Morons And Monkeys...

 Yeah, I'm a cranky old bastard.  

Kinda surprised me too.  I still find great joy in technical problems - and solutions to them.  So I guess it's kind of a quadruple-edged sword with the work I do these days.

I am not exactly certain where it happened, but I joined my present employer three years ago.  And for the first eighteen months and two weeks, I was the new kid.  I could look around the room and see all the folks whose experience greatly exceeded mine.  Then, about ten months ago, now, I got moved.  

Actually, that's not literally true.  I've been pretty much in the same spot when I work for about the last eighteen months.  But actually eight months ago, word came down that my employer was assembling a...  Well, I don't suppose they still use the term "tiger team" but this was billed and sold as an elite team of professionals who do my job to strap into rocket sleds and take a ride into the company's future.  That is, our primary work process system, which was rather obviously assembled from bits and pieces that did different things that could be combined to perform the functions we need were going to be replaced by a system which is in the process of becoming something of an industry standard which is also leading the way into the future.

Now, if you've any experience in going to see your doctor, you are aware that, in about the last forty years, the field of medicine in general has been almost completely and substantially changed by the computer.  When I was a child, and even a young adult, one had medical records.  These records were fairly standard on paper, and were very often thick, massive files.  And I am guessing they often had to be purged as information was simply no longer needed.

That is, it wasn't, then.  It sure as hell is now.  Because all of the time there are things that are found that can be pulled from old records.  Symptoms from ten or fifteen years ago may very well today become the tip of the iceberg in diagnosing something that, today, we can treat, control, and sometimes even cure.

And those medical records are no longer on paper.  In fact, very rarely at all.  

And my day-to-day job goes along the lines of doctor says you need this therapy, and my employer has people who can deliver it and make sure it's working to fix that which ails you.  My job in that giant puzzle is to take the information from the doctors who have seen the patient and make sense of it in terms of delivery of the medication.  We very often hear that patient X has infection Y, thus drug Z is required.  Which is where I turn around and look at your insurance coverage.  Actually, I do not do that.  We have other people that confirm you have it, it is in effect, it will, in theory, cover the therapy the doctor says you need, and my job is to tell your insurer, whom you shovel a fair amount of money to through your employer, who also contributes, that this doctor person says you need this.  The doctor in fact has documented the reasons, all of the things that they've found that brought them to their conclusion, and I get to ask the insurer if it so pleases them might they possibly consider maybe paying us for the stuff we're send to their customer to keep them alive so they can keep sending their money to the insurance company?

Yeah.  Day in and day out I am confronted, either through a login to a portal or an automated telephone system greeting, that authorization is not a guarantee of payment, but rather a statement that the insurer may have believed at a point in time that the therapy may be considered medically necessary.

And some of those insurance companies are really good.  We present the bill to them, along with the little batch of numbers/letters that they gave us to indicate that the specific combination we provided was reviewed and considered a legitimate medical treatment that could help the patient endure and or recover from that which the doctor has determined they had.  

Getting back to systems, my employer currently has a large group of people who are still working "the old way".  It's a group of systems and a collection of processes which I learned and did well for several years.  But back as of early May this year, all of that changed.  And I was part of a team which was going to assist a few of our locations in getting used to this new system and figure out how we would convert the rest of the company's operations from this vast collection of pieces that kind of did what we needed them to do to a system which was designed from the ground up to work with medical practices, operations, patients, and processes.  

And it has been a huge mountain to climb from our side of the world because most obviously our functions were so poorly or utterly misunderstood that the tools we need and the features which will make us much more productive aren't there yet.  And there very obviously are features which were designed for organizations of some significant size, but very clearly certain features have not been fully considered or thought all the way through for organizations as big as we are.

And some of my previous experience has come in quite handy.  

One of the critical functions we have is reviewing documentation, extracting that documentation which we need.  Let's say, off the top of my head, you are off at the cabin this past summer, you slipped and fell and scraped the heck out of your left knee.  And when you hit the ground, you hit a nice, soft, loamy spot right next to the rock which tripped you and scraped the skin off the side of your knee.  And you decided, since the scrape looked decidedly minor, you'd spray some sort of ointment on it and toss a bandaid over it.  And when you got home, you noticed the wound hadn't yet sealed, but you washed it, poured some rubbing alcohol over it, howled like a wolf at full moon, and re-bandaged.  After a few weeks, the problems persisted.  You made an appointment to see your doctor.

