Ten Dumb Things About Medicare

  1. Reimbursement – At least in my field, it is nearly impossible to run a practice off of what it pays.  Most physicians who are on Medicare offset its bad reimbursement with private insurance or procedures that are outside of Medicare.
  2. Prevention is discouraged – A person cannot come in if they are well.  They have to develop a disease before being seen.  They tried to fix this with the \”Welcome to Medicare Physical,\” but the rules were so laborious, it is nearly impossible to take advantage of this.
  3. Fraud Accusations – If you do anything that is not by the rules, you are defrauding the government.  This includes choosing to not charge any of your non-Medicare patients.  If I choose to make less money on my poor patients by not charging them I am committing fraud because I am not offering that same discount to my Medicare patients.  Docs routinely down-code notes to avoid coming under scrutiny for fraud.
  4. Part D – The pharmacy benefit has helped some people, but the concept of the \”donut hole\” has caused many of my patients to go off of medications they need.  The system is so complex with so many Part D plans that I never know if a medication is covered until the patient tries to fill it.
  5. Stupidity – Drug companies give discount cards or coupons to us to give to our patients.  Medicare patients cannot use these cards.  Obviously it is not in anyone\’s best interest for Medicare patients to pay less for medications.
  6. Balance Billing – We must always accept whatever Medicare says they will pay and not balance bill the patients.  I can\’t set my prices.  Furthermore, the other insurance companies pin their fee-schedules on Medicare\’s rates.  There will never be \”transparent pricing\” as long as this is the case.  We cannot charge what we choose to charge.
  7. The RUC – The RVS update committee sets the Medicare fee-schedule.  It is dominated by specialists, and so it protects the interests of specialists over primary care.  It is so tied to special interest groups that it is hard to believe it is used as an \”unbiased\” source of advice for the fee-schedule.  Actually, it is a travesty to the system.
  8. Dropping Out – If you drop off of Medicare as a provider, you cannot reapply for 2 years.  This stung us when we tried to hire a physician who had previously dropped off of the list.  He simply could not see our patients.  I am not sure I understand the rationale for this.  Are they just spiteful?
  9. Sustainable Growth Rate – On the surface, this looks OK.  If we can\’t afford Medicare, it automatically cuts the reimbursement.  The problem is that the cut will be equal across all areas.  This hits primary care extremely hard, making it even more difficult to afford to take Medicare.  Specialists can afford to have office visits reimbursed less because they make most of their money off of procedures.  Are they hurt too?  Yes, but they are not living on the edge like PCP\’s.
  10. PQRI – The new \”pay for performance\” system is a mess.  The system is based entirely on billing (by putting in special modifiers when you bill), and reimburses a very small amount.  Plus, you don\’t ever know how you are doing and whether you will qualify for the bonus.  I look forward to my $30 check…if I get anything.

22 thoughts on “Ten Dumb Things About Medicare”

  1. 5 start post. Excellent summary. We’re done. There’s nothing else to say. Just quit blogging. These are THE issues at hand. It’s amazing how nobody else is talking about them.

  2. 5 start post. Excellent summary. We’re done. There’s nothing else to say. Just quit blogging. These are THE issues at hand. It’s amazing how nobody else is talking about them.

  3. I feel for you and I am concerned that someday you will have to refuse medicare patients. Although, with our baby boomers aging that is a large population and so how can physicians afford not to take them as patients?
    It all seems so very complicated Rob and I don’t know how you all keep track of everything and still see/tteat your patients.

  4. I feel for you and I am concerned that someday you will have to refuse medicare patients. Although, with our baby boomers aging that is a large population and so how can physicians afford not to take them as patients?
    It all seems so very complicated Rob and I don’t know how you all keep track of everything and still see/tteat your patients.

  5. Seaspray, how can doctors afford *to* see patients when the reimbursement is so poor it is tantamount to doctors handing every Medicare patient $25 on the way out the door?
    The solution is to pay the doctors sufficiently so that their incomes can keep up with inflation/student loan escalation and still take good care of people by being given the time to do so.

    Yes, this makes the healthcare bill for the nation a lot higher, but just like gas prices, we have enjoyed artificially low prices for too long, and it has to come to an end unless you want to see a nurse practitioner for the rest of your life.

