[As many of you know, Hillary has not yet completely given up on
a nationalized health care system. This article details many of
the problems now facing providers and patients involved with
MediCare. It would be considerably worse if the entire health
care system became nationalized. Currently HCFA deals with
various companies, often called carriers, to administer the
Medicare program. However, these carriers (some including HMO's)
still have to go by all of Medicare's rules and regulations.
Although the article is relatively self-explanatory, I would like
to point out two things which are touched upon in the article. In
1990 +/- it was Medicare, not the AMA, which changed virtually
all of the orthopedics procedure codes. To this day, I have never
found out a rational explanation as to why. Also, keep in mind
that it is to the insurance companies' advantage to delay payment
to providers. If a provider is owed, for example, $100, instead
of paying promptly the carrier delays payment for several months
earning interest on that $100 (also called the float). Multiply
this by several thousand providers and the interest becomes quite
substantial.]
YOUR GOVERNMENT AT WORK
Medicare snafu breaks podiatrist
Agency's non-payment of claims forces closure of doctor's office
By Jon E. Dougherty
� 2000 WorldNetDaily.com
An Indiana podiatrist claims he was forced to close his medical
practice because Medicare refused to reimburse him for legitimate
claims, WorldNetDaily has learned.
Dr. Willie F. Ray, who says "95 percent" of his practice was
made up of elderly patients, says that because his federally
contracted Medicare insurer has stalled his reimbursement
payments since January, he has been forced to close his office,
leaving his dozens of patients without proper foot care.
Ray said Medicare has reimbursed about $1,000 worth of claims
from his office since the beginning of the year, but "literally
tens of thousands of dollars in legitimate claims" remain
unprocessed. He said the agency instead "keeps sending me
letters requesting more information, which I send," but that
officials so far have failed to issue payments.
At issue, Ray said, was the system of "billing codes" physicians
must use to classify medical conditions. Medicare reimburses
doctors based on the codes; mistakes can delay payments, and
Medicare often audits claims made by physicians to ensure proper
coding. Incorrect coding can lead to reduced payments, withheld
payments, fines and -- in the worst cases, where fraud is
suspected -- even jail.
Physicians and health-care providers can also be held liable for
"undercoding" -- or undercharging -- patients, as well as
"overcoding" -- or overcharging -- them. Physicians can be jailed
or held liable for huge fines -- as high as $10,000 -- for each
occurrence.
Health-care professionals told WorldNetDaily that many auditors
sent to examine the coding procedures of physicians and
health-care providers have no medical background.
"They're told to go in and look for specific numbers or codes,
and if they don't find them, then the doctor is in trouble," said
one source who asked not to be identified.
"Also, in some cases, even if the staff goofs up and enters the
wrong code -- without the physician's knowledge -- that doctor is
held liable and the staffer is not," the source said.
In Ray's case, he said the codes he has submitted to Medicare
since January were "essentially unchanged" since they were
defined in 1998. Consequently, he said, "I can't understand why
[Medicare] is stalling or refusing to pay claims for this year."
Ray said his Medicare claims were audited "all of last year and
about two-thirds of this year." He was paid last year, he said,
but "this year they seem to have zeroed in on about three codes.
"Even though we have all the criteria for [Medicare's codes],
they just don't want to recognize them and pay them," he said,
adding that he had been audited "10 of the last 13 years." In one
case, Medicare asked for $6,000, which Ray paid but said wasn't
owed.
"I finally got it back after considerable hardship a year later,"
with no interest added, he said.
Worse, Ray explained, "every time they audit me, it's a thing
where I have to close down for about three to five days, go
around to all the nursing homes and collect the data, photocopy
it, then send it all in."
Medicare payments are handled by the Health Care Financing
Administration, a division of the U.S. Department of Health and
Human Services.
A spokesman with HCFA in Washington, D.C., told WorldNetDaily he
could not speculate as to why Ray's claims weren't being paid.
