Posts tagged 'General-Medicare'
It stands to reason that the most vulnerable individuals in the United States who have some of the most extensive health problems and have paid into Social Security and Medicare while they worked for years, should not have to worry about how they will be able to get their medication. In their minds – and most of the rest of the nation’s – they have paid their money dutifully, month after month and year after year, and they were told that they wouldn’t have to worry when they got older and retired. They have been thinking that Medicare would take care of them and they would have the medical treatment – and medication – that they need to live as full a life as possible with their medical symptoms controlled as much as possible.
Unfortunately, for individuals who are in this situation and happen to have a very low income, it is not working out that way. What has happened is that with the “new and improved” Medicare prescription coverage, things have changed.
The new Medicare drug plans were introduced three years ago. At that time, numerous health insurance companies made bids to provide prescription coverage for low-income Medicare recipients because Medicare paid for part of the premiums, therefore the company was reimbursed, theoretically making money, not losing it.
Companies started realizing that they were not making the money on low-income individuals – especially those with serious or chronic illnesses – so they began bidding higher rates so that they would not get chosen to supply this coverage. Last year 1.2 million people had to be moved from one plan to another due to lack of companies providing prescription coverage. This year, the number will be even higher because there are even fewer companies offering low cost prescription coverage for low-income Medicare beneficiaries.
As a result, many of these Medicare enrollees could be left without enough coverage. They could be in a position where not all of their prescriptions are covered, yet they are among the sickest among us, and they cannot afford to be without their medication because it will seriously compromise their health and could lead to fatalities.
Studies have been done showing that this is the case, however, Medicare says that there will still be several choices of companies and prescription plans for low-income Medicare beneficiaries. The government automatically assigns these individuals to a plan that should cover their needs.
If you are on a limited or low income and have prescription drug coverage you can contact Medicare and/or your prescription plan and ask what will be happening for 2009. You are allowed to change plans at any time during the year. Make sure that you are covered. If you are not sure, contact your local Office on Aging, Medicaid Office or talk to your doctor’s billing office to get your questions answered.
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.
Just when we are talking about going back to the basics of house calls on one end of the spectrum, the other end of the spectrum is beginning a pilot program in telemedicine.
House calls will begin being expanded soon and paid for by Medicare for those with multiple serious conditions and other situations that make house calls the best form of care for them.
Now, with that out of the way, Medicare is still looking for ways to provide effective and adequate treatment to patients while containing costs. They are finally looking at telemedicine.
Telemedicine has been around for quite some time now. Some private insurers have paid for certain treatment by telemedicine. For example, I have a nephew who was born with serious heart problems and had a pacemaker installed when he was younger, nearly a decade ago. Once his initial treatment was completed, telemedicine was used to keep him in sync of his heart surgeon and keep his heart surgeon abreast of his condition.
At the time, what would happen was that we would call a particular phone number and use our phone and another instrument to measure my nephew’s heart rate, heart rhythm, blood pressure and other vitals, as well as whether the pacemaker was working. The doctor would get the reports and then we would have a conference by phone. If there were problems or complications we would go to the local emergency room where my nephew’s doctor would communicate with the emergency room doctor by phone and computer. If things got too serious, we would get my nephew up to the Children’s Hospital where his doctor was on staff.
Today’s telemedicine is more advanced than it was a decade ago. There are cameras and TV screens that allow doctors and patients to see one another. Patients have some of the instruments such as stethoscopes, so that they can be instructed by the doctor when and how to use them so he can help them remotely. There are also touch screens patients can use to answer doctor’s questions to aid in a diagnosis.
Now that insurance companies – and Medicare – have realized what doctors and patients have been saying for years, they are finally trying telemedicine out. Doctors and patients have been telling insurers that it is better for everyone that telemedicine evaluations, where appropriate, cost under $1,500 on average as opposed to a hospital admission or other tests that often add up to somewhere between $2,500 to $15,000.