  6. Seaspray, how can doctors afford *to* see patients when the reimbursement is so poor it is tantamount to doctors handing every Medicare patient $25 on the way out the door?
    The solution is to pay the doctors sufficiently so that their incomes can keep up with inflation/student loan escalation and still take good care of people by being given the time to do so.

    Yes, this makes the healthcare bill for the nation a lot higher, but just like gas prices, we have enjoyed artificially low prices for too long, and it has to come to an end unless you want to see a nurse practitioner for the rest of your life.

  7. Does this mean that you would like to do away with the insurance industry and turn to a government run system? (Just a joke).

  8. Does this mean that you would like to do away with the insurance industry and turn to a government run system? (Just a joke).

  9. Yeah, I’m just being introduced to things like G codes and Q codes and all of that craziness, none of which I learned about in college. Medicare is so fussy about the “content” of the services they’re willing to cover, and the documentation has to be incredibly specific or they won’t pay a dime. It’s troublesome enough for those of us in medical records; I can’t imagine what a headache it must be for primary care docs like you…YIKES!!!
    I’m also learning that what you guys say on the blogs is really true; when you look closely at the numbers for primary care docs, the reimbursement rate stinks! Particularly since Medicare patients tend to be older, and at an age when the laundry list of chronic problems (and hence a doc’s workload) gets longer and longer. I’m only getting a sideways glance at it and it’s still not pretty. Don’t have a clue how to remedy the problem, though…it’s a complicated mess of yuck that will take a huge overhaul to really address it. And for all the things I learned about Medicare/Medicaid/CMS/HIPAA, etc., it just barely scratched the surface.

  10. Yeah, I’m just being introduced to things like G codes and Q codes and all of that craziness, none of which I learned about in college. Medicare is so fussy about the “content” of the services they’re willing to cover, and the documentation has to be incredibly specific or they won’t pay a dime. It’s troublesome enough for those of us in medical records; I can’t imagine what a headache it must be for primary care docs like you…YIKES!!!
    I’m also learning that what you guys say on the blogs is really true; when you look closely at the numbers for primary care docs, the reimbursement rate stinks! Particularly since Medicare patients tend to be older, and at an age when the laundry list of chronic problems (and hence a doc’s workload) gets longer and longer. I’m only getting a sideways glance at it and it’s still not pretty. Don’t have a clue how to remedy the problem, though…it’s a complicated mess of yuck that will take a huge overhaul to really address it. And for all the things I learned about Medicare/Medicaid/CMS/HIPAA, etc., it just barely scratched the surface.

  11. PQRI’s 1.5% bonus for Medicare patients is a JOKE! Although, PQRI is a very good tool to use as a GUIDELINE that shows where Medicare will be measuring patient outcomes going forward.
    Virtually every U.S. Industry is compensated based on quality. The U.S. Healthcare System has historically been the exception. NOT ANYMORE!

    A major realignment or restructuring of the U.S. Healthcare System began in 1996, accelerated in 1997 under the balanced budget amendment, and continues today under the Pay for Performance initiative. Congress calls it “value based purchasing,” but it is an effort to improve the quality of care.

    Every physician has felt the negative financial impact of these changes, as revenues have been reduced for office visits, procedure complexities, and therapies.

    Specialist’s are earning 2:1 over the primary care physician. On average, specialists are earning near $300K while the PCP earns roughly $150K, sometimes LESS! Do you know why?

    It doesn’t make any sense considering there are more ICD-9 and CPT codes available in the primary care setting. It’s because the U.S. Healthcare System has changed… it has “moved” money away from office visits and therapy, and shifted it towards patient outcomes. Reimbursements are down, costs are rising!

    As a result, physicians who continue to operate as they have in the past are feeling “financially” squeezed! In attempts to offset their losses many are working longer hours seeing more and sicker patients, while earning less. They are also trying to reduce nonessential services and overhead by working with fewer people, in less space. Then there are some who are choosing to decline services due to capitation issues. None of this helps! Do you know why?

    Because the Healthcare System knows most PCP are “flying under the radar” by operating in “waived” settings and avoiding the responsibilities that accompany providing quality care. The money has been moved to three main practice areas- diagnostics, imaging/radiology, and clinical lab. The idea behind the shift is to improve patient outcomes by placing money as an incentive for PCP to uncover asymptomatic illnesses before they become chronic disease states and cause catastrophic costs to the overall system.

