Jay Edelberg, MD, FACEP & Caral Edelberg, CPC, CCS-P

50 Years, 50 Voices Transcript

Recorded July 2021

Jay Edelberg: Well, believe it or not, I always thought I was going to be a dentist and went to dental school. Then I went to an oral surgery program down here in Jacksonville, and my director got terminated, so I didn’t want to stay in that program. I had been encouraged by some people at University Medical Center at Jacksonville, which is now Shands, that I should go to medical school, so I called back the University of Connecticut and they accepted me, and I went back up there and got a medical degree. Then I came back down for my emergency medicine residency. (The year) was 1976-78, and (Dr. John) Stimler was my senior resident. I considered him a mentor.

It felt good (being in EM), and the senior residents above me were very knowledgeable. There was just one year of residents, and I came in as a new resident. It was a great experience; I learned a lot. That was in the days of “see one, do one, teach one” – we didn’t have a formal curriculum, so I’d watch Dr. Stimler put in a test tube, and then I’d have to do it in the next patient. It was just touch and feel. It wasn’t a bad way to learn! I think a lot about the doctors coming up now who are all trained technologically: “what’s the CT show? What’s the lab work show?” We were just hands on, winging it.

When I was a resident, I went to an FCEP educational course, and I got talking with people. Then they asked me to run for the Board, so I became a Board member when I was resident. I mean, it was just weird how things happened, you know?

When I was a senior resident, I was driving by the Regency Mall in Jacksonville and saw this van plow through a bus stop. So I jumped out of my car and started rendering aid at the scene. A doctor came up, jumped in and helped me, and we got some people back. We had people in triage and off to different hospitals. When it was over, he introduced himself as a pediatric surgeon at Baptist Medical Center. He had been a doctor in Vietnam, so he had seen that kind of triage there, and he wondered where I got that understanding from. It was from my residency program. I told him I was a senior resident in EM – which, not many people knew what that was at the time.

About a month later, I got a call from the CEO of Baptist Medical Center, saying he wanted to interview me to become the director. Turns out that Dr. Harris was on the search committee! I was in the right place, right time. It was sheer luck – it was a Saturday afternoon, and I jumped in. So I went and I interviewed, and I was named the director of the ER of Baptist Medical Center, which I think was the biggest private hospital in town at the time, and I was still finishing my residency. So I asked for 2 weeks off, July 1-14, and then took over. I’ll tell you that, as a young director in a new specialty, that actually wasn’t even a specialty in ‘78, I was either bold or foolish; I’m not sure which!

I spent a lot of time meeting with EMS. I’d break bread with them in their fire stations and I’d ride with them as they’re intubating people on the interstate or whatever. And I demanded that they let me hire a paramedic to work in the ER, which had never happened before. The nurses were very offended, but they got used to him, and it was less expensive. He was so well trained that he could start an IV and recognize a medical emergency, “hey doc, you need to get into room 2” – so the nurses really began to appreciate him. On the flip side, I really pissed of the director of nursing at the hospital. I’d go to these medical staff meetings and be on a committee or something, and they just despised me… I remember my chief of surgery stomped out of the room once saying, “I’m not going to come to any meetings as long as Dr. Edelberg’s in them,” so this is the kind of sh*t I took.

My CEO at Baptist was fairly new and came from Baylor, where EM was a little more advanced in terms of residents coming out. So he was convinced the way to grow Baptist Medical Center, i.e. market it, was to bring in some trained emergency physicians. So he gave me a greenlight on just about everything, and he’d sit me down and he’d say, “I know you didn’t quite handle that meeting well, but let me tell you what you could’ve done a little bit better to not piss off so and so.” He really mentored me as a medical director; not just a physician. I think had I been at another hospital, I probably wouldn’t have had that administrative training… I had no education in business or hospital administration.

For me, (FCEP) was an opportunity to meet other emergency physicians because we were a new specialty. Rather than being isolated in Jacksonville, I met people. In my 2^nd or 3^rd year on the Board, I drove all around the state and found doctors in rural areas and encouraged them to join FCEP. I put several of them on committees and put ACLS courses that they didn’t have access to on in their communities. (I wanted to) make them see that EM was real and that it really has something to offer. And I think that helped me personally grow.