And when you got to the doctor's office, the nurse took a look at the wound, shook her head, and waited for the doctor.  She came in, took a look at it, and decided you needed some antibiotics.  You got two shots in the hind quarters, a prescription for oral antibiotics, and you were told to return in two weeks, or call if things looked worse.  

If you're thinking any of this sounds somewhat familiar, you're damned right.  Rather than slip on a rock and land on a soft spot, yours truly kept banging his shin on the trailer hitch he had, himself, installed on the car.  He had installed it because, well, he thought it would be a good idea.  And so how the hell he kept forgetting it was back there, well, I am idiot.  

But 72 hours after I got those two injections of antibiotics and was taking oral antibiotics, things were actually getting worse.  So my wife called, and was told to have me swing by to see the doctor.  But, oh, hey, the doctor did not have immediate openings right that day, could I just stop by the hospital, where she was doing her rounds?  And, what the heck, it's convenient, so just stick my head in the ER and let them know that I need to take up one of their precious waiting room/beds for a bit while the doctor sees what the hell I have done now.

Which is how I landed in the hospital for ten days, and still to this day have a hole about a half-inch deep in my left shin that's about the size of a golf ball.  

But we're not talking about that experience that was helpful, we're talking about my technological know-how.  Because we usually receive orders and files from doctors, hospitals, and health practitioners of all sorts via fax.  Yes, that's right.  Except these days, that process is typically done via computer networks and computer-connected fax "machines" which generate documents in PDF format.

And here's where we get into an odd, strange, sticky legal area.  Once a doctor has signed a document, I am not allowed to modify, change, mess with, or in any other way alter it.  

Except that on occasion, some ... less technologically intelligent individual makes what we in technology term as "really stupid fucking mistakes" and things go wrong.  And I see it daily in our archive management system.  Many documents in our new system are stored in bog-standard PDF format.  This is a massive improvement over our old system, where documents were most often stored in TIFF format, but could be in PDF, word Docs, Excel spreadsheets, JPG images, PNG images, or the high holy terrifying documents, the PDF with color photographs.  I very rarely ran across these, but they still make me shudder.  

An Abscess is a hole in body tissue that is usually infected.  These are almost never right out in the public portion of the body.  They're almost always in a covered or easily hidden spot.  Mine happens to live on my lower leg, which is why I very very rarely wear shorts any longer.  But I have had to scroll past images of abscesses on body parts that, frankly, no one really wants to see.  Even if they are medical professionals.  

But when documents were converted from our old to our new archive system, some of them were ... well, let me just say that whatever was done to these nice, innocent documents should never be done to such innocence, the raw, careless destruction to simply move from one spot to another and not do the conversion properly, well, hell.  I've been working in that new system for a few days short of five months now, but I have yet to determine exactly what format they've been smashed into now.

But the desperate need to be able to create exact screen shots to use for various training materials and other documents, well, here is where the rubber really hits the screen.  Yeah, I'm abusing metaphors.  You new here?

That's right.  I, with the best of all intentions, have to resort to a practice which is utterly likely to be skirting the very gray edge of legal.  And while it is absolutely forbidden of me to modify or alter the original documentation, I am not presenting an altered or modified document.  I am, however, presenting a virtual representation of a document which is, and remains, virtual, and due to the necessity of processing deadlines and our inability to go back and change the past, well, I have a method.

And you do as well.  If you need to capture something exactly as it appears on your screen, you can very simply press Control and Print Screen at the same time.  Once you have done this, you can start paint.  No, not grab a can of paint, but go to your Start Menu, find the Paint program, and once it comes up, press Control and the letter V.  No, it doesn't have to be capital V, a lowercase v works just as well.

And, to help you remember the v, voila!  That is, we did magic!  You just pasted a picture you took of your screen into the paint program!  Oh, sure, I have three other tools on my work computer to allow me to actually select the portion of the screen I want, but with the paint program, you can select what you want to keep from the image you took, copy it, and paste it into a new image - then paste it into a word document.  

Which is the process I use all the time to extract these un-extractable documents from our archive and create a new PDF which I need.  And as it is an exact representation of the original document, I have not in fact committed any sort of forgery, modification, alteration, or changed the document in any way.  What I have done is rendered it back into a transmitable, usable document, which was the intent of the ordering physician when they transmitted it to us, as they intended for us to be the agents to provide the medication to go from the container into the patient's body.  

