Dear Mr President, Medicare Stinks

Dear Mr President, Medicare Stinks

39
SHARE

Dear Mr. President:

The physicians and management in our office had a discussion this morning about the upcoming audits physicians are facing from CMS. I had to wait for my blood pressure to get out of dangerous range to write this letter. The frustration, fear, and powerlessness I felt made me really question whether it is worth continuing to see my Medicare patients.

I am a primary care physician and about 20% of my patients are covered by Medicare. As a whole, they are wonderful people, but difficult patients. The elderly are truly a delight to talk to, learn from, and care for; I consider it an honor to be their doctor. But the complexity of a person’s medical problems goes up exponentially as they near the end of their life. This means that I spend more time per patient for my Medicare population – which is OK if I can be paid for my extra time and effort.

But here is the message we physicians are being given:

Medicare auditors will be knocking at our doors, and if there are “problems” with our charting we will be told to send money back to CMS for our whole Medicare population. We are obligated to prove that we did not defraud Medicare to reclaim the money for the work we did. This is, obviously, consistent with the cornerstone of the American legal system, “A person is presumed guilty unless they can prove that they are innocent.”

The “problems” they are looking for are inconsistencies in the charting and the billing we do. These “inconsistencies” are not just egregious attempts at stealing money from Medicare, they are little things like this:

The failure to mention the EKG we ordered in the note (even if it is right there in the chart).

The appearance that we are using a “cookie-cutter template” to do our notes – i.e. if all of our physical exams, review of systems, or impressions look similar, then it will be assumed we are trying to defraud Medicare.

Forgetting to document a discussion of the patient about a diabetic eye exam.

Certain ICD-9 codes will be accepted by Medicare, but will be “flags” that we are possibly trying to cheat Medicare out of money. Diagnoses like Hypertension ICD-401.9 and Diabetes Type 2 ICD-250.00 will be flags. We need to be more specific in our coding to avoid immediate suspicion.

While my information may not be 100% accurate, the fear in the medical community is. We practice very good medicine in our practice and probably save money for the system (as studies have shown that a higher percentage of primary care in a community means lower cost – ask the Brits on this one). We use an EMR and are very tuned in to the quality of our care (NCQA recognized for our diabetes care). I strongly suspect that our quality of care and documentation are in the top 10%. Yet we are fearful that your government employees are going to use us as scape goats for the out-of-control costs of Medicare and put us out of business in the process.

We see what is being done to the hospitals with the “No Pay” diagnoses. That whole debacle is irrational and unfair, but the hospitals have no recourse. That makes us extremely pessimistic about our odds when facing the hit-men from CMS. If a hospital with its lawyers and other resources can be hung out to dry, what chance does a PCP have?

So at an increasing rate, we are discussing the option of dropping Medicare altogether. That really is an amazing thing, as we have always played by the rules and have seen our care for the elderly as a responsibility and civic duty we have. We have never considered our acceptance of Medicare as something that actually makes business sense – we just want to and like to care for the patients. But the increasing hostility we are seeing from the witch-hunters with their torches and angry mobs is making us really consider whether we can afford to stay on board.

The practice of medicine would be far simpler for us if we dropped Medicare and Medicaid – and probably more profitable. But I don’t want to. I love my patients and want to continue to have the honor of being their doctor. Please don’t convince me that it is not worth the effort. Please don’t hurt our elderly in such a way. Please don’t let the CMS cronies make it look like we physicians are the root of the problem. We may not be totally innocent; but most of us are doing the best we can in a system that is becoming increasingly hostile and incredibly burdensome.

On behalf of all scared physicians out there,

Dr. Rob

ROB LAMBERTS is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at Musings of a Distractible Mind, where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player.  He is a primary care physician.

