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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    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.
    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.

  2. 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.

    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.
    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.

  4. “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.

  5. 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!!!!

  6. 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.”

  7. 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.

  8. 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.

  9. 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.

  10. “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.

  11. 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.

  12. 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

  13. To bevMD, thank you for your comment. Unfortunately, I will have to look for a new profession WHEN this garbage is unfairly passed by these narcissistic, and in my opinion, antisocial legislators. After all, what is the basis of antisocial behavior: to do whatever you want irregardless of the impact on those around you.
    To Ms GA, if you are inferring you are playing a “devil’s advocate” type role with me, I don’t enjoy that! And, watch out for being so free to announce being liberal. This is a term being used by your arch enemies, conservatives, in a manner that borders on the way Nazis referred to jewish people.
    Also, I respect what you believe above, but, this legislation will not help your beliefs be maintained or corrected. If you support the Democrat party just because of your philosophies, they do not represent what is right and responsible for the people of this country, and you write as an educated and aware person, so you should know this!
    I used to be a bit more liberal in my views, and then as so accurately said in a Doonesbury cartoon back in the 90s, when Doonesbury’s daughter asked him why he changed into a more conservative person and was it painful to do so, his answer of “YES!” really hit the mark for me. You can’t responsibly help people unless they are equally willing to help themselves, and this legislation only reinforces the adage “what’s in it for me!?” I see dependency at very pathological levels in my office more and more. This bill will not change it for the better.
    So, isn’t it time for people to learn how to fish? I’m tired of throwing out the bleepin’ line day in and out, and now looking at more people to feed!
    It is about moderation. People like me who are tired of the bashing by the right for the first decade of this millenium are equally sick of the bashing by the left now! At the end of the day, different faces, same lack of respect by these alleged representatives.
    George Carlin was right: selfish, ignorant citizens elect selfish, ignorant leaders. And there really, up to now, has been no one of conscience and integrity to stand up and lead the way, to improve the course. I see this, the current political arena, as a form of terrorism that is slow and insidious, that is why terrorists from other lands won’t waste their time and lives to come here. Our politicians are adequate substitutes, just less flash and blood to make the news nightly!
    Hey, I know that is a harsh and rude statement. Listening to the pure idiocy that spews from the Speaker of the House and Senator Leader’s mouths these past 6 months is how they come across to me!
    Good luck, America. You’ll get what you wish for! You certainly won’t get it from me!

  14. Dr. Lamberts;
    I still would like to know where you got your scary information. Not saying it’s false (I wouldn’t put it past the feds); just wondering.
    Gary – so then when docs threaten to stop seeing Medicare patients, many of them are really threatening to close their practices, if they are seeing 75% plus Medicare patients. True? Unless they go to a boutique model,which would be tough for the specialists you mentioned.

  15. Gary! You are absolutely right. The problem with the RAC is that they are rewarded for finding fraud. That makes them motivated to find anything that can be called fraud. That’s why docs are scared.

  16. I am biting my tongue in order not to rant here. It’s like groundhog day….the same thoughts and writings over and over.
    What is true is that the majority of medicare fraud is done by false claims by criminals that set up sham companies for DME, and those who steal provider numbers and bill for dead patients, and those who have never been treated. I was the victim of such a scheme by a ring that stole my provider numbers and billed medicare over 1 million dollars for patients I had never seen, and for ridiculous procedures such as 25 eye laser procedures in the course of two weeks. Now that is what fraud is, not some ridiculous error in a code or modifier. Of course I was assumed guilty until it was proven I was not the perpretator…but that is another story.
    Most ophthalmologists, urologists and cardiologists have a heavy preponderance of medicare patients…some around 75-85%

  17. I’ll offer two thoughts on this.
    First, with respect to Medicare and Medicaid fraud, I think every provider including doctors, NP’s, representatives of home health agencies and DME suppliers and anyone else with the authority to order or provide a service, test, procedure or drug that Medicare and Medicaid pay for should have an ID card with a picture, a biometric identifier and a unique billing number separate from any large practice or corporation that bills under its own separate ID number. The idea here is to be able to track utilization at the individual authorizer or provider level as opposed to just the corporate level. Individuals generating bills well outside the zone of reasonableness should quickly arouse suspicion and can be investigated.
    Second, regarding the adequacy of Medicare and Medicaid payments, I suggest you copy the approach used by CVS and Walgreens. When Medicaid tries to push drug reimbursement rates too far down, these companies will reach a point where they will no longer accept Medicaid patients because they can’t make an adequate return from that business. Before long, a deal satisfactory to both parties is ultimately worked out. This dynamic has played out numerous times over the years. If you think Medicare and Medicaid payment rates are too low, at the very least, stop accepting new patients. If you really think you cannot make money after staff salaries, office rent, malpractice insurance and other expenses, stop seeing existing patients as well. Though it’s unpleasant to say the least, payers will get the message if enough doctors in a given state or region see the situation the same way you do. Healthcare is now a $2.5 trillion annual BUSINESS in the U.S. Like it or not, that’s the reality.