So my mis-spent youth in the technology field, all twenty years of it, has come in handy to aid me and many of my coworkers who know that trick and can now use it.

Which is why today's little impromptu team meeting came with an out-of-the-blue shock that was really nice to hear.

Our team, which is currently about 20% of the folks who do this job, and we're responsible for about 30% of the work getting done (you will note that there's a bit of a difference, as we're fewer people, and we're doing more work), were informed that, rather than the continued bad news we had been fed by our higher-ups who recognized we were doing everything we could but we were seeing the roadblocks and the problems deserved some encouragement, as we were, in fact, outperforming expectations.  That is, while certain phases of the project have been delayed, those delays, we've been informed, are BECAUSE of what they've learned through our experience, and it will improve the future rollout of this new system and process to my co-workers.  

So yeah, that was some nice news to hear.  And while, frankly, I'm still something of a bastard stepchild when it comes to the team I'm on, some of my tricks have helped some of my fellow teammates do more - and do it with less - which makes us all look pretty good.  

So yeah, I'm just keeping my head down, doing the job I need to do, and do it in such a fashion that I make sure that the people I help do not notice that everything we do in the background just flat out works.  Don't get me wrong.  We still have days, and insurance companies.  

Today I had one of those oh shit moments that left me not sure whether to laugh, cry, or scream.  Though at the time, screaming won out.

I had a patient who had traveled from home for medical treatment, another one of our locations took care of the patient for a while, and the patient returned home.  Now, I am still relatively knew at this job, and I am finding daily that there are others out there who know less than I do.  Why this continues to surprise me, I do not know.  But back a few months, when this patient needed some medications, we delivered them.  And it was my job to find out if we would be getting paid for them.  Yes, I know, we're supposed to do it the other way around, but until we get to a point where everyone can at least manage to schedule their illnesses and let me know at least a month in advance, the word "prior" in "prior authorization" means, at best, well, they ain't dead yet.  Some of our payers have rather liberal policies for what we term back dating, while others are far more draconian, and you are almost full-stop certain they don't live on the same planet.  That, or their own family doctors have not yet been trained in the identification of the "recto-cranial inversion" which I tend to encounter at least weekly.

And to get back to the point of my little story, a few weeks ago I asked a particular organization I do not regularly deal with if we might be able to get an authorization approved for services we were going to provide the patient when they traveled.  While we typically try to find this out before the patient leaves home, if we know ahead of time, sometimes we find ourselves surprised that the individual patient has relocated.

And in this case, it turns out that some folks were aware of the patient's plans, but their ability to speak, type, or communicate in any other way was severely, and quite possibly, totally eliminated - until I asked why we weren't informed.  Then these otherwise well-trained and highly intelligent people said "oh, we need to let you know?"  What, that your patient relocated by several hundred miles?  And you'd helped to prepare their travel packets and documents for the new doctor, but it did not occur to you to let someone in your own organization know this was happening?  Nope.

But I was the right dope here.  I called, and I asked a nice young lady if I could request an authorization of a few medical codes, which is how we go about doing it, for the patient's services.  We could ask for a medication by name, but most of these damned things have names that look like the wretched refuse of leftover scrabble tiles after a three-hour hard-fought game - so almost every medication we put in a person's body has a five-character code.  That will be the same code whether it's a generic or name-brand medication, if generics exist, and if there is no medical difference.  In some cases, the brand and the generic drug have different codes because, well, they're different.  In some cases, they do not, but the doctor might specify that the patient needs to receive only one specific version of the medication due to the patient's response.  Some medications differ between brand and generic, so ... well, you get the picture.  

And if you're getting a fairly common antibiotic like Penicillin, we would call up the insurance company's specific department for authorization, and ask for J0561.  And here's where the fun is.  Most drugs are delivered in doses that range from micrograms (1/1000 of a gram) to grams - though most are milligrams.  And let's say the doctor said you need to get three doses of penicillin daily, at 2 grams each dose.  

