News and Analysis (November/December
1999)
Inflammatory HCFA Notices
I reviewed the "new" non-inflammatory" notices
which the AMA says that they have finally convinced HCFA to use on Explanation
of Medicare Benefits (EOMBs) and find that these are the very same notices
our local Medicare carrier has been using for a number of years now. I fail
to appreciate, however, how the "new" notice stating "The
information provided does not support the need for this service or item"
is any less inflammatory than the "old" term "not medically
necessary."
The inflammatory nature of these little notices sent to Medicare beneficiaries is compounded by the fact that they are sent to the patient before the physician is given a chance to respond or dispute Medicare's determination.
Even if the physician is successful in reversing Medicare's adverse determination, the physician's reputation and the patient-physician relationship suffer damage which is not undone when the carrier sends a cryptic "adjusted" EOMB to the patient. Medicare has been systematically damaging patient-physician relationships and physicians' reputations like this with impunity for many years now.
HCFA Bureaucracy Unable to Keep Up
The AMA's testimony to the House Ways and Means Subcommittee on Health on
Feb. 11, 1999 contained a number of interesting comments. On page 3, they
state that "there is a growing sense among Medicare experts that HCFA
is ready to collapse under the sheer weight of its administrative duties."
Their administrative duties, of course, have been increased in recent years
by the HIPAA and the Balanced Budget Act of 1997. As one who writes to HCFA
frequently to complain about carrier bungling and abuse, this has been my
sense of HCFA's precarious position as well. HCFA has had extreme difficulties
during the past year or two keeping up with my voluminous correspondence,
and I'm just one person. Whereas my letters in the past would receive a
response within weeks, the delay is now usually months if they respond at
all. The same is true of the Medicare carrier. I've noticed recently that
they are also unable to keep up with responding to my correspondence.
Unfortunately, the AMA feels the solution to this mismanagement of the
Medicare program and lack of oversight by HCFA is to give HCFA more money
and hire more bureaucrats to do a better job of harassing more physicians.
HCFA Errs....Again
Just how abusive can Medicare's pre-payment audits get? Well, physicians
billing for high level office visits in the Kansas City area found out the
answer to that question earlier this year when some were required to produce
documentation on literally hundreds of patients. According to HCFA's director
of program integrity, it was all due to a carrier training session that
"had gone awry" (AMNews, May 3, 1999, "HCFA ends erroneous
claims review system in Kansas.") In their unrestrained zeal to make
physicians' lives as miserable as possible, the trainers apparently forgot
to tell the carrier trainees that "requesting information on 500 claims
from a single physician was not a good idea." Although HCFA admitted
the mistake, there was no mention of any reparation for the damage they
undoubtedly caused to the physician offices. This bureaucratic assault on
physicians is, of course, reminiscent of the description of the King's bureaucrats
in our own Declaration of Independence --- he has "sent hither swarms
of officers to harass our People, and eat out their substance." The
physicians who were subjected to HCFA's harassment and who have had their
substance eaten out are reportedly considering dumping the Medicare program
as a result of their experience.
New Jersey Physicians Reject Clinical
Pathways
In a bold stand against cookbook medicine, thousands of New Jersey physicians
threatened to boycott the state's new rigid treatment protocols that went
into effect in March --- the Automobile Insurance Cost Reduction Act.
"This is going to be a national model for how insurance companies
and legislatures can screw doctors and hurt patients. If they can get away
with this in New Jersey, they can get away with it anywhere. They're not
going to pay us to treat patients properly. This is the most restrictive
managed care system you can imagine" --- Steven Lomazow, M.D. (AMNews,
May 10, 1999).
Medicare HMOs Breaking the Law
Nearly half of the calls to the Appeals Hotline of the Medicare Rights Center
were for HMO non-compliance with Medicare rules and regulations. Violations
included failure to cover emergency treatment, failure to process appeals
in a timely fashion, failure to cover out-of-network services when appropriate
in-network services were not available and failure to provide other benefits
as guaranteed by the HMO's Medicare contract. No mention was made of any
adverse consequence suffered by the offenders who are members of the privileged
public-private partnership (AMNews, Oct 5, 1998).
This edition of News and Analysis was written by AAPS president-elect, Lawrence
R. Huntoon, MD, PhD. It appeared in the Medical Sentinel, November/December
1999, Volume 4, No. 6, p. 206. Copyright©1999 Association of American
Physicians and Surgeons.