It is good news that Medicare is now looking at ways to see if telemedicine will work well for certain patients. If it only keeps a few patients out of each hospital, Medicare can save potentially over $100,000 per hospital while patients receive quality care. This is an issue to keep an eye on.
We have been hearing a lot lately about a new way that Medicare plans to keep the highest quality of procedures and services in hospitals. Most of the feedback has been excellent, except for – you guessed it – a few hospitals whose track records aren’t so great.
The new rules are considered a bold new plan to help the elderly, seniors and those who are ill. Basically, the rules have been put into place so that hospitals can and will be more careful in the way they perform everything from drawing blood to inserting a catheter to performing serious surgery.
Any and all of these procedures can cause complications such as serious infections, blood clots, pneumonia, the need for another surgery due to mistakes during the original surgery and more. Medicare has proposed not paying for these avoidable issues for a long time now, and the rules regarding the situation went into effect today.
It is important for patients to know that hospitals are not allowed to charge the patients for these types of issues that Medicare will not pay for. The reason that Medicare will not pay for them in these cases is because the hospital was at fault due to negligence or carelessness and should have to absorb the cost. It is hoped that if this happens in a particular hospital enough times, the amount of errors, problems and complications will decline.
This is a great step toward hospitals providing higher levels of service and keeping patients safer with better outcomes. Unfortunately, some states are not following Medicare’s lead and they are reimbursing certain hospitals – especially in low-income areas – anyway. Even though Medicare states that these complications and other issues are not acceptable, some areas are reimbursing them which lets them know that some losses are acceptable, service does not have to get better and in low-income areas you get what you get.
Most states are following Medicare’s lead and looking to hospitals to make the necessary changes to become safer. Hopefully this will eventually take place throughout every state in the country. Until then, depending upon where you live, you are most likely a lot safer in the hospital today than you were yesterday before the rules went into effect.
Home health care is not a new concept. In fact, for centuries, that was pretty much how health care was administered. A person fell ill and someone in the household fetched the local doctor to come to the home, make a diagnosis, prescribe treatment and a plan and wait to see how the patient fared.
This method of health care worked pretty well for several reasons. For one, the person who was ill – especially if they were quite ill – did not have to struggle through the exertion of leaving their home, their family and their bed to go out and take the ride to the doctor’s office which could be quite a distance away. In addition, they could stay home and sleep or rest while waiting for the doctor, not exposing themselves to the elements especially during the cold times of year that brought rain, sleet, ice, hail and snow. Most of the time the doctor knew his patients and when given the description of the medical situation at hand by the individual who went to fetch the doctor, the doc knew what medicines and tools were needed and brought them to the house.
Today we live in a medical world full of incredible research, extensive hospital systems and services and doctors who specialize in everything from headaches to heartburn to hangnails to heart replacement. Medical breakthroughs happen daily and the progress being made is extraordinary.
All of this being the case, however, there are still those among us who would do better having more of their healthcare performed at home. Chronically ill patients – especially with more than one serious illness – and seniors who find it harder and harder to get around could benefit from having health care performed at home more often than having to go to a doctor’s office, a clinic or a hospital for routine care.
In recognition of the situation, two senators have sponsored a bill that would keep seniors at home and pay for doctors, nurses or other medical practitioners to visit them there. The bill would involve doctors or nurses creating a plan of care with the patient and showing that overall, the plan which would include more home care, would help the patient more and save at least 5% of what they are paying now. If doctors could do this, they could keep 80% of any savings over 5% as an incentive, which would help the doctors and save the Medicare system money.
Even with all the fancy medicine we have available to us today, it is good to know that we have come full circle on a few things that will help seniors and chronically ill patients get good care while remaining comfortable at home when possible.
There have been many debates recently as to how to handle the situation of healthcare for individuals who are living in the United States but are not U.S. citizens. With elections around the corner, this issue has become an intense topic for discussion on all sides of the aisle.