Leave a Reply

39 Comments on "Dear Mr President, Medicare Stinks"


Guest
review
Jul 29, 2010

FEDERAL JUDGE SAYS IF THEY DID NOT PROMISE OR SIGN ANYTHING KICKBACKS ARE OK??? WHICH IS NOT TRUE BY THE WAY.
Turning next to relators’ claims based on alleged violations of the Anti-Kickback Statute, the court concluded relators failed to allege “that United Health certified compliance with the Anti-Kickback Act, nor did they allege that such compliance was relevant to the Government’s funding decisions.” The court then declined to exercise supplemental jurisdiction over relators’ state law claims and refused to grant relators leave to amend.
MEDICARE FRAUD, MEDICADE FRAUD, AND KICKBACKS AND BRIBES BUSINESS AS USUAL,INSIDER INFORMATION GIVEN. 9B BS ONE THING BUT WHAT ABOUT YOUR “HANDS OFF POLICY” BY THE DOJ AND CMS AND HHS, AND WHY NO INVESTAGATIONS OR AUDITS TO CONFIRM OR HELP? “SELF DISCLOSURE BY CARRIER ANOTHER JOKE”.
WHAT ABOUT “TAXPAYERS TO PREVENT AND STOP AND PREVENT FRAUD FOR MEDICARE AND MEDICADE” WHAT ABOUT WILLIS AND WILKINS BEING FIRED FOR NOT WANTING TO BREAK THE HEALTH FRAUD LAWS?
NJ CEPA CLAIM NOW ON FILE…..FALSE CLAIM UNDER APPEAL AND FILED….. WHERE WAS ANY HELP FROM YOUR DEPARTMENT?
The U.S. District Court for the District of New Jersey dismissed May 13 a qui tam action alleging violations of the False Claims Act (FCA) by United Health Group and its subsidiaries. According to the court, the complaint failed to state a claim upon which relief could be granted under the FCA. Relator Charles Wilkins began employment with United Health Group and its subsidiary AmeriChoice in October 2007 as a sales representative. Relator Darryl Willis began employment with United Health Group and AmeriChoice in 2007 as the general manager for Medicare/Medicaid marketing and sales.
In their qui tam complaint, relators allege 11 violations of Medicare and Medicaid regulations. The United States declined to intervene in the case and the relators filed an amended complaint that stated one federal count—violation of 31 U.S.C. § 3729(a)(1)-(3)—and nine state law counts. United Health moved to dismiss under Fed. R. Civ. P. 12(b)(6), arguing relators failed to plead the elements of a “false certification” claim, they failed to plead any anti-kickback violations, and failed to adequately plead a conspiracy. Relators alleged that because United Health entered into a contract expressly certifying that it agreed with all “terms and conditions of payment,” they made a false claim when they submitted claims despite any one of the 11 purported regulatory violations alleged in the amended complaint. Rejecting relators’ express false certification claim, the court found “[not once in the Amended Complaint have Relators identified even a single claim for payment to the Government.”The court also held relators’ implied false certification claim failed. According to the court, relators argued that because United Health agreed to comply with all CMS regulations when it contracted to become a prescription drug plan sponsor, and because at times it was in violation of some regulations, it therefore committed fraud each time it submitted a claim for payment. The court found such a theory of liability overly broad. “If Relators’ theory were correct, the FCA would become a federal tort fountain, flowing claims for every trivial violation of Medicare/Medicaid regulations,” the court said. Relators next argued that under the recently enacted Fraud Enforcement and Recovery Act of 2009 (FERA) a relator need only show whether compliance with regulations would have a tendency to influence the government’s payment decision. While that argument is true, the court reasoned, “Relators must still show a claim . . . and [t]hey have not done so.” Turning next to relators’ claims based on alleged violations of the Anti-Kickback Statute, the court concluded relators failed to allege “that United Health certified compliance with the Anti-Kickback Act, nor did they allege that such compliance was relevant to the Government’s funding decisions.” The court then declined to exercise supplemental jurisdiction over relators’ state law claims and refused to grant relators leave to amend.
United States ex rel. Wilkins v. United Health Grp. Inc., No. 08-3425 (D.N.J. May 13, 2010).
FCA claim alleging aggressive marketing tactics by health plan provider dismissed
Publication: Health Law Week
Date: Friday, June 4 2010
The U.S. District Court for the District of New Jersey dismissed a qui tam action brought by two former employees of healthcare plan providers alleging violations of the False Claims Act (FCA) arising from excessively aggressive marketing methods. United Health Group Inc., a provider of access to healthcare services, had as its subsidiaries AmeriChoice and AmeriChoice of New Jersey, which each offered Medicare Advantage plans. Charles Wilkins and Darryl Willis (the relators), who were each employed by United Health Group and AmeriChoice, initiated a qui tam claim against United and its two subsidiaries under the FCA alleging numerous violations of Medicare and Medicaid regulations governing administration of the Medicare Advantage plans. The complaint alleged that the defendants engaged in unauthorized and aggressive sales methods in marketing the plans — including the provision of illegal cash payments to providers to induce them to change beneficiaries to AmeriChoice and the provision of illegal kickbacks to doctors for obtaining the names of patients they could call and approach. The defendants moved to dismiss.
The district court concluded that the complaint failed to identify a single instance in which the defendants submitted a false claim to the government for payment as required to prosecute a qui tam claim as relators under the FCA. Under applicable federal appellate court precedent, the absence of such an allegation was fatal to the relator’s false certification claim. The relators’ theory of liability at base was that because United Health agreed that it would comply with all Centers for Medicare and Medicaid Services regulations, and because it was at times in violation of some regulations, it committed fraud each time it submitted a claim for payment. The district court concluded that this contention confused the conditions of participation in a Medicare or Medicaid program with the conditions of payment, and would open the door to a flood of tort claims of a type not contemplated by the FCA. Moreover, the complaint failed to allege that the violation of any regulation was actually relevant to any funding decision. As a result, the complaint failed to state a claim on which relief could be granted and, accordingly, the defendants’ motion to dismiss was granted.
Source: Health Law Week, 06/04/2010
Copyright © 2010 by Strafford Publications, Inc. http://www.straffordpub.com / All rights reserved. Storage, reproduction or transmission by any means is prohibited except pursuant to a valid license agreement.

