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Tag Archives: Medicare

Here is the Problem

ERP here again while WC recovers from the revelling in Boston Personally, I agree with medicare and insurance regulations that require that someone receive some REAL benefit in order to be covered for an admission to the hospital. Even the “social dispo” admits usually serve a purpose – preventing elderly or the otherwise helpless or nearly helpless from injuring themselves or insuring they get proper medical treatment like antibiotics or seizure medications. However, if you can be safely discharged from a medical AND social point of view (ie no admit-able diagnosis exists AND you can either care for yourself or someone is there to care of you (like in a nursing home), you should have to pay out of pocket if you (or your relative) demand you be admitted. You can’t just come in for “tests” or to see a “specialist” or to “recuperate”. I am sorry, if you are demanding and non-indicated admission, prepare to ante up. The other day I had several situations where elderly, demented, bedridden, and or chronically ill elderly people from nursing homes were admitted solely because the entitled relatives refused to allow them to be transported back to the home. They had no acute diagnoses requiring admission but their relatives had such a fit that the PMD’s acquiesced and admitted them. Now, the hospital has to try to recoup payment from medicare. This is an epic waste of resources and public health care dollars. Here is what I did. I documented that the patients had NO indication for admission and recommended the patient (ie family) be charged fully for the admission, thus destroying the hospital’s ability to bill medicare. My hope is that the hospital not even try for medicare reimbursement and instead submit their entire bill to the entitled family, and if they refuse to pay, send them to collections. Hopefully they will learn that there is no free medicare lunch. Who knows, maybe the hospital will reprimand me. Regardless, I had to do it.

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How Payments Affect Care

When an unconscious intoxicated multiple trauma patient was brought to the ED, we did a bunch of CT scans to look for injuries. Fortunately there wasn’t anything life-threatening. He was admitted and was later discharged in good condition. I then got a memo from the hospital several days later stating that Medicare would not pay for the CT scan of the patient’s cervical spine. There is a list of diagnosis codes for which Medicare will reimburse hospitals for performing a CT scan of the cervical spine. That list is contained below. If one of the selected codes is not on the patient’s final diagnosis list, then Medicare tells the hospital “tough luck” and pays the hospital nothing for the scan. As part of Medicare’s Conditions of Participation, the patient may not be charged for the exam unless the patient specifically agrees to the charges. When Medicare doesn’t pay, almost always the hospital gets stuck holding the bag. If a patient is a victim of multiple trauma and is unconscious, CT scans of the cervical spine are more likely to show significant injury. This study showed that in multiple trauma patients, CT scans picked up on 98.5% of fractures while cervical x-rays only picked up 43% of fractures. It is uncommon to pick up ligamentous injuries on x-rays or CT scans – generally need an MRI for those. If physicians choose to do a CT scan on an unconscious or poorly responsive patient, according to the “permissible” diagnosis codes, in most cases hospitals have to hope that either an injury or some type of cancer shows up on the CT scan. Otherwise, the CT scan won’t be reimbursed and the hospital eats the cost. What are the other options in multitrauma patients? We could just do only x-rays of the cervical spine, and, if negative, tell patients that everything is OK because the government won’t pay for CT scans unless you meet certain criteria. The 57% of patients with cervical spine fractures missed on x-rays will have all their medical needs met under the new health care reform measures anyway. Or, while bleeding to death and strapped to a backboard wondering if they’re going to live or die, we could give patients an ABN form to sign. “Medicare might not pay for this test, if Medicare doesn’t pay for this test, do you agree to pay the cost of the test yourself — assuming that you live, of course?” We could always perform x-rays on everyone’s necks first and make up notice some “abnormality on radiological or other exam of the musculoskeletal system” to justify the CT scan. That will be a 793.7 to all you CPT coders. We could just say that notice that the patient winced in pain when the neck was palpated – causing “cervicalgia.” That’s CPT code 723.1. Or we can just practice good medicine and let the hospitals get shafted by the system. Of course, if hospitals get shafted enough by the system, they end up closing or reducing services. Then access to care suffers. You get what you pay for. Do a search for “hospital bankruptcy closures” and see how often it happens. Here are a few examples. CT scan payments are just one example of the cat and mouse game that constantly goes on between those providing the services and those “paying” for the services. It is also an example of the “Golden Rule” – he who has the gold makes the rules. Things aren’t going to get better.