There are many varied opinions regarding healthcare for these individuals and families. Studies have shown that the money they generate in the economy and sometimes in taxes offsets most or all of the medical expenses they incur. Other studies say the opposite.
With Medicare and Medicaid budgets and services struggling financially there have been questions raised as to how these individuals receive medical care and what it costs the system.
In Ohio, the Columbus Dispatch Newspaper stated in an article that the poor and/or undocumented in central Ohio, line up at the free health clinic near Ohio State University. The lines begin to form hours before the clinic – which is staffed by volunteer doctors and nurses - opens for services.
There is now a proposed bill requiring Clinica Latina and other clinics that serve undocumented residents to check for immigration status and turn away any individuals who do not have documentation. The bill states that the reason is that part of the funds for this particular clinic and some others come from Ohio State University. If the clinic were to receive funds only from private sources, they could continue treating these individuals without checking their status.
The issue that this leaves could have a huge financial impact on Medicare, Medicaid and the healthcare system because it would leave undocumented citizens with only the hospital emergency room for treatment. Unlike clinics, federal law states that hospitals cannot deny services to individuals based on various issues, including immigration status. As a result, seeing a doctor at the free clinic and receiving a $5 prescription for blood pressure or diabetes medication could now cost hundreds of dollars at the emergency room, and Medicare, Medicaid and taxpayers would have to absorb those costs.
The issue of undocumented residents in this country is not a simple one, nor will it be solved simply or quickly, however, it is important for lawmakers and administrators to look at the big picture and the overall costs before eliminating programs that could save an already struggling system money just to prove a point.
Most of us start getting creaky knees as we get older. Some of our knees just creak here and there and other creak all the time. Others creak and hurt too often, usually as a result of osteoarthritis.
This is actually an uncomfortable situation, but it is normal for these symptoms to begin to happen to us between age 45 and 55 and develop into chronic problems after age 60.
Medicare used to pay for arthroscopic surgery on the knee to address the issue of osteoarthritis. In 2002, a study was done stating that there was no better improvement in the knees of patients who had arthroscopic surgery than there was in those who simply had physical therapy and used ibuprofen and other medications.
Many doctors and patients were quite unhappy with the fact that this study prompted Medicare to stop covering the procedure. They felt that this particular study, which was performed on about 175 men, was too limited to make such a sweeping decision which affected hundreds of thousands of Medicare recipients. Medicare finally has the results of another study performed by Boston University School of Medicine and a separate study performed by the University of Western Ontario in Canada.
The results of both recent studies confirm the results of the 2002 study: arthroscopic knee surgery for osteoarthritis is over-performed and does no better than physical therapy and medication. Of the nearly 1300 participants in the studies, the individuals who received physical therapy reported that they felt better and had less pain after receiving physical therapy, taking anti-inflammatory medication and sometimes using glucosamine. The results of those who had arthroscopic surgery were exactly the same.
The biggest difference was that the bill for the surgery alone is about $5,000 or more, plus any doctors fees, lab and hospital fees and other ancillary fees. That is much more than some physical therapy, exercises the patient can do at home and medication. In addition, the studies show that the procedure is unnecessary.
In some cases arthroscopic surgery is warranted, and certainly, in some more severe situations arthroscopic or other knee surgery would be appropriate. It is important to get a second opinion and to try physical therapy and other treatment before you opt for arthroscopic surgery. There are two reasons: first, experts are saying that it doesn’t work and some doctors are simply making money on the procedure. Second, Medicare will not pay for it.
So, if your knees are creaking or hurting, or both, look into your options to determine what will be best for you.
Medicaid is supposed to help families take care of medical and dental needs, and this is especially important for children. A recent study by the United States government revealed that millions of poor children on Medicaid are not getting the dental treatment they need because they cannot find dentists willing to accept Medicaid as payment.
