F.R. Duplantier reporting Behind The Headlines
Week of:
September 24, 2000
Medicare May Be Hazardous to Health



F.R. Duplantier

by: F.R. Duplantier

"Medicare patients receive the care that their physicians think Medicare wants for them."


"The Medicare bureaucracy is threatening the quality of medical care for American seniors," charges Washington DC attorney Jonathan Emord. "It is reducing care for these patients to the lowest common denominator," he explains. "It is also driving solo and small group practices out of existence in favor of large managed care groups and hospitals."

In a lecture on the adverse impact of Medicare paperwork requirements on doctors and their patients, published by the Heritage Foundation, Emord points out that physicians are "mindful of the fact that the Medicare insurance carrier will scrutinize every billing entry, questioning its medical necessity and reasonableness. They are also mindful of the fact that the Medicare fee schedule places caps on billing amounts for services and is uniformly below market rates. In addition, they know that the costs of complying with Medicare record-keeping requirements often equal or exceed the fee amounts Medicare pays."

Emord contends that physicians "greatly fear the Medicare bureaucracy and hope to get by without its notice. They know that the bureaucrats can rob them not only of their precious time, but also of their money, their reputations, and, indeed, their ability to practice medicine. To avoid the risks associated with Medicare inquiries, investigations, and audits," he notes, "physicians frequently select common billing and service-level codes. They thus choose what they perceive to be the path of least resistance, the one likely to make them least visible to the Medicare carrier's billing review staff."

Every decision a doctor makes "can be called into question if examined later in microscopic detail," Emord observes. "As a consequence, physicians not only tend to bill Medicare for common services at common levels, but also tend to provide Medicare beneficiaries common services even when the best patient care would require different or more intensive service. They are forced to balance their desire to help the patient with their fear that doing so in a manner not generally accepted by Medicare may result in substantial costs and penalties down the road."

Emord complains that the Medicare bureaucracy offers "no master list of covered and non-covered services," making it "impossible to discern all services that are covered and non-covered, necessarily resulting in a guessing game for physicians. Doctors who guess wrongly," he emphasizes, "are the subject of inquiries, investigations, and audits and may be charged with Medicare fraud or abuse."

Emord reports that "the Medicare bureaucracy demands copious record-keeping to justify all billings. Full justifications are required to be written in the patient file for every material decision affecting billing. The absence of adequate record-keeping is the basis for a reimbursement demand or, in extreme cases, a fraud or abuse charge." This regulatory burden is forcing "solo and small group practitioners to devote substantially less time to patient care," he laments. "Doctors incapable of affording the lawyers, accountants, and risk managers now needed just to avoid high risks of adverse government action are electing to close shop and go to work for large managed care groups and hospitals."


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