Medically Unbelievable Edits

The agency that processes Medicare claims, the Center for Medicare and Medicaid Services (CMS), came up in 2005 with a computer system designed to lower the number of claims paid out to fee-for-service providers that are paid in error. For example, if a doctor submits a claim for performing an appendectomy say, and accidentally a typographical error is made on the claim form—hey, come on, it can happen!—and, for example say, a two is put in the box for the number of procedures done instead of a one, well, CMS wants a way to catch that kind of error before sending a check out paying a doctor for doing two appendectomies on the same patient on the same day.

They initially named this project “Medically Unbelievable Edits” (MUE). Kind of a humorous name, I think, when you think about some of the mistakes that the system might uncover. Apparently though, they ended up changing the name last spring after they got "into it" with some providers at a feedback meeting last spring. Now they call the project “Medically Unlikely Edits” (MUE). How clever, they don’t even have to change the initials of the acronym.

When I reflect on the name change, I can see the logic in it. While it does seem unbelievable that an individual patient could have two appendixes that would need removing on the same day, anyone that has practiced medicine for any length of time knows that you can never live long enough to see everything there is to see. The human being and this world in general has just got some awfully strange, unusual, and let’s face it, occasionally downright bizarre things in it. Never say never, unlikely is a better word than unbelievable.

Personally, what I find unbelievable is that Medicare has been sending checks out to doctors when obvious typographical errors have been made on the claim form. I mean, sending out a check for taking out more than one gall bladder, or appendix, or uterus, or whatever is, well, unbelievable to me. Obviously, no one looks at these things.

Now at least they are getting a computer to do it. The problem with that is, since the computer doesn’t have a brain, it is going to end up thinking a mistake has been made when it really hasn’t and then deny paying a doctor when the doc legitimately should be paid. Too bad a real person can’t just do this stuff, it seems like it would be so much simpler.

At any rate, I’m glad the term “Medically Unbelievable” is gone. No one who actually does medicine thought that one up. If you have been around long enough, you know there is nothing medically unbelievable. I guess that’s one of the many reasons I like medicine.