  18. Dr. Exhausted,
    This is almost comical, since I suspect we are not disagreeing on anything other than the President’s value and that doesn’t have much to do with anything health care.
    So for your clarification, here are my “official” positions, in no particular order 🙂
    I believe PCPs are grossly underpaid and undervalued.
    I believe some specialists are overpaid for some procedures.
    I believe hospitals are, with some exceptions, making lots of money at both physicians and tax payer expense.
    I believe insurance companies are as bad, and probably much worse than hospitals.
    I believe our Congress is in a sorry state and the entire political system is in dire need of repair.
    I believe the documentation requirements from CMS are absolutely ridiculous and have nothing to do with quality of care.
    I believe the current environment is strangling small practices and it will get much worse, to my personal chagrin.
    I believe patients are patients and don’t really understand the term consumer in this context.
    Since Dr. Lamberts mentioned EMRs, I think technology is just a tool and cannot and will not turn a mediocre practitioner into a brilliant medical mind. Sure, as a tool, they may bring efficiencies and improve coordination of care, but there is no silver bullet there. There is no silver bullet anywhere.
    If you have time, you can read a couple of things I wrote a while back, on this blog, and see that I am not at all the enemy, even if I so happen to be of a very liberal persuasion 🙂
    I don’t know I am trying so hard. Maybe because I sense that regardless of your politics, your heart is in the right place and I have a “liberal” weakness for that… 🙂

  19. Bev: I have practiced in a setting where my practice was owned by a hospital – and I left. I found that they had less motivation to make my practice efficient than I had at my worst moments. They wanted me as a name on their rolls and someone who referred to them for ancillaries. Working in a larger system was very demotivating.
    I have only 20% because I do 1/2 pediatrics, and there are very few pediatric Medicare patients. If I had a higher percentage, I would be contemplating a job change. My comments may exaggerate (as I said in the post), but they do give a very good picture of the mistrust and anxiety in the physicians in our country. Since private practice physicians in a small office are in the majority still, transition to an IDN model is a long way off. I personally don’t trust our local hospitals anyway.

  20. To Exhausted MD:
    Your statement:
    “You people keep applying the rules of business to the practice of medicine! Medicine is NOT a business, and it fails now as it has foolishly, stupidly, and painfully allowed itself coerced into behaviors by forces it mistakenly thought it could not repel. I do not treat customers or clients, and anyone who argues those terms apply never took an oath of clinical care.”
    strikes a chord with me. I argued vehemently and unsuccessfully when our hospital started trying to get us to call patients “guests.” It cheapens what I used to regard as a sacred trust of practicing medicine. The result is now clear: patients regard themselves as consumers and us as service providers, to the detriment of both. (If someone has my life in his/her hands, I want to think more of them than my insurance salesman.) Unfortunately, many of our colleagues have willingly embraced medicine as a “business”,including many of our professional organizations. The reality is that medicine IS a business today, and that’s why it is referred to as such. It is too bad that docs who still want to be left alone to practice have to act like businesspeople. It’s one reason I retired early, lucky enough to be married to another professional. I hope you can find happiness in some way.

  21. First, Dr. Lamberts, I have a question which I’ve had for some time – don’t a lot of practices treat a larger percentage of Medicare patients? After all, it is old people who get sick the most, and therefore I would think you would see them the most. In an orthopedic practice based on total joint replacements, for instance, I would think the vast majority are Medicare patients. Are you speaking of Medicare patients who have no Medigap policies, or anyone covered by Medicare at all?
    As for your post, I guess I have mixed feelings about this. First, there are scaremongers among physician organizations just as among political parties; therefore I would question where you got your information and its accuracy. Second, whether Matthew calls it “fee for service” or you call it “fee for procedure” doesn’t really matter; the point is the same and that is that docs are reimbursed for the wrong things. Third, I firmly believe that the long term future of medicine is aggregated practices if not totally integrated delivery networks with payment based on aggregate outcomes; and that far from docs’ fears of losing their independence, these networks can reduce your hassles, provide malpractice coverage, help you with on call issues, provide an infrastructure for meeting federal and other requirements, etc., probably in return for a somewhat lower, but more predictable, income and a return to actually practicing medicine instead of business. (The key is NOT giving the leadership power to hospitals in these networks).
    So, while I have short term sympathy for your situation, I think it is based on what will be a fairly rapidly outdated mode of practice.
    And ps – I practiced as a hospital based doc where I was regularly inspected by the state, acting for Medicare. If they found something bad, they said and wrote all sorts of bad things, threatened disbarment from the Medicare program, and gave you (the hospital, no matter what dept. was at fault) 90 days to produce an action plan to improve and implement it. Rarely did anyone ever actually lose Medicare payments.

