Friday, November 30, 2012

I'm Going To Have To Sue Medicare

     Medicare hasn't paid my clinic for ancillary services for nearly two years.  That means it hasn't paid for IV's, x-rays, surgeries, labs, ultrasounds, casts, heart monitors, flu shots or Pap tests.
     It's not a punishment or take-back for overpayments.  Medicare simply sends a standard letter requesting copies of the patient's chart "before payment," then sends another once the records are received, saying all the services were deemed "unnecessary."  There is no one at Medicare who can explain why.  Once, Medicare responded to our perpetual queries and said that a registered nurse had reviewed our documentation and deemed every single service unnecessary.  Medicare is a factory zipping off these letters like thumbtacks, and I suppose it's saving America lots of money.
    True, after one and a half years of 100% scrutiny of my office records, Medicare now pays for every patient visit without demanding documentation first.  But I perform diagnostic procedures and treatments in the clinic, too, saving patients the trouble of having to go all over town before getting better.  Medicare withholds payment for all my work, even after its offices have received my records--thousands of pages.
     Medicare replacement policies, on the other hand, have paid for every service--and they, too, ask (sporadically) for copies of documentation to confirm that the services were "necessary" and "legitimate."  Replacement policies are issued by insurance carriers that supplant Medicare, providing similar coverage for medical services and exacting a fee from Medicare for "managing patients" at lower cost, or at least with less hassle.  Blue Cross, United Healthcare, Humana and AARP are some of the replacement policy companies which attract Medicare patients by promising lower co-pays and deductibles, or better inpatient coverage.  They follow Medicare's protocols for spot-checking and paying doctors.
     The only difference is, they pay my clinic for a parallel population of patients, and Medicare doesn't.  It makes no sense.
     "You're providing the same care, for the same types of patients, for the very same reasons," my billing clerk told me in frustration, "but the Medicare replacement policies pay you, after looking at the same caliber of record-keeping--and Medicare doesn't."
     "Why is Medicare refusing every single service I provide?" I complain.
     "I don't know," he said.  "It doesn't make sense.  And their appeals procedure doesn't work."
     Yesterday, a new Medicare patient arrived at my office in a wheelchair.  She was a sprightly woman--eighty but looking twenty years younger--and had tripped and fallen--like an eighty-year-old.  It looked as though she'd broken her ankle and elbow.
     "I came here because you're three blocks from my house!" she exclaimed, "and I need your x-ray machine."
     "I can't do x-rays for you," I told her.
     "Why in heaven's name not?" she demanded.
     "Well, I'm not sure why not," I fumbled.
     "My husband will have your goat, if I don't get x-rayed," she warned me.  "And my elbow hurts!"
     I looked at her left forearm, where she'd fallen onto a cement sidewalk.  It had a small scrape, but the bones were misaligned, and she flinched and slapped me with her other hand when I touched it.
     "What are you trying to do?" she reprimanded.  "Make it worse?"
     Her left ankle was puffed up like a tennis ball and had begun to turn purple.  She couldn't bear weight on it--hence the wheelchair, which my assistant had rolled out to the parking lot to help her into an exam room.
     I was wondering how to proceed.  I'm not used to being a traffic cop (known in the industry as "gatekeeper"), pointing every patient who comes to see me in the direction of other medical facilities:  x-ray, lab, bone density, orthopedics.  We do most everything under one roof.
     If my patient's ankle was broken, I wanted to know now.  If she needed a splint and crutches, I'd get them out of my supply closet and fit them today.  If a cast was required, she could return in two days, when the swelling had gone down, and I'd unroll the wet fiberglass over cotton padding to immobilize the bones until they healed.
     "I have an x-ray unit, casting materials, and crutches right here, but I can't give them to you," I informed her, "because Medicare won't pay me for any of it.
     "Well, then, let me pay you," she said, reaching for her handbag.
     "No, no, no," I remonstrated, "that's illegal."
     "By Jove, it's not illegal in my book," she told me.  "You have something I need, and I have the cash to pay you."
     Medicare forbids Medicare providers like me from accepting cash payments for medical services.  All medical tests and treatments must be processed through the Medicare system.
     "I'm sorry," I said.  "I can't take your money.  But I can call an ambulance for you."
     Never mind that the cost of an ambulance is twice that of x-rays and treatment in my clinic.)
     "I don't need an ambulance.  I need a doctor who can treat me.  What good are you?" she shouted.  "Why did I even come here?"
     I felt terrible.  She was right.  It was as though Medicare had tied my hands and feet.  I couldn't do anything for her, unless I did it for free--as I've been doing for the past year.  And this week, definitively, I had decided to stop giving Medicare freebies.
     One of my nurses walked in.
     "No, Dr. C.  You can't do it."
     She had read my mind.
     "You told us, No more procedures for Medicare patients.  You need to follow your own rule."  She was right:  we couldn't afford to serve half our patients for nothing...I had to stop.
     So, I sent my patient to the hospital in pain, and she was unhappy, and I was frustrated and, finally, I was angry.
     Therefore, I'm going to have to sue Medicare to get payment for the services I have already provided their "beneficiaries" (my patients).  I've never sued anyone before, but enough is enough.
     Can I sue Medicare?  Can I sue the government?  Doesn't the government have sovereign immunity?
     Besides, isn't ours a government of the people, by the people, for the people...I mean, aren't you and I the government, and could we--would we want to--sue ourselves?

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