Guest
R. L. Clay
Mar 24, 2010

Since the Republican govenors want to sue the US government over the healthcare bill- Can the American people file a lawsuit against the Republicans – listing each member – for accessory to murder for approving the funding to go into Irag and kill Saddam as well as innocent soldiers/civilians who lost their lives in regards to alleged “weapons of mass destruction?”
Cheney and Bush may have gotten “immunity” from the government whereas they would not be tried as war criminals – but what about the members of congress?
It’s insidious how the Republicans are making a big deal out of a healthcare bill and not over the lives lost in a fake war.

Guest
Mar 20, 2010

THIS IS A PETITION TO THE UNITED STATED FEDERAL GOVERNMENT
FOR A INDIVIDUAL OPT OUT REQUEST FOR HEALTH CARE
We The Undersigned Wish To Convey By Their Signatures Below That They Wish To Have The Same Rights Under The Current Health Care Legislation. That Allows The Individual States That If This Would Place An Economic Burden On That State They Have The Option To Opt Out Of This Mandate.
Currently Over 38 Of The 50 States Have Or Will File A Legal Action Against Washington To Claim This Is An Unconstitutional Bill.
If The States Are At 38 against and 12 Not Yet Heard From, It Would Seem That
“We The People” Are More That 51% Against This Health Care Bill.
THIS WOULD BE A CLEAR STATEMENT THAT IF AN UP OR DOWN VOTE WAS HELD TODAY BY THE GENERAL POPULATION OF REGISTERED AMERICAN VOTERS THIS BILL WOULD NOT EVEN SEE THE LIGHT OF DAY AND ANY LEGAL ACTION FILED BY THE INDIVUDAL STATES WOULD NOT EVEN BE REQUIRED.
IF THIS BILL WOULD Place A ADDITIONAL ECONOMIC BURDEN ON THE STATE,
If Would Seem Logical That It Should Also Be AVAILABLE TO THE INDIVIDUAL PERSON AS WELL.
We the Undersigned Wish To Opt Out Of The Average
$12,000.00 Per Year Price Tag
The Current System We Have In Place by Law Already Mandates That Any Hospital Cannot Refuse Medical Treatment to Anyone That Is In Need Currently Any One Who Asks For Help Will Receive It
This Bill Will Be Imposed By A Federal Mandate On Each Man, Woman, Child, And Even Unborn Children That Live In This The United States If This Bill Passes.
That This Mandate Is Actually an Unconstitutional Bill in Many Ways
The Federal Government Does Not Have the Right to Mandate that it’s Citizens Will Have to Purchase a Product Such As Health Insurance Policy.
To Mandate That An Unborn Child Will Have To Purchase This As Well Is The Same Taxation Without Representation.
We As Citizens Are Now Already Over Taxed the Federal Government It Takes the First 4 Months of Our Income
The States Take Another Two Months Of Our Income.
If You Live You Pay Sales Tax on All Purchase’s And Even More On Other Taxes Such As Property Taxes, City Taxes, Cigarettes, Alcohol, Death Taxes, And Soon Even A Carbon Tax On Breathing.
At The Present Time With All Of The Visible Taxes And The Taxes That Are Hidden In Every Item That Is Purchased We Are Taxed At If Not More Than 50% Of Our Income’s An Additional $1000.00 Per Month $12,000.00 For A Federal Health Care Product That Once Implemented Will Only Cover 60% Of Medical Expenses After An Already High Deductable This Will Place A Large Burden On Any If Not All United States Citizen’s.
WE CITIZENS OF THE UNITED STATE RESPECTFULLY REQUEST TO OPT OUT OF THE CURRENT HEALTH CARE BILL
PLEASE COPY AND EMAIL TO ALL OF YOUR CONTACTS AND ON SUNDAY WHO EVER HAS A COPY FORWARD IT TO THE HOUSE,SENATE, AND THE WHITEHOUSE