    The trick is to align your practice within the changes that have taken place in the healthcare system. By align your practice, I mean according to your specific patient base and data requirements to ensure the additional revenues generated will greatly exceed the cost of change. (e.g. “addressing the baby boomer comment previously stated” If you are seeing 3 elderly patients per week with dizziness symptoms, Medicare reimburses $450 per procedure for VAT/ENG testing which is used to prevent future falls. Buying the box costs $700 per mo. So figure an increase of $5200 per month or $60K per year!) I know it seems stupid to offer FREE information like this when I can sell it, but that’s what I do! I help physicians address the problems within the primary care setting and I’m structure to be compensated by the medical distribution companies who are STEALING your money. I don’t charge physicians a consulting fee, they pay enough out already! Sorry this is just one example. Every situation has specific needs and this may not be beneficial to your practice. I can tell you there are many different ways to improve patient outcomes while enhancing NET revenues. It’s just a matter of knowing what to do for your specific patient base and volume requirements.

    Trust me when I say this, almost every PCP practice seeing 25+ patients per day, including the solo practitioner can increase their income by $125,000.00. It’s just a matter of OPTIMIZING their practice!

    http://medicalsource.biz/free-practice-analysis.html
    Have a personal pro-forma built, based on medical necessity, for each individual area of your practice.

  12. PQRI’s 1.5% bonus for Medicare patients is a JOKE! Although, PQRI is a very good tool to use as a GUIDELINE that shows where Medicare will be measuring patient outcomes going forward.
    Virtually every U.S. Industry is compensated based on quality. The U.S. Healthcare System has historically been the exception. NOT ANYMORE!

    A major realignment or restructuring of the U.S. Healthcare System began in 1996, accelerated in 1997 under the balanced budget amendment, and continues today under the Pay for Performance initiative. Congress calls it “value based purchasing,” but it is an effort to improve the quality of care.

    Every physician has felt the negative financial impact of these changes, as revenues have been reduced for office visits, procedure complexities, and therapies.

    Specialist’s are earning 2:1 over the primary care physician. On average, specialists are earning near $300K while the PCP earns roughly $150K, sometimes LESS! Do you know why?

    It doesn’t make any sense considering there are more ICD-9 and CPT codes available in the primary care setting. It’s because the U.S. Healthcare System has changed… it has “moved” money away from office visits and therapy, and shifted it towards patient outcomes. Reimbursements are down, costs are rising!

    As a result, physicians who continue to operate as they have in the past are feeling “financially” squeezed! In attempts to offset their losses many are working longer hours seeing more and sicker patients, while earning less. They are also trying to reduce nonessential services and overhead by working with fewer people, in less space. Then there are some who are choosing to decline services due to capitation issues. None of this helps! Do you know why?

    Because the Healthcare System knows most PCP are “flying under the radar” by operating in “waived” settings and avoiding the responsibilities that accompany providing quality care. The money has been moved to three main practice areas- diagnostics, imaging/radiology, and clinical lab. The idea behind the shift is to improve patient outcomes by placing money as an incentive for PCP to uncover asymptomatic illnesses before they become chronic disease states and cause catastrophic costs to the overall system.

    The trick is to align your practice within the changes that have taken place in the healthcare system. By align your practice, I mean according to your specific patient base and data requirements to ensure the additional revenues generated will greatly exceed the cost of change. (e.g. “addressing the baby boomer comment previously stated” If you are seeing 3 elderly patients per week with dizziness symptoms, Medicare reimburses $450 per procedure for VAT/ENG testing which is used to prevent future falls. Buying the box costs $700 per mo. So figure an increase of $5200 per month or $60K per year!) I know it seems stupid to offer FREE information like this when I can sell it, but that’s what I do! I help physicians address the problems within the primary care setting and I’m structure to be compensated by the medical distribution companies who are STEALING your money. I don’t charge physicians a consulting fee, they pay enough out already! Sorry this is just one example. Every situation has specific needs and this may not be beneficial to your practice. I can tell you there are many different ways to improve patient outcomes while enhancing NET revenues. It’s just a matter of knowing what to do for your specific patient base and volume requirements.