"If he's having a problem, he should take it up with his
contractor," said Craig Pulaski, a spokesman with HCFA's press
office. "I'm not able to get into any details about a particular
physician's problem."
Asked about a general situation where Medicare would suddenly
begin to reject claims made by physicians using the same codes
that have been approved before, Pulaski said, "I really couldn't
speculate about that. Codes for what?"
Pulaski said physicians use billing codes established by the
American Medical Association, and are paid through insurance
companies that contract with Medicare.
When pressed to describe the generalities surrounding Medicare
claim rejections, Pulaski was ambiguous: "I just simply don't
know. The circumstances are too case-specific for me to
speculate."
Nevertheless, the Health Care Financing Administration issued a
letter to all 800,000 of the nation's physicians, medical
suppliers and home health agencies June 1 asking for their "help
in assuring that Medicare pays correctly for their services."
In the letter, HCFA Administrator Nancy-Ann DeParle cited some of
the most common payment errors and urged doctors and other
health-care providers "to prevent such errors by providing
adequate documentation." She also said HCFA planned to establish
a new toll-free hotline for health-care providers with Medicare
questions, adding that the agency would "test new, simplified
guidelines for physicians to use when evaluating and managing
patients."
"Doctors share our interest in making sure that Medicare pays
correctly for the covered care that they provide to Medicare
beneficiaries," DeParle said in her letter. "By working together
to explain Medicare's requirements and prevent common errors, we
will build on our progress and better serve beneficiaries and
taxpayers."
The letters, the agency said, "are the latest step in ...
ongoing efforts to pay providers correctly while preventing
waste, fraud and abuse in the Medicare program."
The statement said such measures have reduced Medicare's payment
error rate to almost half of what it was in 1997.
"Although Medicare pays virtually all claims correctly based on
the information submitted, improper payments occur for reasons
such as insufficient documentation, lack of medical necessity,
and improper coding by providers," the statement said.
Dorman Cordell, a senior scholar at the National Center for
Policy Analysis, a public-policy think tank, told WorldNetDaily
that Medicare routinely rejects claims for the flimsiest of
reasons.
"Physicians are having to hire a tremendous number of people
nationally just to pursue insurance payments," Cordell said.
"Some have even begun to set up practices where they don't accept
any insurance payments -- from private insurers or Medicare."
Insurance companies "will kick back any kind of claim, as long as
there is some reason -- some minor reason, even -- to deny the
claims, such as submitting the wrong code," he said.
The answer, the policy center suggests, is "for people to be
allowed to have their own medical savings accounts." Such
accounts, Cordell said, "allow persons to pay for medical care
directly, and leave the insurance companies to pay for
catastrophic occurrences instead." Such payments "could also
supplant Medicare payments," thus freeing a medical consumer from
the constraints and procedural hurdles often presented by
insurers.
"Most physicians who deal with Medicare are in trouble with
payment," agreed Tampa, Fla., physician Dr. Donald J. Carrow,
M.D., well known through his popular, nationally syndicated radio
program, "Here's To Your Health." "This is true for most family
or general practitioners, but not for the specialist. Medicare
does cover specialists, but at a rate that induces the physician
to inflate the value of their service or to cheat."
Dr. Jane Orient, executive director of the Association of
American Physicians and Surgeons, told WorldNetDaily her
organization also has received many complaints from physicians
and health care providers about the cumbersome payment process --
or outright non-payment -- for services rendered under Medicare.
"Medicare denies claims for no reason at all and they demand,
repeatedly, redundant documentation from physicians, which I
think is just a delaying tactic," Orient said. "They don't
necessarily want to deny the claim -- they just don't want to pay
it," she said, "so they'll require doctors to send in boxes of
information, but there's no evidence that anyone ever reads it."