Guest
Nate
Mar 19, 2010

“The problem with Medicare is that it’s Fee-For-Service.”
BS the problem with Medicare is its Medicare. Rob, how would you feel if Medicare dropped all PCP coverage and became catostrophic insurance. You would never have to collect a penny from them. You would bill your patients/clients at time of service, or hey its none of our business you can do payment plans or accept eggs if you like, and they would pay you what ever price you and they agree is fair.
Tens of millions of people with no insurance live just fine under FFS and 80 million or so private insured aren’t complaining about FFS. The problem is the government and insurance company trying to dictate how FFS will work to best suit them and then taking a huge cut in taxes or Admin.

Guest
Mar 19, 2010

As long as we continue to provide “sick care” and not “health care” it will never work. Prevention of disease is better than treating it. But no one makes money keeping people healthy!!!!

Guest
Mar 19, 2010

Estimates of fraud in Medicare range wildly from $13 billion to $80 billion; there are simply no good, reliable data.* Laying blame, then, for the “majority” of Medicare fraud at the door of DME providers—which account for less than 2% of Medicare costs—is inflammatory and unsupported by the evidence.
We share your concerns about the health care bill and the unchecked powers of Medicare auditors. DMEs are also, as Dr. Rob wrote, “obligated to prove that we did not defraud Medicare to reclaim the money for the work we did.” However, we are held responsible not only for our own records but also for our referring physicians’ charting errors. Therefore, one error in YOUR chart could essentially halt all Medicare payments to MY business for an indefinite period. Haven’t updated your physician record in PECOS? Then WE won’t be paid for the equipment you ordered for your patient. There is no due process for suppliers.
I’m tired of the unfair representation of my business by the media, CMS, and referring doctors. This industry has had its problems, to be sure; last year, CMS finally implemented the barriers to entry that reputable providers have been requesting for years: accreditation, surety bonds and on-site visits. After seeing reimbursement cuts of 9.5% last year alone, we are now fighting “competitive bidding” legislation that will award Medicare contracts to the lowest bidders, and which the GAO estimates will result in about 90% of providers going out of business.
My company has been in this community for 17 years. We volunteer, we love our patients, we educate ourselves about new products and train our patients how to use them. Whom do you think your patients will be calling if their oxygen equipment or wheelchair malfunctions—and their new service provider is in Michigan, or California? Your already overworked staff.
Dr. Motew, the AMA is second only to financial services in lobbying expenditures, having spent >$200 million over the last decade, which makes your “easy targets” argument inaccurate. If you don’t feel represented, look to your own leadership. If you really want to know how it feels to not have a seat at the table or a voice in the discussion, open a DME.
*On May 6, 2009, Daniel Levinson, the inspector general of the Department of Health and Human Services, testified before the Senate Special Committee on Aging that “it is not possible to measure precisely the extent of fraud in Medicare and Medicaid.”

