reinsures, all of whom add absolutely nothing to the true issues that make sick people get better or keep healthy people healthy.
  • The entire medical billing industry exists because of the screwed-up system we have created. You would think that a medical test is a medical test, but the 10,000-plus insurance companies in the United States came up with the bright idea to require something called a modifier, or local code, to ensure that no one without a Ph.D. would be able to figure out how to submit the test for reimbursement.
  • If prescriptions drugs are so much cheaper in Canada, why don't we just merge with them? I see two major benefits. First, we'd have more affordable prescription drugs, and second, we would only have to listen to one national anthem at hockey games.

    QUESTIONS TO PONDER (These may be too heretical)

  • Why is medical-procedure coding so complex? Because of the complexity it has created an entire career path for people who must become "certified coders."
  • Why can a person who is not a trained medical professional decide if a procedure or service is medically necessary or not? They should try living with a marble up their nose.
  • Why are there five levels of service for an office visit or emergency-room visit? Even if you follow the all the rules, which are "subjective" in nature, you have the same odds of winning the Power Ball lottery drawing as you do of coding each case correctly.
  • Why does healthcare have its own coded language? To make a claim, you must deal with the HMO who sends you an EOB or refuses to send you an EOB because of the COB potential. All the major rules are written by CMS and interpreted LMRPs which are enforced and investigated by the OIG or the FBI. So my question is, who was the SOB who came up with all of these acronyms?

    IDEAS TO PONDER (These may be too simple

  • Every insurer should be forced to issue a smart card to its subscribers. The information on the card would indicate patient eligibility, co-pay and deductible amounts, plus indicate what services are covered. Cash would be transferred into the healthcare provider's bank account immediately after a service is rendered and a CPT and ICD9 code is entered into a terminal similar to what is used for any major credit card transaction.
  • When a doctor wins in court and a jury decides the doctor didn't harm a patient, I think lawyers should have to pay millions of dollars for the "malpractice" of law and for tying up the court system with frivolous cases.
  • I think we are getting closer and closer to universal coverage. Why should one person have an advantage over another for access to healthcare? Today, coverage and access to care is based on whom you work for and how generous a benefit package you have been offered.

    Some of the above may seem disheartening or overly complex, but keep in mind, even with all its problems, our healthcare system is still the best anywhere in the world-even if you don't have money. Whenever I need care, I'm sure glad I'm here in the good old U.S.A.

    Send your questions and comments to Or I can be contacted at Seminars & Consulting, 86 Hall Avenue, Pittsburgh PA 15205. 412-921-0976.

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