Poll of the Week – Opting Out of Medicare?

August 7, 2012

Practice Notes blogger and attorney Martin Merritt points out that September 1 is the current deadline for physicians who wish to opt out of Medicare. And he notes “record numbers are doing just that.”

Merritt provides six reasons physicians are dropping Medicare patients:

1. Forced Pay Cuts. By many estimates, Medicare reimbursement falls far below the cost of providing services.
2. Bureaucratic Nightmare. It’s difficult for physicians to document a patient file sufficiently to satisfy CMS.
3. RAC Auditors. Physicians must return payments, long after the claim has been paid, often because an auditor “with a financial interest in contradicting the physician overrules the doctor.”
4. Stark Law. No Medicare means no need to comply with Stark Law. As a result, physicians can engage in any free-enterprise arrangement, as long as it complies with medical ethics rules.
5. Whistleblowers. As with Stark Law, without Medicare there are no whistleblowers to deal with.
6. Criminal Prosecution. The OIG has redefined fraud to mean “anything the OIG doesn’t like, under the mantra ‘fraud, waste, and abuse.’”

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Have another answer or comment on our poll of the week? Share it below.

by Martin Merritt | August 13, 2012 5:09 PM EDT

Author, Martin Merritt responds: It sounds as though you have a carrier which restricts the use of CPT Code 99215. I realize it is frustrating, but using a "flagged"code can be dangerous. First, you must make absolutely certain you aren't making the same mistake Dr. Krizek made In the seminal case, Krizek v. U.S. http://caselaw.findlaw.com/us-dc-circuit/1097064.html, Krizek, a D.C. psychiatrist used the "Cadillac" of psychotherapy codes (45-50 minute face to face) when he at best, should have broken the coding into smaller units, as he often met the patient for 25 minutes and worked on charts and other patient matters for the balance. . He was sued for $80 million, ($10,000 penalty for each of 8,000 claims) One of the two appellate courts, I forget which, observed that it seemed as if $80 million in liability hinged upon which room Dr. Krizek was standing when he performed the service. In your case, if you have the code correctly charted, while I cannot give specific legal advice in a chat room, , and it is understood this is not legal advice, Medicare contractors may have simply refused to honor this code. They have learned that "if someone were to attempt to defraud the government, their behavior would involve heavy use of the highest code for a particular range of procedures, apparently, 99215 is one of these. (See, http://www.acpinternist.org/archives/2000/05/prevention.htm for a discussion of 99215 in an article entitled "How to Bill Medicare for Preventive Service." If you are right and they are wrong, and you do wish to fight on this point, I would suggest you contact your State Medical Association to see if there is any political will to take on this fight. This way, you aren't risking retaliation as you might if you go it alone. (I have heard many horror stories of not so coincidental audits and other bullying tactics following a refusal to lie down and take abuse.) On the other hand, it sometimes helps to recognize that Medicare is insolvent. (no one wants to admit this publicly,) but when an organization can't pay its bills, the first thing to go is any contracts, deals or promises to pay made before the organization went broke, and the money available is spread out as far as it will stretch. No different here . . .of course HHS is breaking its promise to pay . . .it isn't sinister and much as it is a collective state of denial. They are playing games with CPT coding, rather than admit what they are really doing . . rationing dollars. Part of the solution, however, is for the government to admit they have a problem, and stop blaming providers for the fact that HHS can't pay legitimate bills. Martin Merritt, a Dallas Health Lawyer, writes a weekly blog appearing each Sunday for Physicians Practice.

by Andrew Johnstone | August 12, 2012 4:57 PM EDT

My biggest problem is that EVEN if I meticulously document a 99215 by indicating the ten medical problems the patient has, the time in and time out of the room, 'nature of the problems discussed', and that over 50% of the time was spent counselling the patient - THEY ARE DENIED 100% OF THE TIME...! On appeal, they are ALSO denied 100% of the time.

So, I asked our "coding consultant"what her advice was, and she said that regardless of whether or not we meet the CPT guidelines for 99215, we should NEVER code 99215, or we will just keep getting audited, as a punitive measure to 'teach us to keep in line'.

So there are two ramnifications:

1. I am being threatened that if I don't commit FRAUD in order to boost the profits of our local Medicare carrier, I will be harassed and fined and driven out of practice. So when I perform a 99215, I HAVE TO LIE AND SAY I PERFORMED A 99214. If I lie for my OWN bottom-line, it's "fraud", and if I lie to make some other provider more money, it's "fraud".......why isn't it also "fraud" if I LIE to make Anthem more profits...?????????????

2. I can shorten-up visits by getting specialists to consult on every problem after the first fifteen-minutes' worth of issues, or order diagnostic tests that are certainly "justified", then have the patient return to go over the results. Of course all these things INCREASES the cost of health care, and I thought my job was to be efficient, thorough, and minimize unneeded testing or referrals, time off work, return trips, and so on.

GOVERNMENT 'regulated' health-care encourages the high-cost, inefficiency, and mediocrity that the politicians all claim they are trying to 'fix'.

Yeah, right.....