    Trust me when I say this, almost every PCP practice seeing 25+ patients per day, including the solo practitioner can increase their income by $125,000.00. It’s just a matter of OPTIMIZING their practice!

    http://medicalsource.biz/free-practice-analysis.html
    Have a personal pro-forma built, based on medical necessity, for each individual area of your practice.

  13. Yes, the system is screwed. Any one with an analytical mind can point out new “profit centers” to increase income, but this flies in the face of cutting costs. A Catch 22.P4P, or paying for better outcomes is problematic especially since it is based upon financial coding…has nothing to do with care, and encourages automated computer systems to be sure the correct codes go into the billing.
    Our son has cystic fibrosis…..eventual outcome…death…so do the providers not get paid because his outcome is fatal?

  14. Yes, the system is screwed. Any one with an analytical mind can point out new “profit centers” to increase income, but this flies in the face of cutting costs. A Catch 22.P4P, or paying for better outcomes is problematic especially since it is based upon financial coding…has nothing to do with care, and encourages automated computer systems to be sure the correct codes go into the billing.
    Our son has cystic fibrosis…..eventual outcome…death…so do the providers not get paid because his outcome is fatal?

  15. I’m starting Medicare as a patient in two months. Thankfully, my docs accept Medicare patients, although I don’t know how they manage it, since everyone knows it does not pay even costs. I have offered to chip in extra, but apparently that isn’t permitted.
    Can someone tell me how Congress, which sits on its own fat health insurance plan, can cut Medicare reimbursements even lower, while it throws away $500 billion to a trillion a year in Iraq and spends billions on earmarks? Throw the bums out.

  16. I’m starting Medicare as a patient in two months. Thankfully, my docs accept Medicare patients, although I don’t know how they manage it, since everyone knows it does not pay even costs. I have offered to chip in extra, but apparently that isn’t permitted.
    Can someone tell me how Congress, which sits on its own fat health insurance plan, can cut Medicare reimbursements even lower, while it throws away $500 billion to a trillion a year in Iraq and spends billions on earmarks? Throw the bums out.

  17. This post is spot on.
    #8 — Dropping out — not exactly spiteful, but they wanted to set a powerful disincentive against physicians dropping out of medicare. I’d say it has been effective in more ways than one.

    #9 — the SGR — is another example of how little clout the physicians’ lobby has in DC. Why was a formula developed to limit the growth of physician expenditures when no effort was made to limit the growth of the (much larger) facility expenditures? Hmmm? It’s because congress (both parties) hates doctors, and our lobby is impotent, pure and simple. And now we have to live with this terribly flawed formula hanging over all our heads.

    #3 — Fraud — An overblown fear. Yes, CMS and its henchmen are kind of scary. Yes, you need to be compliant in your coding. Yes, the RAC program is going to be looking at professional charges. But honestly, how many doctors do you know who have been audited? Who have had to pay money back? I’m betting that number is pretty low. And those are usually small settlements for “overbilling,” not fines, and not accusations of fraud. Nobody is losing their license or going to jail over this. There’s a lot of hysteria and fear on this point, but the reality is not as grim as the hype.

  18. This post is spot on.
    #8 — Dropping out — not exactly spiteful, but they wanted to set a powerful disincentive against physicians dropping out of medicare. I’d say it has been effective in more ways than one.

    #9 — the SGR — is another example of how little clout the physicians’ lobby has in DC. Why was a formula developed to limit the growth of physician expenditures when no effort was made to limit the growth of the (much larger) facility expenditures? Hmmm? It’s because congress (both parties) hates doctors, and our lobby is impotent, pure and simple. And now we have to live with this terribly flawed formula hanging over all our heads.

    #3 — Fraud — An overblown fear. Yes, CMS and its henchmen are kind of scary. Yes, you need to be compliant in your coding. Yes, the RAC program is going to be looking at professional charges. But honestly, how many doctors do you know who have been audited? Who have had to pay money back? I’m betting that number is pretty low. And those are usually small settlements for “overbilling,” not fines, and not accusations of fraud. Nobody is losing their license or going to jail over this. There’s a lot of hysteria and fear on this point, but the reality is not as grim as the hype.

Comments are closed.