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Medical Billing, A President's Cousin, And The Pain-In-The-Butt Index

Every morning at 6 a.m., a mail truck arrives outside the headquarters of athenahealth. The truck is filled with other people’s hassles: box after box of medical bills and paperwork.

Jonathan Bush, the company's CEO, got into the health-care business in 1997, when he became co-owner of a birthing center. But he quickly figured out what doctors and hospitals already knew. Getting paid is a huge pain.

Say the patient is covered by Blue Cross. Which Blue Cross? Did she need a referral? What’s the right billing code?

"It became our obsession," Bush says. "We thought nothing about women’s health. We thought nothing about birth. We spent all our time screwing around with trying to get checks."

So Bush got into a different part of the health-care business: He launched athenahealth, a company that handles billing for doctors’ offices. (Bush, by the way, is a cousin of George W. Bush.)

These days, athenahealth processes about $1 billion a year in paper checks. Some are hand-written checks from patients. But a lot of checks come from insurance companies.

The insurance-company checks are printed out and sent through the mail.  Then they get opened, scanned into a computer, and deposited to a bank — in some cases, the same bank where the money started.

Still, only about a third of the payments Athena processes come via paper check. The rest are electronic payments. That’s in part because companies like Athena can call up the insurance companies and say, “What do we have to do get rid of the paper?”

Bush says some insurance companies have been easier to work with than others.

“We have this Pain-in-the-Butt index,” he says. “It ranks how big a pain in the butt all the different insurance companies are to deal with.” (Here's the complete list.)

Near the bottom of the list is New York state’s Medicaid program.  New York Medicaid requires claims be filed on special paper that has to be ordered from Albany. The form has to be signed by hand by the doctor.

Officials at New York’s Medicaid program say that this system helps prevent fraud.

“We believe that many of the difficulties that Athena has experienced in the past were the result of a lack of understanding of NYS Medicaid billing procedures,” the state’s Medicaid program said in a statement.

Bush says he understands why some of this is still such a pain to deal with.  Our health care system is complicated, with lots of insurance companies offering lots of different plans. And each plan has its own unique billing quirks.

There’s “a whole smorgasbord of little tidbits to know to keep in mind when treating this type of patient or that type of patient,” he says. “Because what health-care really is, is this awkward word slapped on top of a million little tiny markets.”

So even if the paper part goes away, the rules that govern things like what gets covered, and for how much, aren’t likely to get much simpler.  For Bush, that’s good for business.

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