This leaves many children in a very vulnerable state. The findings, released by the Government Accountability Office stated that millions of poor children between the ages of 2 and 18 have untreated dental decay and disease because they cannot get the needed treatment.
It might not sound like a huge issue to have a cavity that doesn’t get taken care of, but think about whether you have ever had a toothache that grew worse and worse over a weekend. When you went to the dentist you discovered that you had a cavity that, if it had been addressed sooner, could have been filled. The dentist feels that you now need a root canal or other serious procedure because the cavity has destroyed too much of your tooth and that is what is causing your pain.
Now think about a child or young adult who has not one but 5 or 10 of these festering in their mouth. They are in pain. They probably are not able to eat right. Perhaps they cannot concentrate – especially in school – because of the pain and headaches due to the dental problems.
If they –or their parents – are conscientious about brushing, flossing and rinsing with mouthwash, they may avoid infection. If not, like 12 year old Deamonte Driver, even though they try to do everything to keep the condition under control, they are unable to. In Deamonte’s case, he ended up with a serious tooth infection that led to a brain infection and he died.
Deamonte had Medicaid coverage. He had a simple cavity. His mother tried to find a dentist – any dentist – that would help him and treat the condition while it was a simple situation and no dentist would do so because they would not accept Medicaid as payment. Because of a few more dollars, 12 year old Deamonte is dead.
Only 1 out of 3 children on Medicaid are receiving dental care, mainly because nobody will provide it. It is essential that while lawmakers are looking at a Medicare fix, they look at Medicaid, as well. It is also essential that practitioners, schools, lawmakers and Medicaid work together to fix this problem. 2 out of 3 children on Medicaid that cannot find dental care should not remain vulnerable to the unconscionable outcome that Deamonte Driver and his family suffered.
Seniors enrolled in Medicare should receive Medicare information in the mail regarding their benefits in October. They should receive a letter and information telling them what they are covered for, what supplements they are enrolled in (if any) and any changes to their premiums and/or their coverage.
It is important to take the time to carefully read this information and make certain that you understand it. It will tell you what your 2009 premiums will be and will tell you what is covered, including prescriptions.
Prescription coverage will be very important to check over carefully. You could currently be covered for all of your medications, but there could be changes in coverage that might cover every medication except for one. This does not always happen, but it could.
In the event that one of your prescription medications is not covered it is important that you check with your doctor and see if there is an alternative or substitute prescription that would work in its place. Then you will have to check to see if the alternative or substitute medication is covered. If you can’t find a suitable alternative medication, you may have to check for a different supplement that will cover the medications you need.
Other things to consider are how much the premiums will increase, if any. Check to see if your co-pays will increase, as well. The more you know about your coverage, the better decisions you and your doctor will be able to make regarding your ongoing treatment.
The fact that this information is being sent to you in October gives you time to get the facts you need about your coverage before the open enrollment period for Medicare Part D, which is from November 15th through December 31st. That is the time during which you can switch plans if you need to, without any penalties for pre-existing conditions or other issues.
If you receive Medicare, be on the watch for your letter describing your current coverage in October. If you don’t receive it, call 1-800-MEDICARE. You can call the Seniors Health Insurance Information Program (SHIIP) at 1-800-443-9354 or check with them on the web at www.ncshiip.com. They are an organization that specifically helps seniors with insurance and Medicare questions and issues.
Identity theft has become a huge problem in the United States and throughout the world, and it is getting worse. It seems that every day we hear about a new way that fraudsters have figured out to get pertinent information about us that they can use to purchase anything from a car to a home to illegal drugs.
Through the years, Medicare cards have displayed the individual’s name and Social Security number front and center, as well as other information that could help identity thieves to get your information and use it.
It is interesting that Medicare is finally getting around to doing this. Insurance companies and other organizations have begun doing this years ago, and when you talk to most places such as banks, insurance companies, the power company or others on the phone, they only ask for the last 4 digits of your Social Security number and they only have access to those four digits unless they are in a specific department.