  22. Matthew: I respectfully disagree (respectfully since you are the boss around here). The problem is the definition of a unit of service being an office visit. We have a procedure based system which makes it tantamount to prove the procedure was done – hence the noose of documentation. All a procedure based payment system encourages is more procedures and more attention to documentation. If we instead focus on outcomes, it will make measurement of service rendered very different. I personally think that EMR is a necessary step before any cost control or any fundamental change to the payment system can happen. I am not talking about EMR as expensive gibberish generators; I am talking about EMR as a clinical database and a tool to inform better decisions. Is that P4P? Of a sort. But one that is informed by clinical, not claims data. It’s complex. I am writing a post on “why EMR is essential for reform.” I am sure it has been done before, but probably not by a private-practice PCP.

  23. Go do a search on a Jeri Hassman, an MD who originally was charged with multiple counts of Medicare fraud, I think back in the mid to late 1990s, that was challenged voraciosly by the government, and then, from what I remember reading, whimsically dropped by the government. Unfortunately, her name comes up later regarding prescription fraud issues that I am not clear if legitimate or not, how convenient another government pursued matter (to clear them of prior transgressions?), but, I remember how they dragged her name through tons of mud without legitimate charges of Medicare fraud.
    As to Ms GA’s repeated badgering of my position, what does this legislation do of good for doctors who went into medicine to treat people and maintain responsible and ethical independence to practice.
    You people keep applying the rules of business to the practice of medicine! Medicine is NOT a business, and it fails now as it has foolishly, stupidly, and painfully allowed itself coerced into behaviors by forces it mistakenly thought it could not repel. I do not treat customers or clients, and anyone who argues those terms apply never took an oath of clinical care.
    You know, the Lamberts on the internet really are making more mistakes than benefits by trying to reason with unreasonable people in a medium that thrives on quick fixes and unaccountability. You can call me hypocritical for using an alias, but, I am not going to be harassed further than I already have been by being honest and direct with others who do not engage on a level playing field.
    Blog sites are more so soundboards these days than sites of facts and responsible discourse. You know what they say about opinions and anal sphincters, so I’ll leave you to finish the thought.
    As to Dr Lamberts, we are screwed because you and I know that this legislation will just lead to more people on Medicare and Medicaid rolls, and you gotta love people who, at the end of the day, are just using lots of words to simply say, “you took a vow of poverty, so deal with it!”
    I’d love to write what is the true and fair retort to this, but, I would be banished because being honest and direct with those who are inappropriate makes me the heavy, while they continue to get away with trying to force non-clinical judgment on those who are clinicians.
    I do not know where you trained, but I had plenty of supervisors and mentors remind me through my training to watch out, everyone is a gd doctor until they screw up and run when the feces hits the fan.
    Today is no different for what that advise entails!!!

  24. The problem with Medicare is that it’s Fee-For-Service. Always has been, and the reason for that is that it was what the AMA wanted when Medicare was introduced.
    Fee for service is a crazy way to run health care. And I said exactly that in the VERY FIRST POST on THCB called “What’s wrong with Meidcare” https://thehealthcareblog.com/the_health_care_blog/2003/08/the_first_post_.html
    So Rob–join a salaried practice, or agitate for single payer–but by definition FFS medicine is going to be bad news for you. And the only reason that the private guys arent as nasty is that they havent needed to be. But when they get squeezed (as is happeneing soon) it’s going to be like 1997 all over again.

  25. I work in nonsurgical specialty care and I am not sure what to think of all that.
    There probably is rampant fraud, esp. in the device and therapy sector.
    What I see from other providers based on their documentation seems usually alright … although there are some who write a handful of words re. history, and then there is some template filling in meds, vitals, ROS, exam, and then there is a very brief plan. I also saw a nonradiologist doing readings of self referred MRIs that seemed to be superficial and substandard, not even proofread. Depending on how these things are billed, these are services for a couple of hundred bucks (and in the thousands for the MRI). I could imagine that one can detect fraudulent work based on review of charts and billing. However, I believe that the big (fraud) bucks are rarely in primary care, but rather with tests, surgeries and devices. I hope they start looking there.

