News and Analysis (November/December 1999)

Inflammatory HCFA Notices

I reviewed the "new" non-inflammatory" notices which the AMA says that they have finally convinced HCFA to use on Explanation of Medicare Benefits (EOMBs) and find that these are the very same notices our local Medicare carrier has been using for a number of years now. I fail to appreciate, however, how the "new" notice stating "The information provided does not support the need for this service or item" is any less inflammatory than the "old" term "not medically necessary."

The inflammatory nature of these little notices sent to Medicare beneficiaries is compounded by the fact that they are sent to the patient before the physician is given a chance to respond or dispute Medicare's determination.

Even if the physician is successful in reversing Medicare's adverse determination, the physician's reputation and the patient-physician relationship suffer damage which is not undone when the carrier sends a cryptic "adjusted" EOMB to the patient. Medicare has been systematically damaging patient-physician relationships and physicians' reputations like this with impunity for many years now.

HCFA Bureaucracy Unable to Keep Up

The AMA's testimony to the House Ways and Means Subcommittee on Health on Feb. 11, 1999 contained a number of interesting comments. On page 3, they state that "there is a growing sense among Medicare experts that HCFA is ready to collapse under the sheer weight of its administrative duties." Their administrative duties, of course, have been increased in recent years by the HIPAA and the Balanced Budget Act of 1997. As one who writes to HCFA frequently to complain about carrier bungling and abuse, this has been my sense of HCFA's precarious position as well. HCFA has had extreme difficulties during the past year or two keeping up with my voluminous correspondence, and I'm just one person. Whereas my letters in the past would receive a response within weeks, the delay is now usually months if they respond at all. The same is true of the Medicare carrier. I've noticed recently that they are also unable to keep up with responding to my correspondence.

Unfortunately, the AMA feels the solution to this mismanagement of the Medicare program and lack of oversight by HCFA is to give HCFA more money and hire more bureaucrats to do a better job of harassing more physicians.

HCFA Errs....Again

Just how abusive can Medicare's pre-payment audits get? Well, physicians billing for high level office visits in the Kansas City area found out the answer to that question earlier this year when some were required to produce documentation on literally hundreds of patients. According to HCFA's director of program integrity, it was all due to a carrier training session that "had gone awry" (AMNews, May 3, 1999, "HCFA ends erroneous claims review system in Kansas.") In their unrestrained zeal to make physicians' lives as miserable as possible, the trainers apparently forgot to tell the carrier trainees that "requesting information on 500 claims from a single physician was not a good idea." Although HCFA admitted the mistake, there was no mention of any reparation for the damage they undoubtedly caused to the physician offices. This bureaucratic assault on physicians is, of course, reminiscent of the description of the King's bureaucrats in our own Declaration of Independence --- he has "sent hither swarms of officers to harass our People, and eat out their substance." The physicians who were subjected to HCFA's harassment and who have had their substance eaten out are reportedly considering dumping the Medicare program as a result of their experience.

New Jersey Physicians Reject Clinical Pathways

In a bold stand against cookbook medicine, thousands of New Jersey physicians threatened to boycott the state's new rigid treatment protocols that went into effect in March --- the Automobile Insurance Cost Reduction Act.

"This is going to be a national model for how insurance companies and legislatures can screw doctors and hurt patients. If they can get away with this in New Jersey, they can get away with it anywhere. They're not going to pay us to treat patients properly. This is the most restrictive managed care system you can imagine" --- Steven Lomazow, M.D. (AMNews, May 10, 1999).

Medicare HMOs Breaking the Law

Nearly half of the calls to the Appeals Hotline of the Medicare Rights Center were for HMO non-compliance with Medicare rules and regulations. Violations included failure to cover emergency treatment, failure to process appeals in a timely fashion, failure to cover out-of-network services when appropriate in-network services were not available and failure to provide other benefits as guaranteed by the HMO's Medicare contract. No mention was made of any adverse consequence suffered by the offenders who are members of the privileged public-private partnership (AMNews, Oct 5, 1998).

This edition of News and Analysis was written by AAPS president-elect, Lawrence R. Huntoon, MD, PhD. It appeared in the
Medical Sentinel, November/December 1999, Volume 4, No. 6, p. 206. Copyright©1999 Association of American Physicians and Surgeons.