Posts tagged 'medicare claims'
Medicare is a system that is supposed to help seniors deal with medical issues by providing coverage for healthcare costs. As an individual works month after month and year after year, they pay into the Medicare system and the payments are taken out of each of their paychecks. The idea is that when they are at the point of retirement, the coverage that they have been paying for all those years that they worked will be there to take care of their health needs.
In theory, this works well, and until recently, Medicare has taken care of millions of seniors. Currently, there are about 44 million people enrolled in Medicare. Most of them have the coverage they need, however, during the past decade or so, Medicare has run into various financial issues, creating a situation in which seniors must pay for some of their coverage.
In addition, though the Medicare system has been overhauled to work better with regard to claims and paperwork, it become more sluggish regarding approvals and claim processing, and it has made it difficult for seniors to get good care and for physicians to give good care. The main reason for this is that many physicians have to wait extremely long periods of time to get paid by Medicare for the patients that they treat.
In fact, some physicians have had to stop treating patients covered only by Medicare or they have at least had to stop taking any new patients covered by Medicare. It is simply too long to wait for payment, and many physicians are experiencing financial trouble as a result.
One such provider is an ophthalmologist in Santa Cruz, California. Dr. Joshua Babad treats many patients covered by Medicare. He cares for his patients and knows they need his help. After all, Santa Cruz is not a large town, and even in large towns, there are not a lot of providers – especially eye doctors – who accept Medicare.
Dr. Babad has tried to do his best for his patients, and in doing so, has ended up over $50,000 in debt. He has had to use retirement money to pay expenses while waiting for Medicare to pay him for legitimate services rendered. In addition, his wife has a brain tumor, so he is struggling with serious family medical and financial issues on top of his long wait for payment. He wonders if Medicare is trying to discourage doctors from treating the elderly or disabled who depend on Medicare for their medical needs.
Dr. Babad has practiced in the same location for over 30 years. He has contacted Medicare, as well as his state representatives to try to deal with the situation. He has stated that if he had to depend on only Medicare, he would have gone bankrupt a long time ago. There are other providers in the general area who are experiencing similar issues with Medicare. Medicare’s response to recent contact is that they have communicated with Dr. Babad and his situation will be corrected soon.
In the meantime, many seniors and their providers continue to struggle with delays and hope that they can continue working together toward good health care while Medicare gets its act together.
It is no secret that there are some serious issues that need to be addressed regarding Medicare. Lawmakers are looking for financial solutions, auditing solutions, quality control solutions and other changes to make sure that the Medicare system becomes sound again and is there to support seniors when they need it.
There have been problems with fraudulent and erroneous claims front and center in the news lately. On top of Medicare paying out billions of dollars that should not have been paid out for claims from phony doctors and patients for phony equipment and services, the Centers for Medicare and Medicaid Services (CMS) has been using their own Medicare officials to do the audits to figure out what types and amounts of fraud were actually perpetrated.
The lawmakers and oversight commissions have come back and stated that the Medicare auditors actually were not the right auditors for the job, were not following the strict guidelines regarding audits and, in the end, needed to be audited themselves because their figures were not accurate. Without following the correct guidelines, much of the fraud was missed. In addition, sending someone from their own agency to audit themselves isn’t a real effective or efficient way to find errors or fraud.
Currently, there are more issues that have arisen. One issue that has created problems for years is the sluggishness of the claims process and the payment process. Medicare beneficiaries and their medical providers are frustrated as they wait month after month for claims to be paid while expenses pile up, making it hard for everyone involved.
The latest situation – which has cost Medicare more money that it doesn’t have to spare and didn’t need to spend – involves overpayments for medication. Because the Medicare system is so slow, Medicare missed the opportunity to pay for less expensive generic drugs rather than brand names. Medicare was so far behind that they did not enter the generic alternatives into their computer systems when they became available, thus paying the higher prices.
One of the main medications, a cancer drug, was paid for at double the generic price because of a two-month delay in entering the new information into the system. The system had no idea that generics were even available for this particular medication, according to the inspector general’s office. There are also overpayments for other drugs that have generic counterparts.