More care is being taken to protect our privacy and a substantial part of that protection comes with protecting our Social Security numbers. The Social Security Number Protection Act has been proposed to Congress as a critical issue that needs to be addressed now. The senators who proposed the action have said that the Federal Government should be taking the lead in this area, not lagging behind. They are asking that the removal of Social Security numbers be mandated and that the unnecessary use of Social Security numbers be eliminated.
It is, of course, impossible to eliminate the use of Social Security numbers in many instances, however, there is a difference between using the numbers and going out of the way to protect people’s identity, as opposed to using the numbers and basically flaunting them or leaving them in plain sight as a temptation and easy road to fraud for identity thieves.
With 8.4 million people victims of identity theft last year alone, this is a critical issue. The legislation would give CMS a limited amount of time to remove Social Security numbers from Medicare cards, correspondence and unencrypted information. This should give Medicare recipients some peace of mind.
It’s not something your accountant would advise you to do if you are a physician or health care practitioner or professional. In fact, your account, financial advisor, closest friends and others would most likely strongly –very strongly – advise against making such a move.
But all business decisions are not simply made for profit only. Some are made because there is a serious need to be filled and there are people that are willing to go the extra mile to fill it.
The news is filled with stories every day regarding senior citizens who need health care and can’t afford it. Many of them receive Medicare benefits, but can’t find a doctor willing to be paid at Medicare’s lower than normal rates and even slower than normal payment pace.
A group of doctors in Amarillo, Texas decided to go the extra mile and help seniors in the area by opening a clinic that provides health care only to seniors with Medicare benefits, Medicare Supplements or enrolled in Physician’s Health Choice, which is a physician owned health plan which provides seniors with more coverage than Medicare.
The clinic, which recently opened, is designed to provide medical care to seniors, but that is not its only purpose. Doctors feel that if seniors had access to more information and accurate information regarding prevention and maintenance of health issues, they could maintain better health, therefore having to visit the doctor’s office for treatment less often.
The Amarillo Senior Care Clinic was established to address the fact that seniors face obstacles in receiving care because fewer doctors are willing to take Medicare for payment, and many will no longer accept new Medicare patients. As a result, seniors have less access to quality care, often exacerbating conditions that, if cared for regularly and properly could be controlled by medication and other interventions with less office visits, keeping more seniors out of emergency rooms, hospitals, long term care and nursing homes, because their conditions would be managed and not get to the point where they were out of control.
Many physicians say that this is a losing proposition financially; however the Amarillo Senior Care Clinic, though cautious, is not worrying. They feel that by stressing prevention and providing education, their patients will feel better and their health will stay more stable.
This is an innovative and exciting idea, and it would be great for physicians throughout the country to keep an eye on the Amarillo Senior Care Clinic and see how well it works. There are seniors in every county in every state who need this type of help to live longer, healthier lives.
With all the financial issues surrounding Medicare it has become harder to find doctors who readily accept Medicare, or even accept it at all.
Before the increase of fraud, red tape, financial woes, budget constraints and the like, doctors who accepted Medicare were not hard to find. Many doctors used to set aside a percentage of their time to devote to Medicare patients. They certainly weren’t making money on these patients, in fact, many times, they did not even break even by covering expenses, but the income from their overall practice absorbed the losses. Though Medicare was not a perfect system, it worked out for the doctors and their patients.
More recently, with all the Medicare woes, including very slow reimbursement at an extremely reduced rate, the majority of doctors say that it is too expensive to treat Medicare patients. They want to treat these patients and try to treat as many as possible, but are unable to take on new Medicare patients for financial reasons. Their regular practices cannot absorb the losses any longer.
This is not just frustrating to the doctors who would like to help these patients, but it is frightening and frustrating to patients who have spent a lifetime paying into a system that promised healthcare coverage but is now in such shambles that the doctors and specialists these patients need the most will not accept it for payment. This critical situation nationwide is leaving too many of our most vulnerable citizens without adequate care and actually making them more vulnerable because of it.
