Gaming the System
by John Delach
My dear senior citizens and fellow travelers, one of the passages we must make when the calendar verifies that we have reached the magical age of 65 is to enter into the brave, new and different world of Medicare. In many ways it is not overt or a shock to the system, but there is also no doubt that we will discover that things are different as we make appointments with doctors for the most mundane of visits. First, almost universally, our bright new red, white and blue Medicare Cards are accepted readily and little attention seems to be made to secondary providers. Despite all of the wringing of hands and doom and gloom articles that doctors are ready to opt out of Medicare, we experience a warm welcome, “Nice to see you.”
Then we discover that every time we see a provider, a CMS, Medical Summary Notice is produced detailing the costs of services rendered, the amount covered, less deductibles and coinsurance and the remainder that you may or may not be billed.
No longer is the bill for a visit a fixed amount. Now, when the nurse – practitioner takes a test, that’s a charge, takes your vitals, that’s a charge, uses a machine, that’s a charge and each charge has a different code; one visit, many codes.
When the doctor finally appears and asks, “How are you?” that’s a charge. “Say Ahhhh.” that’s a charge, “Let me see you walk?”: A charge. Test reflexes, that too is a charge. And, if during the course of your discussion you mention another non-related symptom, that will lead to additional tests and multiple new charges.
…And so it goes because that is the Medicare way. But you come to realize that there is something basically wrong with the system that encourages a menu of tests, treatments and examinations to be undertaken without regard to their actually being necessary, appropriate or beneficial.
Then, finally a wake-up call. Take Dr. Salomon E. Melgen, a North Palm Beach, Florida ophthalmologist who received $21 million in Medicare reimbursements in 2012. All hail Dr. Melgen, king of Medicare payments.
Better yet, he is worthy of being Fighting Dr. Melgen, he is suing Uncle to claw back $9 million he over-billed in 2007 and 2008. He protests the activities the federal lawyers charge he undertook with patients where they state: “(He) seeks to game the system by seeking reimbursement of three to four times its actual costs.”
The New York Times explained this charge further on April 10, 2014:
Each vial of medication (Lucentis) comes with up to four times the amount that a patient requires. Investigators said the doctor was using one vial to treat three or four patients and billing as if he had purchased a new vial each time. The doctor would be reimbursed $6,000 to $8,000 for a vial that cost him $2,000.
Fighting Dr. Melgen isn’t alone. Thanks to the Wall Street Journal taking the Department of Health and Human Services to court, the DOH&HS has been forced to release the list of the top Medicare earners. Joining Melgen in the second spot is Dr. Assad Qamar of Ocala, Fla, an interventional cardiologist at $18 million in Medicare reimbursements. Dr. Michael C. McGinnis, a pathologist from Wrightstown, N.J., finished third at $12.6 million.
Like Melgen, Assad doesn’t mind throwing money at politicians including $100,000 to the DNC. Assad also hired “…a former Justice Department official and Capitol Hill aide from the firm named Gregory W. Kehoe – helped Mr. Oamar contact more than a dozen members of congress asking them to help him address why he was subject to such intense scrutiny from Medicare auditors.” (NY Times.)
And, just in case you are wondering, both Melgen and Assad, according to the Paper of Record…”are still certified to receive Medicare payments.”
But wait, there’s more. Witness the lead story in the April 28th edition of the NY Times that ran under this headline:
One Therapist, $4 Million
In 2012 Medicare Billing
8 of Program’s top 10 Earners in Physical
Therapy Practice in New York
The four million dollar therapist is Wael Bakry. The Times notes that his practice treated 1,950 Medicare patients in 2012 and that Medicare paid him for 94 separate procedures for each patient. “That works out to 183,000 treatments a year, 500 a day, 21 an hour.”
Bakry’s rejoinder and rationale: His patients receive good care and return when they have other problems. “If the patients didn’t get good care, they wouldn’t come back to us again.”
Why is it I have this feeling this is still only the beginning with more to come down this Medicare pipeline? Good God Almighty, Only in America!
John, Have you also noticed it’s virtually impossible to tie in any of those CMS summaries to an actual visit because by the time you get them and then get the secondary insurer’s form time has passed. Lots of time and in some cases it flips over to the next year so to really figure out what happened you’d have to dig out your previous year’s records. It just wears me out and I usually pay what the physician wants figuring he has a large staff of clerks who hopefully keep good records. I do sometimes wonder, however, how to explain the occasional check I get from a physician or the secondary insurer that may not have any date of service. I tried to reconcile it a couple or times but now just deposit the check. It won’t get better. I was at my primary care guy Monday and after being asked to fill out a ream of forms, all of which info they clearly had, a nurse told me if was for the hospital which now owned the practice. I asked the doc about it and he seemed resigned to his fate of becoming a government employee due to the paperwork just becoming overwhelming. I sympathized with him(he’s nice guy) and said well at least he’d have more time to spend with patients and be able to hope for better outcomes. He smiled and shrugged saying my care would get worse. He noted how previously if I’d sat there with him and a condition he didn’t like became apparent he’d just call a colleague he knew had the skills to deal with it and have me in to see him within a day or so. Not any more. He said it takes weeks, not because his colleague is unwilling but because the clearance system is unwieldy. I should have asked him if he’s now telling patients like that to walk across the street to the ER. Onward and downward. Geoff
John, having been on Medicare for many years I have been able to see first hand what a screwed up system it really is and how easy it is to game it. My opinion (worth exactly what I will charge for the email) is that we will continue to see millions p—– off each year as long as it costs the patient nothing out of pocket. How quick think it would change if the patients had some real skin in the game??? Like you said this is one great country!!!
I’ve still got a few years to go before I face the Medicare quagmire. Glad to hear that your experience has not been as bad as reported. But on a brighter note . . . at least the government has made health care affordable!
BTW. I have some fellow retirees who have told me that their financial advisors are coaching them on how to manage down their taxable income so that they can qualify for subsidized health care. So now our kids can not only fund our Medicare but can also subsidize health care for their wealthy parents who have not qualified for Medicare yet. God bless our children.
That’ a wrinkle I had not heard about. That’s the problem with government systems, the grafters move right in.