With Medicare’s financial woes, they should be at least working faster to save themselves money. When confronted with the information about the overpayment, Medicare acknowledged that they should input information in a timelier manner so that it will reflect current market prices.
With lawmakers and others trying to save Medicare, it’s time for Medicare to help save itself.
Mike Leavitt, head of Health and Human Services wrote to lawmakers a few days ago asking for their help in healing Medicare. In the position he is in, he should know what some of the essential issues are that face Medicare and he has some straightforward ideas as to how to address these issues and begin fixing them.
Leavitt started out by stating that Medicare has done a great deal of good over the years, and this is important for all of us to remember. Medicare in and of itself is a good program, but the world, the United States, and the economy today is far different than it was 43 years ago when Medicare first began. In addition, medical costs have skyrocketed for many reasons including new treatments for diseases such as cancer, heart disease, diabetes and others. Many incredible medical discoveries have been made, however, the costs of caring for individuals with ongoing medical issues – especially critical issues – is much more prohibitive than in the past.
Today’s Medicare has more beneficiaries and fewer workers to fund the program. In addition, the costs of the funding will fall to our children and grandchildren, and if lawmakers – on both sides of the aisle – are not moved to fix the problems inherent in the system sooner, rather than later, the burden on the next generations will be overwhelming.
Leavitt states that in 1970 the cost per Medicare beneficiary was about $2,000 and now, in 2008, it is about $10,000. To make matters worse, there are over double the amount of Medicare beneficiaries now as there were before. Add to this the fact that health care costs have doubled but Medicare costs have quadrupled and baby boomers haven’t yet retired, and this is a recipe for disaster.
It is estimated that in the next 20 years the U.S. will be spending more on Medicare each year than on national defense. Families who are now spending about 23% of their wages on medical care will be spending over 40% of their wages on medical care, and Medicare will account for about 23% of that price tag. Add to that the fact that in 1970, about 4 workers paid for each Medicare beneficiary, and currently, less than 4 workers pay for each beneficiary. Then, looking 20 years ahead, only 2 to 2 and 1/2 workers will pay for each beneficiary, which means that workers will carry a heavy burden and the Medicare system may not be able to handle the toll of paying claims for all the beneficiaries enrolled in it.
Mr. Leavitt is urging Congress to consider these critical issues carefully and act on them in a bipartisan effort to fix as much of the problem as possible before it is too late. After all, it is our children and grandchildren, as well as their children and grandchildren who will be forced to deal with the problem if it is not dealt with now.
In an effort to control quality and costs Medicare is now watching for a number of specific mistakes and other preventable conditions that will not be paid for if claims are submitted for them. This is the latest set of safeguards that Medicare is using to ensure safety and eliminate erroneous claims and payments on those claims.
A “Do Not Pay” list may sound quite harsh, however, items on the list are not just lightweight mistakes. These items are serious, such as giving a blood transfusions using the wrong type of blood. Basically Medicare will not pay for transfusions gone wrong due to human error, and they will not pay for other services that are botched or that should not have been rendered to begin with.
The bottom line is that Medicare will not pay for complications that are preventable. Some of these complications that will not be paid are extra care costs for breaking up blood clots that are created as a result of knee or hip replacement surgery. Poor control of blood sugar levels will not be paid for.
Some individual insurance companies have begun using these strategies as well. Medicare’s move to keep these situations under control will likely bolster insurance companies in taking steps to do the same. In addition some of the states are considering having Medicaid adopt a do not pay list, as well.
There are opponents to this line of thinking including the American Medical Association (AMA). They have stated that there are better ways to contain costs and that they fear that quality of services rendered will actually decrease by enforcing a strict no-pay list because it does not address all circumstances and sometimes situations arise that are not necessarily the hospital’s clear and actual fault. In addition, it could lead to not attempting to provide treatment or services that could help a patient because of the fear of a complication.
It is clear that the do not pay list will have to be researched and addressed further, but for now it is another tool in trying to keep medical care safe and the costs of the care from skyrocketing further.