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My Interview With Mass

Mass left some questions in the comment section that I thought were insightful and added to the discussion about health care policy. So I’m treating them like an interview. 1) I’d like to know how Dr Whitecoat is an “Independent Voice for Emergency Physicians”? Does that mean that all or most independent ER docs are conservatives or Republicans or anti-HR 3200? It would seem so as there are plenty of references in his blog to the loaded phrase “socialized medicine” as well as (at times indirect) links to groups like CAHI (the health insurance lobby) or the NCPPR (a conservative lobby) or to other conservative blogs. Either admit you’re a proud conservative or give some left-leaning blogs and groups some links. First, I’m not, nor have I ever asserted, the “Independent Voice for Emergency Physicians”. That phrase refers to the magazine Emergency Physicians’ Monthly, and you won’t find a better forum in emergency medicine for emergency physicians to express their views. You could even submit an article and have it published if it was germane to the practice of emergency medicine. Dis me, but don’t dis the mag. I actually had to go look up conservative versus liberal qualities on a web site before I could respond to your challenge. I’d have to agree that if I had to choose between personal responsibility and government intervention, I’d pick the former. However, the news is replete with stories about how people and businesses, when left to their own dealings with the public, take advantage of others. Government intervention is necessary to establish and enforce rules by which everyone must abide. 2) How would WC doc define “socialized medicine”? Are patients in the VA system, or those who have Medicare or Medicaid part of such a system? Does it matter that Medicare patients have higher satisfaction than other insured patients? I would submit that if WhiteCoat Doc would term universal healthcare as “socialized medicine,” then I can call the present system, “Darwinian every-man-for-himself medicine.” Unwieldy, but accurate. Socialized medicine = publicly funded health care. Period. I don’t think that anyone can draw a line between “socialized” medicine and “single payer” medicine (in which government pays, but does not participate in delivery of care). The “golden rule” always applies – he who has the gold makes the rules. Look at the Medicare system now. The government pays for care, but conditions payment on a plethora of byzantine rules. Fail to follow the rules – even if you provide the care – and you don’t get paid. Technically, even though the government is not “providing” the care, it is orchestrating the care – sometimes on an “ubermicromanagment” level. Many people are content with Medicare because they get what they want at no current cost to them. Don’t forget that most people receiving Medicare have paid into the system through payroll deduction for all of their lives. I think that people in stories like this or this or this would disagree with your general assertion that Medicare patients have “higher satisfaction than other insured patients”. Being “insured” by Medicare doesn’t mean much if no providers accept it. Our Medicaid crisis right now is what Medicare will look like 10 years from now unless the system changes. 3) Is this blog written from the perspective of a professional concerned about his income, independence, status, the overall health of his patients, or some mix of these? While I too am a physician, I don’t believe that physicians’ and patients’ interests always go hand-in-hand. There is no shame in defending our incomes and status – let’s just not ...

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More Analysis of Healthcare Reform Bill

I put the blog on autopilot while I was away for a few days. I was a little surprised by the reactions to the Health Reform Bill post. My intent in posting that e-mail was to generate discussion and encourage everyone to actually read what our elected officials are putting forth as the law controlling our health care for the foreseeable future. I had planned to do a point-by-point analysis, but didn’t have the time before I left, so I picked the end-of-life issue to comment because the comments made by the person who created the e-mail sounded inflammatory. They were.  It seems as if the mere fact that I posted the e-mail meant to most people that I ratified all of the contents. Not true. However, some of the comments were still on point.  Had hoped that others would analyze the wording similar to what I did with the  end-of-life issue. Oh well. For those who did look at the bill and post specific comments, I want to address them. “Page 22: Mandates audits of all employers that self-insure! (Section 142(b))” Here’s the exact text: COMPLIANCE EXAMINATION AND AUDITS (A) IN GENERAL – The commissioner shall, in coordination with States, conduct audits of qualified health benefits plan compliance with Federal requirements. Such audits may include random compliance audits and targeted audits in response to complaints or other suspected non-compliance. The language “shall” is a mandate, it is not permissive. The wording of the remainder of the sentence is poor, but it appears that the mandate requires the commissioner to conduct audits of whether qualified health benefits plans are complying with federal requirements. Unlike Shadowfax’s assertion, the wording does not “require[] ‘random compliance audits and targeted audits in response to complaints.'” Instead, the plain language states that the mandated audits “MAY INCLUDE” random compliance audits and targeted audits. The language does not limit the audits to those vehicles and states nothing about the degree or extent of the audits. Little different, don’tcha think? Since Shadowfax also picked out the “All non-US citizens, legal or not, will be provided with free health care services” statement, let’s look at that one, too. Section 401 changes Chapter 1 Subchapter A of the Internal Revenue Code to impose a 2.5% tax on a portion of the adjusted gross income any individual who does not have acceptable health care coverage. The exact language is ‘(a) Tax Imposed- In the case of any individual who does not meet the requirements of subsection (d) at any time during the taxable year, there is hereby imposed a tax equal to 2.5 percent of the excess of– ‘(1) the taxpayer’s modified adjusted gross income for the taxable year, over ‘(2) the amount of gross income specified in section 6012(a)(1) with respect to the taxpayer. Section 6012(a)(1) of the IRS Code is here and it makes no mention of what the “gross income specified” should be, so I am unclear how the 2.5% tax will be computed. However, the language of the Act creates exceptions for certain classes of people who have to pay this tax. Those exceptions include (2) NONRESIDENT ALIENS- Subsection (a) shall not apply to any individual who is a nonresident alien AND (5) a “RELIGIOUS CONSCIENCE EXEMPTION” where individuals do not have to pay such tax if their religious tenets make them conscientiously opposed to receiving benefits of any private or public insurance. Another part of the Act, Section 246, states SEC. 246. NO FEDERAL PAYMENT FOR UNDOCUMENTED ALIENS. Nothing in this subtitle shall allow Federal payments for affordability credits [note: See Section 241] on behalf ...