I remember going to one rural (community) to put on a course and brought my son at the time, who was 10 or 12. We were at a schoolhouse at night and he helped me set everything up. I was doing the testing and I remember this big burly paramedic was trying to intubate. My son walks over and was like, “oh no no no…”

Caral Edelberg: My business is compliance and coding. We do coding, called projection coding, for hospitals across the U.S. We also do compliance auditing and compliance program management for a number of hospitals and groups across the country.

So much of what I’ve done in recent years has really been policy-related, you know, working with national ACEP to try and set policy on a number of committees. That’s been the most enjoyable because we take a huge issue, like we’re dealing with today, with United Healthcare denying all of these emergency medicine claims – I mean it’s happening across the country and costing a fortune to try and manage these denials, and they’re all coding correctly. But the payors have their own internal systems that allow them to downcode these things, so it puts the responsibility and pressure on these groups to go back and fight this. National ACEP is now sort of picking it up and fighting it. There’s a number of class action suits that have started with United and some of the other insurers who are doing this; they just make up their own rules.

It’s interesting because we, as providers – and I consider myself a provider because I’ve worked with them for so long – the coding guidelines were given to us. Payors are not tied to that. So when you assume that we’re coding for millions of patient visits a day across hundreds of facilities, each facility can tweak their guidelines to a certain extent. You have Medicare going their way, commercials going their way, Medicaid going their way – and the responsibility of people in the coding industry has become incredibly difficult, because it’s more than coding: it’s also advocacy. You can’t just code the chart and walk away from it; you have to fight for the pay. And when you think about how hard these emergency physicians work, and you look at what they get paid, for example, critical care, which is lifesaving, compared to what an orthopedic gets paid for saving a broken bone – it’s horrible! So we have to fight for every dollar, and you have to have the right people in place who know how to do that.

What’s interesting is that we have EMTALA, and we have prudent layperson that ACEP fought to have passed in all these states, and that was supposed to protect us. But when it protected us to the point that we were getting paid those higher dollars – and it did for a while – the payors reacted and said, “ok, we’re going to find another way. We’re going to say even though PLP is effective in this state, we don’t believe that that diagnosis qualifies as an emergency visit, so we’re going to pay you a very low amount.” But wait a minute; you’re ignoring the other diagnosis! And we’ve actually had experiences with some of these payors where they have guidelines and coders follow them to the letter, they agree that coders have followed them to the letter, and they deny the claim anyway.

(FCEP) has been very rewarding for us. Florida and California kind of led the way in the early years. My involvement with EM stated in the 70’s with the Findeiss group. We all worked together tirelessly to establish the specialty, and then fell into billing and coding, because the hospital one day said, “you have to do this yourselves.” I mean, this was before computers. It was all done on paper. It was all typed; all the claims were typed. We’re write in, “sudden, severe” in red on the claims to get them paid. We learned as we went. Now we find it’s highly sophisticated, and in many ways, that makes it more difficult because the payors have such amazing criteria on our use of the codes that they can compare you to other physicians in your specialty and your state and say you’re over-coding or under-coding, without acknowledging that you’re in a trauma center with higher acuity, out of nowhere. So physicians really have to know what they’re getting into. It’s unique and special to their facility.

I think it’s important to note for those of us at the end of the careers, that the rewards obviously were job-related: we built a specialty, we did. We built it from the ground up. We suffered all the pros and cons. But the biggest gift (of FCEP) was the ability to make friends. And when I say friends, we’re all family. We raised each other’s kids together. Not all kids are created equal; we had our ups and downs together. It’s been a community; it’s been a family. And in my opinion, that’s been the most amazing part, and particularly here in Florida, because we are so close. The guys all did their residencies together. Missy (Stimler) and I worked in other areas, but we were part of it. It’s the family, the friends that you make, and that we’re still close to. You don’t find that in every career; you don’t find that in every place.