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Dear Mr President, Medicare Stinks

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.

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reviewR. L. ClayMYMILLIONSITENatechris Recent comment authors
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review
Guest
review

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… Read more »

R. L. Clay
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R. L. Clay

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… Read more »

MYMILLIONSITE
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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… Read more »

Nate
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Nate

“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… Read more »

chris
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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!!!!

Lisa Shaw
Guest

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… Read more »

Private Citizen
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Private Citizen

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.

gayle b
Guest
gayle b

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.

Rob Lamberts
Guest

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

Rob Lamberts
Guest

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.

MD as HELL
Guest
MD as HELL

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.… Read more »

Kevinh76
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Kevinh76

“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.

Ivan
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Ivan

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.
https://thehealthcareblog.com/the_health_care_blog/2010/03/dear-mr-president-medicare-stinks.html#comments

reformdocs
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reformdocs

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,… Read more »

Propensity
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Propensity

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