After hours care by doctors for patients who are ill or who have an emergency has been a fact of life as long as there have been doctors and patients. After all, as any mother of a sick child knows or any child of a sick or elderly parent knows, the phone call usually comes in the middle of the night, and your child’s fever seems to go up after midnight. We have all spent too much time too late at night trying to get someone to feel better.
These days, most of us end up trying to tough it out all night or, in a more acute situation we end up at the emergency room. Sometimes, a friend or loved one is admitted to the hospital and has to stay. Usually, their doctors come to see them during regular hours, but there are provisions within Medicare that pay doctors extra if they need to see their patients after hours.
Most doctors use these provisions responsibly. It makes sense that once they go home from a day’s work, they really don’t want to return to the office or hospital to see a patient unless it’s a true emergency. There are legitimate times for doctors to make that trek. For instance, my daughter broke her leg and needed surgery which lasted for hours. She was doing well, asleep late at night when she woke up screaming in pain with a high fever. The doctor was called; he came in and found a problem. He corrected the problem that night. Had he not come in at that time, she could have ended up not being able to walk again. That was a legitimate after hours visit.
The problem that Medicare is looking at is the fact that there are some doctors that are billing for after hours visits that are not necessary – or are not actually taking place after hours. As a result, Medicare is considering changing the rules and making it harder for doctors to get paid for this often essential service.
If your doctor tells you in the future that he or she cannot see you after hours don’t be upset with them. You can thank the doctors who abused the system for jeopardizing or eliminating a service that doctors have provided for many years because they care about their patients and their profession.
Medicare fraud is not a new thing. It has, unfortunately, been going on for years. The problem is that years ago the amount of money at stake was not nearly as high and the Medicare system was not in nearly as much trouble financially. When you put those two factors together in today’s system, fraud is hitting Medicare harder during its most difficult time in the last 60 years.
For one thing, Medicare fraud has become a multi-billion dollar business. There are people making multiple millions of dollars defrauding Medicare every year. With Medicare funding being cut and with lawmakers trying to keep payments to doctors and healthcare professionals competitive enough so that they can afford to continue treating Medicare patients, just eliminating part of the fraud could provide the funding for the shortfall.
CMS, the Centers for Medicare and Medicaid Services, has been looking into the situation for quite some time now and is in the process of enhancing its anti-fraud efforts. They have announced that they will be implementing some aggressive new steps in cracking down on fraud.
Some of the changes CMS will be making include enlisting program integrity contractors who will study billing trends throughout the Medicare system. In doing so, when it finds providers whose billing is higher than or otherwise out of sync with the majority of other providers in their region, these providers will be audited. Since it is impossible for Medicare to look behind every claim, this is a cost effective way to look at any red flags that are going up.
In addition, another way that CMS will fight fraud will be to actually contact beneficiaries to be sure that they received the equipment or supplies that Medicare is being billed for and that these were the right equipment and were in good condition. Billing will be reviewed before and after payment and physicians who order an unusually high number of the same or related item(s) will be audited and/or reviewed as well.
These ideas alone, when implemented, should save Medicare millions of dollars. They should also discourage some individuals from engaging in fraud, as the penalties will be quite stiff and will be handled by local, state and federal law enforcement agencies, including the FBI if necessary. With this new program and the strength of law enforcement, hopefully fraud will decrease and the money saved by Medicare will be used to help the beneficiaries who need it.