Penicillin is a relatively low-power antibiotic in the world I work in, so a 2 gram dose is still pretty small, even every 8 hours.  But I would ask the insurer if I could get approval for 42 units of J0561 and 42 units of S9502.  That second code is the stuff it would take to get the medication from whatever form it comes into the pharmacy as and put it inside you.  The number 42 comes from the number of doses - that is, if you are receiving the medication for two weeks, that's 14 days.  14 times three doses a day means 42, right?  3 x 14 also is 30+12, or ... 42.  And because penicillin is calculated in gigantic units, we don't have too many.  One "unit" of penicillin is 100,000 units - which is a bit like chasing your tail.  But in this particular case, 100,000 units is likely somewhere around 100 grams.  And since you're getting only 2 grams every 8 hours, we just need one unit per dose.

There are other medications with different unit sizes, which makes it tricky.  I very often see antibiotics in 500mg units - so a 2 gram dose might be 4 units per dose.  But as we work up the strength scale, the unit size goes down.  There are some antibiotics that are calculated in 250 mg units, some in 100 mg units, some at 100 mg, some all the way down to 10 mg, and one or two in 1 mg units.  So if you were receiving one of those higher-powered antibiotics, off the top, it's very much unlikely that you'd be getting it more than once a day.  So if a patient was receiving, say, a 750mg dose of one of these higher-powered antibiotics, for two weeks on a daily basis, I would have to request 10,500 units - because 750 units a day works out to 1500 units every two days - or 7 x 1500, which gets me to 10,500.  Or if you have a calculator like I do, you can do the math on that.  

But anyway, back to my story, I asked the nice young lady if I could get five specific codes submitted for approval.  She instructed me on how to do it, which in this case involved filling out a PDF form (I have an electronic tool to do that, I don't need to print it out and do it by hand), and then sending to their fax machine the form along with the signed orders from the doctor and the clinical records the doctor sends along to make sure that someone else looking at the documentation understands the doctor's reasoning for selecting that particular sort of therapy.

And so I sent off my documents.  And then got very busy doing other things, and forgot about that task.  Not completely, it would still sneak past my eyes every couple of days, usually when I was on hold with another organization who had neglected to do me the honor of responding to my request, so I would have to very literally beat my way through a computerized telephone menu to reach a live human who might be able to hear me, understand my request, and know how to dig into the computer to find the result.

Which is what I did this morning.  And I was able to reach a nice lady who had to give me the bad news that my request had been voided.  I asked why, and she said part of the request had been approved.  In these situations, I get to go onto the hot seat with my managers and explain what I did, what I was told, and why we would not be getting paid for the services we shipped out.

This happens at least once a day, and it is rarely a cut-and-dried situation.  Sometimes it is flat out the reviewer did not understand the ordering doctor's logic.  It's important to understand that very few of the people doing these front-line reviews are doctors.  They are most often experienced nurses under a great deal of pressure, and sometimes they flat out make mistakes. 

But when I informed my management of the issue, I was asked why certain specific questions had not been answered.  And since they were legitimate questions that had not occurred to me while I was on the phone, I called back.  To be fair, I am never just on the phone.  I typically have a headset on one ear, while my eyes and hands are involved filling out another form, working with a web site to submit a request there, or doing something else to endure the wretched hold music and continual commercial and legal announcements many of these organizations pack into their hold "noise" to keep us amused until a live human speaks to us.

So I called the insurance company back, and I asked another question.  Of course, when I call another large company, the odds are almost 25-75 that I'll get the same person I just spoke to.  I don't know how that is, but it worked today.  The woman recognized my voice, my name, and after we completed the necessary verification steps, I asked her my questions.  And she checked.  And then she came back on the phone, and I could hear the embarrassment in her voice. 

She hadn't read to the bottom of the notes on my case.  And in fact, it turns out that my request had not been approved - but not voided because it was not medically necessary.  Nope, way down at the bottom - rather than putting it at the top as most of the reviewers would do - they noted that the request had been voided because it didn't need to be approved.

In our world, that's called a "nar" - that is N - A - R - No Auth Required.  That means "hey, kid, go away, we'll pay for that if you submit the bill.  Always."  Happens with some less expensive treatments - though this particular one was right up near the top of the pole when it comes to expensive, but some companies have certain plans which will cover most anything - and had I phrased my initial request differently, it is possible the first person I spoke with might have checked to see if authorization was required - and it wasn't.  

So yeah, it's the little things.  But the good news for me was that a request that took a little longer to resolve turns out we'll get paid for anyway.

So some times, you do get lucky even in this business.  So it goes.