  26. Dr. Exhausted,
    I asked you before and I will try asking you again, what is it that you find so offensive to physicians in the current bill?
    As Dr. Lamberts mentioned RACs and Medicare audits are not new and the ludicrous “undercover patients” idea came from a conservative doctor, outraged by all the fraud in Medicare.
    So is it this particular healthcare bill that is angering you, or is it just general unhappiness with the current President?

  27. Dr. Lamberts accurately relates the conversations that are occurring at provider office meetings today. Certainly fraud in Medicare has to be addressed, however once again it seems that the ‘low hanging fruit’ ie the providers, are the focus rather than the DME suppliers, home health agencies etc. We are easy targets because as a whole we have historically bent over and taken it on the backside with little fight.
    The limitations and realities of RACs etc. are that indeed the system suggests a standard of ‘guilty until proven innocent’, the appeal process is heavily limited and weighted against the provider and in order to perform audits, consolidate EHR and paperwork and defend accusations, there will be substantial costs. In addition, cost-shifting will certainly be reigned-in with insurance reform, further widening the gap. Quite simply, it may not be economically feasible to continue to care for Medicare patients under this system.
    There is no doubt that fraud must be addressed and the costs recouped if possible, but it is incumbent upon us to remove the targets from our backs, consolidate our voices and publicize our position.

  28. Let me point out that this is not a partisan problem. RAC’s were developed under the Republican administration. I don’t see either side as friendly.

  29. Ironically, these are some of the arguments behind true socialized medicine. If all physicians and other medical professionals were on salary and there were no insurance companies, then they wouldn’t have to worry about any billings: they would only have to focus on patient care. Of course, I’m sure they would find all this worse than what they desribe above. But it’s an invitation to think about how you would build a better health care system for everyone.

  30. Dr Lamberts:
    Don’t wait for non providers to get what you have written, as most are expecting this pending health care deform to save the day. Yeah, on our backs.
    If you are truly sending this letter to the current occupant in the White House, as I am not willing to address this man as President per his agenda, please consider either cc to me, as you can contact me at my email address to confirm my name, or if willing to allow cosignators, feel free to add my name. It is completely and totally on the mark.
    Thank you for writing this, even if just for this blog site. Some colleagues not only agree with you, but feel it is time for the alleged powers to be in Washington to hear from us: add another yet stifling layer of control and supervision without true equal quality of management, and watch your health care system become that of a third world country. As handled by providers who are gutted and uninvested.
    It has come to this point, Americans. You can hear it from invested and caring providers like Dr Lamberts, myself, and your own doctor, or, believe the lies from politicians.
    2014 won’t come fast enough as is now!

  31. Doctors are being selected by profiles for further scrutiny. There is abuse in every Federal program. In a different light it is called “stimulus”. Finding abuse cannot be arbitrary and capricious.
    My office did not take Medicare for the 1 plus days the senate failed to delay the fee cuts. If it becomes too dangerous to participate in caring for Medicare patients, we are done with it.
    The RAC is very much like the Gestapo, Ja?

  32. If your “progressive” friends manage to revive the Public Option provision of HR 3200 through the “reconciliation / deeming” process, I don’t believe you will have the option of declining to treat the beneficiaries. On the bright side, you will be compensated, as I understand it, at Medicare rates + 5%.

  33. “Undercover patients” sounds like a witch hunt to me. I think EMR adoption will allow for better monitoring of docs’ behavior and reward better outcomes. I get the heebie-jeebies thinking about “undercover patients.” I feel like it’s setting a trap. It might not be – it may be a good idea – but I am not the only one with serious distrust.

  34. This is a rant. It is a very frustrated physician who is asked to jump through incredible hoops and still is on the hook at the end of the day if someone wanted to come after me. We pay by documentation, and that is a large part of the problem. “Rampant Medicare Fraud” is not because of doctors coding a 99214 instead of a 99213, it is a little more overt than that, yet the RAC brings the specter of slipping up and “being made an example of.”
    I am not alone to think that the RAC’s will justify their existence by getting enough “rampant fraud” even if it is simply coding errors.
    The point of this post was to explain how terrified this makes the rank and file of physicians. It is yet another argument in favor of docs dropping Medicare altogether. We are not raking it in from Medicare (not even close), yet we have to fear an audit, fines, and worse for not documenting properly. The documentation requirements are incomprehensibly complex.
    It’s very depressing from my perspective (and I tend to be more optimistic than most physicians, believe it or not).

  35. So, if RACs are not a good idea, what would be your proposal for fighting the rampant Medicare fraud, that folks all over the spectrum are agreeing needs to be addressed?
    Would do you think of Senator (Dr.) Coburn’s method of using “undercover patients”?