Lawmakers continue to say they are trying to fix the ailing system but are caught up in partisan arguing rather than bipartisan efforts, while the situation continues to worsen. The question arises as to whether they would rather pay out hundreds for office visits that prevent major health issues or thousands to pay for the health conditions that are not treated because of being penny wise and dollar foolish, as well as short sighted. Surely if there is enough money to fund billions for war, there should be enough to send Medicare recipients to the doctor.
As fewer doctors accept Medicare, there is the real possibility of a far worse health crisis than we see today. If you have Medicare benefits, check with your doctor and call others to make sure they will accept it. You can also call your local health department or hospital for further information about doctors in your area.
There are doctors who continue to accept Medicare, but it is becoming more difficult to find them and Medicare recipients who should be automatically taken care of are having to search for services. The system needs fixing NOW.
There was a time not too long ago when many doctors made house calls, especially for the elderly or disabled. It was more of a comfortable, less stressful and easier situation for the individual who needed medical care.
With the increase in “big medicine” people have gotten used to going to the doctor’s office. There are many reasons for this. Doctors are able to treat more patients if they can stay in one place and have the patients come to them. They also have all of their equipment set up in their office, as well as usually having a laboratory, x-rays and other services located in their medical building or close by, making it much easier for them to diagnose and treat their patients. And, of course, if they are at the office and the patients come to them, they can schedule up to 30-35 patients per 8 hour day in 15 minute increments.
Though this is convenient and cost-effective for the doctor, it has its down side for both the doctor and patients. If a doctor takes longer than the 15 minute time slot with a patient, it has a domino effect and backs all the other patients’ appointments up, making them have to wait longer. We have all sat for what seemed like forever just to be rushed through a doctors appointment and we have left wondering if the doctor actually heard anything that we said in the rushed 5 minutes that we were able to the doctor face to face.
Though most of us can sit through the wait and get through the appointment, it is often much harder for a person who is elderly, frail or disabled. Medicare knows this and so do doctors. There are still some doctors that will schedule house calls and Medicare will pay for these visits, though most patients don’t know it.
There is a quiet but powerful move by a number of doctors across the country to try to see ore patients in their homes. With an elderly or disabled patient, an appointment at home saves the often difficult trip to the office. A home visit also allows the doctor more time to examine and talk with the patient to take a closer look at any changes in health or any difficulties the patient might be having. If a problem is discovered that cannot be dealt with at home, the patient can then be seen at the doctor’s office, but most often, with regular care, most treatment and observation can be carried out at home.
If you receive Medicare benefits and find it too difficult to go to your doctor’s office, ask if your doctor makes house calls or if the doctor knows of a doctor, nurse or nurse practitioner who does. You can also ask for information from the home health care agencies and hospice in your area. There is not an overabundance of doctors who make home visits, but there are some and the numbers are slowly growing making it easier for individuals covered by Medicare to receive the care they need.
As Medicare tries to become more effective, efficient and streamlined, eliminating paperwork and unnecessary time, the Centers for Medicare and Medicare Services has planned an online system to help providers enroll to be providers. This system will be available to most states in early 2009, and will also be available in California, New York and Missouri by October 2009.
Not all enrollment materials will be available on the web-based system, however there will be enough to get the process started and move it along more quickly than the old system. In the past it took 90 days – and sometimes much longer – for a provider to complete the enrollment process. With the new online process, it is estimated that it will take 30 to 45 days instead.
One drawback that providers are talking about is the fact that since the system will not recognize online signatures, the online paperwork must be followed by actual paper forms with original signatures sent to employees at CMS who process the paperwork and combine the files. Providers are skeptical about this, as they feel it will continue to take more time, however, CMS says that they can be working on everything in the computer so that the process goes quickly and the original signatures on paper will simply be verified, not re-processed.
