Not all health providers accept Medicare insurance, the federal program for seniors. The vast majority of those who do are completely ethical and bill as accurately as possible for services rendered. They do so because they are honest. After all, these professionals have dedicated their careers to the services of others, not their exploitation.
As in any other industry, there is a small minority that abuses the system and engages in fraud for personal gain. Medicare recently published the amounts paid to individual physicians throughout the country. Some of the culprits were at the top.
Some are over the top. Just after graduating medical school, I got to know a physician administrator who had long since retired. Decades before, he had an ownership stake in several hospitals in Southern California. I was mortified when he shared that once he visited the basement of one of his hospitals only to find that there was a team working around the clock printing fictitious claims for patients who had never received services at his facility.
There are, however, other, more reasonable explanations for sitting at the top of the Medicare reimbursement list. For example, cataract surgery is the bread-and-butter procedure performed by ophthalmologists. Cataracts tend to develop later in life, and as such, the majority of these patients carry Medicare insurance. A hardworking, efficient ophthalmologist can restore crisp vision to a good many patients on a given day.
Other specialists such as rheumatologists might build laboratories in their offices — not a bad idea since most of their patients need blood tests at each visit.
Orthopedists might have X-ray machines that enable them to diagnose fractures and follow bone healing while saving their patients an extra trip elsewhere, especially while they are disabled.
In fact, to date, more of the people’s resources have been spent trying to stop fraud than has been returned to the system. Perhaps the ratio will improve as providers continue to move over to electronic health records, which are easier to mine.
The bad news is President Barack Obama promised that a good portion of the costs for the Affordable Care Act would be covered by catching fraudsters. Unfortunately, not only did this not bear out, it caused many physicians who were already deeply frustrated with Medicare to voluntarily relinquish their participation.
The truth is that Medicare, once hailed as the mark of a civilized society, one that provides a health safety net for its retired citizens, is deeply flawed and difficult to work with. To begin, the process of credentialing a new provider is long, arduous and unpredictable, even if it is only to add a new location. Over the years, our clinic has had to wait as long as six to nine months for approval. In the meantime, providers working at the clinic still must be paid.
In addition, reimbursement is typically lower than for any other payer aside from Medicaid, the insurance program for low-income individuals.
Bear in mind that because of their age, Medicare patients tend to be more fragile, more complicated and more time-consuming to care for. At the same time, coverage for preventive services and immunizations is minimal.
Medicare provider support staff are also routinely poorly informed and provide inconsistent responses and incorrect information when queried on claim delays and denials. There is also poor coordination and maintenance of benefits. That means it is hard to know for sure who is covered. In the end the collection ratio for health services rendered in good faith suffers, and indirect costs of running a billing department can be driven skyward. If this is any indication of what national health care would be like in this country, we should all run for the hills.
The only reason Manakai o Malama continues to accept Medicare insurance is because we believe it is unconscionable to turn away the elders of our society because the federal health care system functions poorly and reimburses too little to cover costs. Our kupuna must have the access to the care they need.
Ira Zunin, M.D., M.P.H., M.B.A., is medical director of Manakai o Malama Integrative Healthcare Group and Rehabilitation Center and CEO of Global Advisory Services Inc. Please submit your questions to info@manakaiomalama.com.