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Highlights from the Health Reform Bill

These highlights were sent to me in an e-mail. I have not read the entire bill. However, I did check some of the highlights against the text of America’s Affordable Health Choices Act of 2009 (H.R. 3200) and they are generally on point, although some of the commentary isn’t entirely accurate. As one example, the Advance Care Planning Consultation in Section 1233 does not permit the government to “order” your end of life care, but only requires that a physician discuss the matter with a patient and denote the patient’s preferences (Section 1233(a)(hhh)(5)(A)(ii). However, the government does plan to establish a “quality reporting initiative” for end of life care that will essentially coerce physicians into doing what the government wants under the threat of being deemed a “low quality provider” if the physician does not comply. If the government states that “quality care” for end of life involves removing life support on patients that show no improvement after 72 hours, any physician that keeps comatose patients on life support longer than 72 hours will get quality “demerits” from the government. The government may then use those demerits to dock the physician’s pay or to post the physician’s name as providing “low quality” end of life care on some web site. Think about a tremendous database of physicians similar to the “HospitalCompare.gov” web site now. Because of Hospital Compare, hospital administrators strive to be at 100% “quality” even though “good” care may sometimes cause excessive costs without benefit, may be more likely to misdiagnoses and wrong treatments (I commented on this issue previously and the link to the actual article on a government website mysteriously went bad), or may even be more likely to contribute to patient deaths. Draw your own conclusions after reading the sections in the bill. Commentary (from unknown source) is contained below. ————– • Page 22: Mandates audits of all employers that self-insure! (Section 142(b)) • Page 29: Admission: your health care will be rationed! • Page 30: A government committee will decide what treatments and benefits you get (and, unlike an insurer, there will be no appeals process) • Page 42: The “Health Choices Commissioner” will decide health benefits for you. You will have no choice. None. • Page 50: All non-US citizens, legal or not, will be provided with free health care services. • Page 58: Every person will be issued a National ID Healthcard. (Section 163(a) – not entirely accurate – potential action, not mandatory) • Page 59: The federal government will have direct, real-time access to all individual bank accounts for electronic funds transfer. (Section 163(a) – not entirely accurate – potential solution, not mandatory) • Page 65: Taxpayers will subsidize all union retiree and community organizer health plans (read: SEIU, UAW and ACORN) • Page 72: All private healthcare plans must conform to government rules to participate in a Healthcare Exchange. • Page 84: All private healthcare plans must participate in the Healthcare Exchange (i.e., total government control of private plans) • Page 91: Government mandates linguistic infrastructure for services; translation: illegal aliens • Page 95: The Government will pay ACORN and Americorps to sign up individuals for Government-run Health Care plan. • Page 102: Those eligible for Medicaid will be automatically enrolled: you have no choice in the matter. (Section 205(b)(3)) • Page 124: No company can sue the government for price-fixing. No “judicial review” is permitted against the government monopoly. Put simply, private insurers will be crushed. (Section 223(f)) • Page 127: The AMA sold doctors out: the government will set wages. (Section 224) • Page 145: An employer MUST ...

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Many Doctors Opting Out of Medicare

This NY Times article notes that many patients who become Medicare eligible are finding that the “insurance rug has been pulled out from under them.” More and more physicians are dropping Medicare and patients can’t find physicians to take care of them. “The doctors’ reasons: reimbursement rates are too low and paperwork too much of a hassle.” There is already a shortage of internists in the US and the ones that are available are unwilling to accept new Medicare patients. Universal coverage doesn’t mean much if no one takes your insurance. The more I think about this, the more I wonder whether this is exactly what the feds are looking for. They keep taking 15+% out of everyone’s paychecks to fund a Medicare system that fewer and fewer doctors participate in – until everyone pays a lot of money to end up with little or no access to medical care.

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