Another drawback according to providers is that each provider who wants to enroll as a Medicare provider must enroll in a separate and different system first. The second system is called the Individuals Authorized to Access CMS Computer Services. Providers see this as an extra and cumbersome step and wonder why there cannot be one system that can deal with all of the hoops they must jump through in one complete system.
In addition, providers are skeptical because there have been promises to speed up the enrollment system for quite some time, and this particular system was supposed to be up and running by March, 2008, according to CMS, making the debut over six months late.
Regardless of how the providers feel about some of the issues inherent in the debut of the new system, one thing is true: there is the potential to enroll providers more quickly and the potential to add further services for providers including billing, budgeting, records and more in the future.
For now, we can all wait and see how the system works and if it saves time and expense for CMS, Medicare, providers, as well as Medicare recipients.
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.
Medicare is an essential program that was designed to help the elderly and the vulnerable. Presently, Medicare covers over 44 million people so that they can receive medical care.
Fraud has long been an issue regarding Medicare. There have been too many loopholes, a system that is designed in a manner that makes fraud easy, and too little oversight of the billions of budget dollars intended for legitimate Medicare expenses.
In addition, there have been – and still are – unscrupulous business people out there who have designed ways to defraud the Medicare system. It is one thing to make a mistake, it is quite another to intentionally set up a business network for the express purpose of taking money from the most vulnerable of our citizens, especially when that money is scarce to begin with.
The latest in a series of fraud-based businesses to take advantage of the lax oversight over Medicare dollars is a scheme involving HIV/AIDS clinics in south and mid-Florida. These clinics have made so much money that officials are asking the public for help in stopping the fraud.
Officials have announced a new “Infusion Fraud” hotline, asking the public to call and report phony HIV/AIDS treatment in an effort to stop clinic operators from receiving millions for services and treatments not provided. These unscrupulous clinic operators have been most prevalent in south Florida and purchase Medicare lists or pay patients to come into their offices, and then bill Medicare for millions of dollars in fraudulent claims for treatments never provided. Last week a couple who ran a billing service was sentenced to 14 years in prison for billing nearly $150 million in fraudulent claims for 85 different clinics.
There are several ways that Medicare is trying to combat fraud in that area. They have set up a hotline that people can call to report fraud if they become aware of it. The fraud does not have to be HIV/AIDS related; it can involve any fraudulent issues or scams with Medicare.
Medicare is also sending out Medicare statements to recipients in southern Florida on a monthly basis instead of quarterly in hopes that people will look at their statements and report any treatments or charges listed that were not received or don’t look legitimate. By doing this monthly instead of quarterly, there is less of a time lag, giving Medicare a better chance of catching the perpetrators while they are still up and running and in business.
Records show that last year HIV/AIDS claims for treatment totaled $1.5 billion in south Florida as compared to only $300 million in New York City. This is an obvious imbalance that is receiving attention.
The phone number to report suspected Medicare fraud is 866-417-2078.
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.
For years we have heard about the plight of seniors on very meager incomes who have to rely on Medicare and Social Security to survive and who have had to buy second-rate food – or even dog/cat food – so they can eat.
Medicare has been designed to help seniors with their medical expenses, especially prescriptions. The prescription drug coverage, a supplement to Medicare, is essential to seniors, as much of their ongoing healthcare is dependent on their medication.
This part of the Medicare coverage available should actually be the easiest to deal with. No doctor, no hospitals, no tests, just medicine. However, with the changes to Medicare, especially with Medicare Advantage on the scene, things have gotten somewhat dicey in the area of seniors and prescriptions.
On the surface, Medicare Advantage is a good idea, but once you look into it, there re dangers lurking just a little below the surface. These dangers can leave seniors extremely vulnerable, because once seniors have reached a particular amount of coverage/paid claims for prescriptions, the bottom drops out.
