At Cardiology Consultants of Philadelphia, one of the region's largest specialty physician groups, the expensive quest to get paid by dozens of insurance companies begins days before a patient shows up for an appointment and can take weeks or months.

It's a quest repeated in doctors' offices and hospitals everywhere, one made more complex and time-consuming by America's hodgepodge of insurers. Each has its own rules and procedures, rules so complex that Cardiology Consultants produced a 100-page how-to manual just for front-desk employees.

We all pay for the ensuing bureaucracy through insurance premiums and taxes. And the heart doctors in this practice have had to organize their business around making shortcuts in the labyrinth.

Before appointments, employees at Cardiology Consultants start calling patients to make sure they have a valid insurance card and a referral from a primary-care doctor, if needed. Without those, any hopes of filing a "clean" claim that is paid quickly are doomed.

Weeks later, 18 employees in a cubicle-filled central office on North Broad Street are still making calls on 17 percent of the claims, fighting denials or figuring out why there's been no response to a bill.

In between, the 78 doctors and 350 employees spend hours talking with insurance companies about which drugs patients can take and which tests they can have and where they can have them.

Workers do their best to collect co-pays that have grown as businesses have shifted the cost of health to workers. Co-pays for an office visit are as high as $75, a sacrifice for elderly patients with heart trouble. One managed Medicare plan charges a $150 co-pay for a stress test. At its 18 offices, the practice handles a million dollars in cash a year.

All in all, Peter Jannelli, executive director for Cardiology Consultants, estimates that 45 full-time employees do nothing but make sure the doctors get paid for their 230,000 patient visits a year.

"Chasing money," Jannelli said. "You're chasing your money all the time."

American doctors and hospitals have to employ far more billing clerks than counterparts in, say, Germany or Canada, Princeton University health economist Uwe Reinhardt said.

"We have without any question the most complex, bureaucratic health system in the world. There is just no other nation that spends as much on paper and computers . . . just claims-processing. . . . To my mind, we get very little for that in terms of social value added."

The raucous health debate in Washington has largely focused on increasing the number of people who can afford insurance. The House and Senate bills recognize that bureaucracy is a problem, though, and address it primarily by standardizing billing procedures. The Congressional Budget Office estimates that standardizing insurance claim forms would save $8.8 billion in federal spending over 10 years.

"Streamlining administrative procedures will reduce cost and reduce the time and effort that go into getting coverage and getting care paid for," said Rep. Allyson Y. Schwartz (D., Pa.), who supports change. That would allow more of our money to be spent on providing care.

The stimulus package funds improvements in information technology that could simplify billing. There's no serious discussion of a single-payer system, and some lawmakers want to go in the opposite direction, encouraging more competition.

U.S. payments for health administration - 7 percent of our health spending - are twice the average of the Organization for Economic Cooperation and Development, 30 countries that share economic data. (That includes only spending by government and insurers, not doctors or hospitals.)

A study this year by the Medical Group Management Association found that "interaction" with insurers, other than for Medicare, costs medical practices $21 billion to $31 billion a year.

David Gans, MGMA's vice president for innovation and research, wouldn't release details but said a new study comparing the United States and Canada found much lower costs in Canada's single-payer system "because they have a single set of rules."

Susan Pisano, a spokeswoman for America's Health Insurance Plans, said the industry lobbying group does think doctors "have a legitimate concern, and we also want it to be more streamlined from our end."

New Jersey will soon announce a pilot program funded by insurers that creates a single billing portal for hospitals and doctors, she said.

That approach standardizes the format, Pisano said, but not the rules.