When I worked in Congress, one of my favorite cartoons outlined the legislative process. The cartoon started with a picture of a tree swing, representing a bill upon introduction. Each frame of the cartoon showed steps of the legislative process, which transformed the swing into something complicated and unworkable. The resulting law did not look anything like what was actually needed.

I was reminded recently of the cartoon while I was trying to compare various rates paid to physicians by different government programs. I wanted to use the information to convince the CalOptima board of directors to raise physician payments. Relatively new to the medical billing world, I knew I was in for some confusion. However, I did not realize just how discombobulated the entire medical billing world really is.

I wanted to compare four government payers--Medicare, Medi-Cal, the Medical Services for Indigents Program (MSI) and the Emergency Medical Services Fund (EMSF). Using 100 percent of the 2006 Medicare rate schedule as the base, I worked to get the rates paid by each program for the top 50 billed CalOptima codes.

To compare apples to apples, I had to determine at what percentage of Medicare each program paid. Because MSI and EMSF paid a percentage of Medicare, it should have been easy. At the time, MSI paid 70 percent of Medicare while EMSF paid 90 percent.

Unfortunately, both MSI and EMSF were not paying off the 2006 fee schedule, but one for an earlier year. Then, when I thought I had made the proper adjustments, I found out that I should not have used the local Medicare payment schedule because MSI and EMSF payments were based on a national average. Huh?

Then, I set out to compare Medi-Cal and Medicare. At the time, CalOptima was paying physicians 147 percent of the Medi-Cal rate. The problem was that the 147 percent rate paid was based on the 1999 Medi-Cal fee schedule, not the 2006 schedule.

Now, CalOptima recently changed its base rate and moved to the 2006 Medi-Cal fee schedule, but it lowered the percentage to 120 percent. According to CalOptima's calculations, 120 percent of the 2006 fee schedule was close to 147 percent of the 1999 fee schedule.

The result of my comparisons for the top 50 codes was a mixed bag. While some codes faired better, many were paid at a lower amount. It was not easy to tell whether 120 percent of the 2006 Medi-Cal fee schedule equaled 147 percent of the 1999 Medi-Cal fee schedule. It varied by specialty and code. For some, the change looked like an increase. For others, it was a decrease in reimbursement.

After living through this process for several weeks, I concluded that medical reimbursement is more confusing than I ever imagined. Jack Lewin, MD, the former CEO of the California Medical Association, would often tell physicians that the system was purposely created to cause confusion so that they would just accept what was paid without asking questions.

The CMA ultimately filed RICO lawsuits against the large health plans because it determined their payment practices were not proper or fair. In fact, the case for unfair payment practices was so strong that several defendants reached settlements with the CMA. Not only have the health plans paid millions back to physicians, they have changed their practices.

While the RICO settlements represent a positive change in the medical billing and payment environment, there is still a long way to go. The reimbursement process needs to be simplified. No more modifiers, geographic factors, base percentages, annual code sets, etc. Oh, to dream.

Perry Cain is public affairs and communications director at the Orange County Medical Association. He can be reached at 714/978-1160 or pcain@ocma.org.