Guest
Private Citizen
Mar 18, 2010

Wasn’t there a recent article of a intervention cardiologist who did many stent procedures even in patients who did not need them. How can consumers protect themselves from such horrible situations? unfortunately the good doctors have to jump the hoops because bad doctors over code and overdo procedures for $$. There people who sell 2nd hand wheel chairs and rip off Medicare, unless there are some penalties, rampant fraud will continue.

Guest
gayle b
Mar 18, 2010

When President Obama compared his healthcare plan to
the famous Mayo Clinic I think he was really thinking of
The VA Clinic. Anybody familiar with The VA Clinic?
worse than Canadian healthcare.

Guest
Mar 17, 2010

Don’t click on that last link, folks. It’s a spammer, I think.

Guest
Mar 17, 2010

MD as HELL (Good Name):
I wrote a post about this that you may enjoy:
http://distractible.org/2009/08/11/fluff-kills/
I call all the junk that we have to look at and put in the charts “fluff.” The problem is that we are choking on fluff.

Guest
MD as HELL
Mar 17, 2010

The feds turned documentation and compensation into a game. The care did not actually change, but the game changed. The game has become bigger than the patient. To the doctor the medical care is easy. A tremendous amount of energy and overhead goes into the game. And the doctor must either play the game or starve. The gamesters of CMS will change the rules everytime the doctor gets better with the old rules. This is all under the guise of accountability and quality.
Total BS.
All involved have employees whose jobs would not exist were it not for the game. The patient’s premiums and copays would be a lot lower without the BS.
Turn the clock back to 1980 and the $15 office visit. Now just factor in simple inflation and you are nowhere near today’s $120 visit. Without the BS my net will still be what I net today.
So this entire national disgrace is about BS, not healthcare.

Guest
Kevinh76
Mar 16, 2010

“You can’t responsibly help people unless they are equally willing to help themselves.”
How true! I want to put these words on a plaque and hang it in my exam room. Thanks, ExhaustedMD! Now, go get some rest. Finding these word here made reading all the comments worthwhile.

Guest
Ivan
Mar 16, 2010

Seriously, I’ve got to agree with you. I am a Obama supporter, however, this time around, I guessed he made a huge mistake. Obama should not have initiated such a big health care reform; espcially the ‘zero-cost consultation fee’. There are also important news about the health care reform in the link below.
http://www.thehealthcareblog.com/the_health_care_blog/2010/03/dear-mr-president-medicare-stinks.html#comments

Guest
reformdocs
Mar 16, 2010

I used to think those codgers who never go to doctors were just scared. Now I’m scared too. I’ve decided I can’t afford to take a bet on entrusting myself to the billing entities known as medical providers. So I might get sick, so I might die, but i’m not giving you a single dollar. That may be the only way to get this done on a societal basis. Let every man pay what he can. The government will pay nothing. Mothers will hold sick babies on the street as in third world countries. Doctors will be unhappy and ashamed, but perhaps that’s what they deserve.

Guest
Propensity
Mar 16, 2010

Medicare is the number one reason for the inflationary spiral in health care. EMRs are coming in a close second. It is so easy to bill level five visits. Patients fill out review of systems, past history and chief complaint questionnaires on each visit. Secretary clicks the boxes corresponding to the answers. Doctor holds patients hand and talks about constipation. Doctor clicks on language of disease templates. Voila, documentation for the feds