A day after WorldNetDaily spoke to HCFA officials in Washington,
Ray said his local Medicare insurance contractor, AdminaStar
Federal, contacted him. A spokesman from the company's Provider
Relations division said the firm would "get to the bottom of all
this" by mid-week. AdminaStar is a subsidiary of Anthem, Inc.,
an Indiana-based mutual insurance company.
Ray said AdminaStar has been his HCFA contractor for a number of
years. Nine years ago, during one of his two audits that resulted
in fines, he met with representatives of the firm in a building
he described as being surrounded by electronic surveillance
equipment and manned by armed guards.
Stranger yet, he said, is the apparent secrecy surrounding the
company.
"In all the times I've talked with them over the phone,
representatives never give me their full name, and they never
tell me where they are physically located. They say it's for
'security reasons.'"
Candy Arnold, another spokesman for HCFA, said in a separate
interview that she, too, could not provide "details" about a case
of non-payment of claims without examining all facets beforehand.
Arnold, who said she had been with HCFA for eight years, said she
had never heard of an instance where a physician provider had
claims rejected by a Medicare contractor for the length of time
Ray has been affected.
"I can tell you that since October [when Arnold became a public
relations spokesperson for HCFA], this is the first time I have
heard of someone not being paid for a year for absolutely no
reason," she said. "But I don't know that this is for no reason.
I really doubt that is the case."
WorldNetDaily attempted to contact a spokesperson for AdminaStar
or its parent company, Anthem, to answer charges surrounding
Ray's claims. No phone calls were returned, however.
A spokesman for the American Medical Association, who asked not
to be identified, said Ray's story is not atypical.
"We generally term this kind of issue as a 'prompt payment
issue,'" the spokesman said. "There have been occasions where we
have had significant amounts of trouble with an individual
[Medicare] carrier. All of a sudden there will be some sort of
change in the proper coding of a carrier, [who then fails to]
educate physicians properly about how to code their claims."
The spokesman went on to say such occurrences "were not unusual,"
adding that there were many "different ways" companies have been
"going out and reviewing claims."
He added that the American Medical Association feels that, based
on research, "delayed payments by managed-care companies and
other health insurers are a national problem, not just a local
problem."
The spokesman said a recent survey conducted by the AMA involving
16,000 physicians and 250 health plans showed that "typically, on
the average, payments [by insurers] are made 120 days late."
Neither Health Care Financing Administration spokesperson would
address the issue of late payments in a general sense with
WorldNetDaily.
Ironically, the AMA spokesman said, the "cost-savings that the
managed-care companies are seeing by catching improper codes
through enforcing -- via strict or sometimes heavy-handed
business practices" -- are overshadowed by the added expense of
compliance borne by physicians.
"It's costing physicians -- and eventually is adding to the cost
of the health-care systems -- about 20 percent more because they
have to hire extra staff to deal with the red tape," the
spokesman said.
"Medicare operates on about a hundred thousand pages of
regulations. Many physicians related their dealings with
Medicare and HCFA to having to deal with the IRS," the spokesman
said.
To HCFA's credit, the American Medical Association source said,
the agency "does give instructions to the carriers to remedy
problems, to get them fixed. But is that followed all the time
by the carriers? No -- it's a big bureaucratic system, and it
has to get to the right person."
The AMA spokesman said HCFA was also trying to circumvent
physician judgment by using medical records.
Patient records, the spokesman said, "are tools for physicians
made by physicians for doctors, to ensure the continuity of
care." However, HCFA, "in recent years, is starting to nickel and
dime physicians by trying to take the medical record and
transform it from a tool used by physicians into something that
can be used by a lay person -- a bean counter. That really
doesn't work. What two physicians can discuss and transmit to
each other ... would take significantly more text and detail" to
translate for laypersons untrained in medical terminology and
procedures, the spokesman said.
A spokesman for the American Podiatric Medical Association said
HCFA has been paying less for podiatric claims in recent years
and that Medicare has changed some of the patient coding, which
makes it difficult for podiatrists to keep up.
