Doctors are begging the federal government to simplify Medicare regulations, which they say are so numerous and complex that compliance is almost impossible.
Pointing to the 92 regulations HCFA has belched out on the Balanced Budget Act of 1997 alone, physicians said they can't keep up with the burgeoning workload.
"Those 92 regulations were about one-third of HCFA's entire task (in carrying out the budget law) and about 10 times anyone's absorption limit," said Brent Miller, vice president of public policy and political affairs at the American Medical Group Association. "They announce changes in many areas in Medicare, and unless you go through them all, you don't know which ones will affect you."
However, having been active in seeking the legislation that results in the red ink, physicians share some of the blame for making the Medicare payment as murky as it is.
"Physicians, over the years, have done this to themselves to some extent," said Larry Oday, a partner with the law firm Vinson & Elkins in Washington.
Take, for example, the issue of private contracting.
Physicians wanted the ability to deal directly with beneficiaries, signing contracts to deliver Medicare-covered services under terms independent of the Medicare program.
So they took the proposal to Congress, but they were disappointed with the results. The 1997 budget law Congress passed permitted such private contracting, but it prohibited physicians who did so from billing Medicare for any other patients for two years.
A later attempt at making the law more favorable to physicians fizzled (June 8, 1998, p. 27).
Physicians also complicated things for themselves with the practice-expense battle that raged in 1997.
Primary-care doctors successfully argued that the current system for reimbursing practice expenses such as office staff, equipment and supplies was unfair to them.
Specialists disagreed and tried to block the proposal because it would take money from them to pay the primary-care doctors.
When the budget law passed and the dust cleared, primary-care doctors had won a $390 million "down payment" on their practice-expense increase, leaving the physician lobby bitterly divided (Sept. 1, 1997, p. 24).
"Inside the Beltway, it's every man for himself, and sometimes we do it at the expense of each other," Miller said. "There are a lot of elements to the revenue stream, and if we don't pay attention, sometimes we find that we've nickeled-and-dimed ourselves to death."
This tug of war between simplicity and fairness most often complicates Medicare regulations.
"HCFA could come up with a wonderfully simple payment system," said one former HCFA official, who asked not to be identified. "But it just wouldn't be fair (to everyone)."
When policymakers are hammering out new rules, simplicity is usually the first thing to go as Congress tries to appease anxious providers.
"Simplicity is always sacrificed for fairness," Oday said. "The other thing simplicity gets sacrificed for is the need to crack down on fraud and abuse. The reason you have all those documentation requirements is because it provides a paper trail, so that HCFA knows whether it's fraud or not."
The result is a system in which minor complications have snowballed into a mind-boggling mire of regulations, some providers said.
"Part of the problem is that when you have a complex system, everyone wants to try and make it work for them," said Bruce Kelly, director of government relations for the Mayo Foundation in Rochester, Minn. "The more complex it is, the more everyone is looking for an exception. It builds on itself."
As Oday and others are quick to point out, HCFA has done plenty on its own to confuse physicians.
"There are many things that physicians have never asked for and have never been properly educated about," Oday said.
Without any cues from physicians or their lobbyists, HCFA also instituted its "correct coding" initiative. HCFA screens claims for certain red flags to ensure that providers are coding procedures properly.
The problem, Oday said, is that the list of red flags is not readily available. It isn't published in the Federal Register and is constantly subject to change.
"They're all hidden rules that are difficult for physicians to keep abreast of," Oday said.
One way HCFA could minimize many requirements and paperwork would be to establish a global capitation system for Medicare, according to Oday.
However, he said, physicians would never give up fee-for-service medicine.
"The federal government will always do what it has to do to please constituencies and make sure the taxpayers aren't getting ripped off," Oday said.
The former HCFA official agreed and said, "It would be very difficult to rewrite the rules at this point because there's an awful lot invested in the status quo."
What happens in the end is anyone's guess. Stephen Gleason, D.O., who led HCFA's Physician Issues Regulatory Team, resigned this month to take a position in his native Iowa. A HCFA spokeswoman said physicians' issues remain a priority for Administrator Nancy-Ann Min DeParle.