from The Tennessean, September 24, 2002

 

CIMplify helps physicians fight insurance companies

Technology enables doctors to keep better track of patient billing

 

by Bill Lewis

Staff Writer

 

Stryker Warren, left, president and chief executive officer of CIMplify, joins Joyce Vollmer, vice president business development, and Jeffrey Heyer, vice president and chief information officer, in the company’s computer room.

 

 

FRANKLIN – In some ways, the most important piece of equipment in a doctor's office may no longer be the stethoscope or the X-ray machine. Now, it could be the computer that keeps up with patients’ bills.

Physicians are arming themselves with technology to level the playing field with insurance companies, which use sophisticated computer programs to review bills submitted by doctors.

Insurance companies such as Cigna say they use the software only to make sure doctors are paid properly. Physicians insist the programs automatically discard or reduce some legitimate claims, allowing insurers to keep money due the doctors.

But doctors are fighting back with computer programs of their own that check for signs that an insurance company unjustly cut or ignored a bill.

One sign that this battle is heating up is the creation of CIMplify, a Franklin-based company that has already provided information used in one lawsuit against an insurance company.

“Doctors are under-gunned when it comes to dealing with Cigna or the Blues (BlueCross BlueShield),” said CIMplify President and Chief Executive Officer Stryker Warren, Jr.

The growing tension has resulted in lawsuits against insurers in a number of states. In Tennessee, some individual physicians and the Tennessee Medical Association are suing four large insurers. An individual physicians practice in Nashville, Urology Associates, is waiting for the Tennessee Court of Appeals to say whether its own lawsuit against Cigna can move forward.

CIMplify provided the information that Urology Associates used in its lawsuit, said Dr. Charles Eckstein, president of Urology Associates. He is also an investor in CIMplify, founded in 1997 by urologists who practice medicine in several states.

The company, originally named Urology Healthcare Group, adopted its new name July 1. The first three capitalized letters of CIMplify (pronounced simplify) stand for Computerized Information Management.

CIMplify offers a menu of services to help physicians manage their businesses. Its computer programs do something that should be simple, but isn't.

“They can help you see what you billed and what they paid you,” Eckstein said.

To do that, physician practices use a secure Internet connection to send their information to CIMplify’s central billing office on Cool Springs Boulevard here.

“It's like they're in the next room, but they're in Nashville,” said Dr. Fred Wolk, a Los Angeles-area urologist who turned his billing over to the company three years ago.

Previously, Wolk had a complaint familiar to many physicians. When he submitted a bill to an insurance company, he was never certain of being paid the amount he believed his contract promised. Sometimes, he said, he couldn't count on being paid at all.

“They delay-pay, under-pay and hope you don't catch it,” he said of some insurance companies.

“They say ‘we never got it.’ You FedEx it. Six months go by and they pay 80%. It becomes too expensive to go after the other 20%,” Wolk said of the business practices of some insurance companies.

CIMplify uses “major horsepower technology” to uncover such practices, said Jeffrey Heyer, the company's vice president and chief information officer.

Many doctors give up and accept whatever amount of money an insurance company sends them. “We don't do that,” Heyer said.

The insurance industry acknowledges that it uses special computer programs to review bills submitted when doctors treat patients. But companies deny claims that they use the programs to filter out claims unfairly.

Cigna, for example, uses a program called ClaimCheck to screen claims. The program reviews the thousands of five-digit codes used to describe medical procedures. When it sees a conflict – such as a hysterectomy code on a bill for a male patient – it rejects that portion of the bill. It also kicks out claims that should already be included in bills for other procedures.

Cigna says it processed more than 110 million medical claims last year and paid most of them as submitted.

Even so, the company is a defendant in a lawsuit filed in April by the Tennessee Medical Association. The 6,600-member physicians group also sued BlueCross BlueShield of Tennessee, United Healthcare and Aetna.

The lawsuits accuse the insurers of reducing payments without justification, a process known as “downcoding,” and failing to pay portions of claims by “bundling” them together.

The companies said the allegations were not justified. Blue Cross pointed out it pays 22 million claims a year, but in the past six years health-care providers have filed formal disputes involving just 1,000 claims.

Cigna said it uses ClaimCheck to fight fraud, which in 2000 ranged from between a projected $39 billion to $130 billion.

“ClaimCheck is an important tool we and many other health plans — and the federal government — use to prevent overpayment and keep health-care costs affordable for consumers,” a statement from the company said.

Joyce Volmer, the CIMplify vice president whose research contributed to the lawsuit against Cigna by Urology Associates, said technology can reveal where the money is, and isn't, going in health care.

“Double-digit premium increases,” she said of the higher insurance rates. “Employers say ‘we can't afford it and now you want more.’ Doctors aren't getting the money.”

Wolk, the urologist in Los Angeles, said his focus is on consumers, too.

“We're trying to see patients and do a good job,” he said. “Let me get on and practice medicine.”