What happens is that if a senior has a Medicare Advantage plan that pays up to $2500 in prescriptions, once they hit that amount, they must pay for further prescriptions out of their pocket – often to the tune of thousands of dollars. Once they reach the next plateau, coverage kicks in again.
The problem with this situation is that if a senior on Medicare Advantage has spent the initial allotment of coverage for prescriptions in the month of August, they will be paying for medication out of pocket possibly for the rest of the year. Many times, the cost of medication is more than their entire Social Security check or entire income that month.
Because of this, too many seniors are simply going without medicine. Imagine being on insulin or heart medication. How long could a senior with diabetes or a history of heart disease go without their medication before there are serious complications, or even fatal ones?
Lawmakers are trying to fix Medicare. This is one area where they have to pay close attention. In the meantime, physicians can try to work with their patients on Medicare to prescribe generics – especially those that are $4 on many pharmacy plans – so that seniors don’t have to risk their health and their lives by going without.
It seems like Medicare continues to have more problems when it comes to keeping records, fraud and audits. We recently reported that there had been an inspection by the Inspector General’s office regarding overpayments, payments for false claims and fraud. That investigation, by the Human Services inspector general’s office originally uncovered what seemed to amount to about $700 million.
The Medicare Officials that conducted the investigation gave these figures. There is only one problem – the information was based on faulty statistics. In fact, the way that Medicare officials conducted the investigation went directly against Medicare rules.
What was supposed to happen was that the billing be matched against purchases, medical records and orders from doctors. They were not handled this way. They were matched against purchases, but limited medical records in only some of the cases and they were essentially not matched against orders from doctors at all. The end result is that many phony purchases were matched against phony billing, leaving much of the substantiating information out of the equation.
As a result of the way that this was handled (remember the fox watching the hen house), Medicare officials investigated their own information and came out with a faulty figure. They determined that the $700 million in fraud that they gave as their figure amounted to about a 7.5% fraud rate.
When looking at the true figures, however, it is actually estimated that the total amount in fraud is actually over $1 billion. The federal report said that if the Medicare officials had made the auditors abide by the rules, the amount of incorrect or fraudulent billing would have been much higher, resulting in the $1 billion mentioned.
With Medicare having the financial problems that we continue to hear about, $700 million was bad enough. Now we are looking at $1 billion. It seems that $1 billion would pay for a lot of prescriptions that the Medicare Advantage donut hole is swallowing up.
Reports have recently revealed that Medicare prescription drug supplements are not being watched very carefully. In fact, there is a fraud prevention program that is supposed to be in effect to deal with the prescription drug coverage offered by private insurance companies.
The Government Accountability Office holds CMS responsible for monitoring and auditing the $39 billion prescription drug programs. That is a great deal of money that could easily be misused. The GAO examined five plans that are unnamed and created a report detailing the shortcomings regarding what CMS is responsible for.
Some of the oversight responsibilities that have not been adhered to by CMS include establishing training programs for employees so that they can recognize fraud and misuse of relevant laws. Only two of the five programs have established such training.
CMS states that though they did not have the training in place, the programs did establish written standards for detection and prevention of fraud and waste. The GAO has strongly suggested that CMS should conduct audits of the prescription drug programs.
CMS says that they have asked the programs to produce self-assessments – (remember the fox watching the hen house, again?) – and said they would use the self-assessment surveys in place of audits for now. They said that they are focusing on complaints, especially since their audit budget was capped at $720 million, stating that this restricted amount makes it difficult, if not impossible, to conduct proper auditing.
This attitude toward auditing fraud, coupled with the fact that CMS has not developed even a streamlined auditing system, might be saving Medicare some tightly budgeted money in the short term, but the billions that are being taken out of Medicare while officials are ignoring the problem, could be saving the country and its Medicare beneficiaries billions. This might be enough to eliminate some of the unaffordable and superfluous supplemental programs and create a Medicare system that is affordable and works for everyone.
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