According to figures gathered by Citizens Against Government
Waste, a non-partisan government fraud and abuse watchdog group,
by HCFA's own statistics medical outlays for Medicare in 1996
were $203 billion and are projected to total $384 billion in
2006.
"If no changes are made, it will consume between 28 and 38
percent of the federal budget in 2030, compared with the 12
percent it accounts for now," a CAGW assessment report examining
the Clinton administration's Medicare reform proposal said last
year.
"By 1997, Congress fully comprehended that the Medicare 'trust
fund,' which pays for hospital care, was going to go broke in
2002 and moved to create a temporary fix," the report said. "By
resorting to funding cutbacks and accounting gimmicks, such as
reducing Medicare's payments to hospitals and transferring home
health care from Medicare Part A to B, Congress managed to delay
the inevitable until 2008."
Citizens Against Government Waste said the only way to ensure
Medicare solvency -- ironically -- was to adopt a model used by
the "Federal Employees Health Benefit Plan (FEHBP), which offers
choice and competition."
"The FEHBP has a reputation for keeping prices down and
healthcare quality high. In addition, according to the Office of
Personnel Management, every FEHBP plan offers a prescription drug
benefit. FEHBP covers 9 million federal employees, retirees and
their families, including the president and members of Congress,"
said the Citizens Against Government Waste report.
Some analysts have said the Health Care Financing
Administration's increased responsibilities, granted it by
Congress, are what is causing so much delay in making payments.
New emphasis on preventing "fraud and abuse," coupled with new
authorities to curb suspected abuses -- such as the agency's
authority to hire specialized anti-fraud investigators -- may be
"outstripping HCFA's capacity to manage its existing workload,"
the GAO said in a February 1999 report to the House Ways and
Means Committee.
On Tuesday, the Clinton administration announced that because
many of the nation's Health Maintenance Organizations were opting
out of Medicare this year, calling it "overregulated and
underpaid," nearly 1 million seniors and disabled persons covered
by the government health plans would be dropped.
Those people will have to scramble to find another HMO offering
Medicare benefits by the end of the year.
=================================================================
Kadosh, Kadosh, Kadosh, YHVH, TZEVAOT
FROM THE DESK OF: <[EMAIL PROTECTED]>
*Mike Spitzer* <[EMAIL PROTECTED]>
~~~~~~~~ <[EMAIL PROTECTED]>
The Best Way To Destroy Enemies Is To Change Them To Friends
Shalom, A Salaam Aleikum, and to all, A Good Day.
=================================================================
<A HREF="http://www.ctrl.org/">www.ctrl.org</A>
DECLARATION & DISCLAIMER
==========
CTRL is a discussion & informational exchange list. Proselytizing propagandic
screeds are unwelcomed. Substance�not soap-boxing�please! These are
sordid matters and 'conspiracy theory'�with its many half-truths, mis-
directions and outright frauds�is used politically by different groups with
major and minor effects spread throughout the spectrum of time and thought.
That being said, CTRLgives no endorsement to the validity of posts, and
always suggests to readers; be wary of what you read. CTRL gives no
credence to Holocaust denial and nazi's need not apply.
Let us please be civil and as always, Caveat Lector.
========================================================================
Archives Available at:
http://peach.ease.lsoft.com/archives/ctrl.html
<A HREF="http://peach.ease.lsoft.com/archives/ctrl.html">Archives of
[EMAIL PROTECTED]</A>
http:[EMAIL PROTECTED]/
<A HREF="http:[EMAIL PROTECTED]/">ctrl</A>
========================================================================
To subscribe to Conspiracy Theory Research List[CTRL] send email:
SUBSCRIBE CTRL [to:] [EMAIL PROTECTED]
To UNsubscribe to Conspiracy Theory Research List[CTRL] send email:
SIGNOFF CTRL [to:] [EMAIL PROTECTED]
Om
