Thursday, September 30, 2010

Medicare Fraud

So, it finally happened! Jay Weaver, the Miami Herald journalist who uncovered many Medicare fraud issues in South Florida, wrote another excellent article reporting that CMS is now being forced to revamp its payment policy. In his latest article he emphasizes that:

"An anti-fraud provision, tucked into the Small Business Lending Act that became law Monday, would force Medicare to end its 45-year-old policy of paying claims quickly without verifying them. The Centers for Medicare and Medicaid Services, which pays out $500 billion yearly for elderly and disabled Americans, would have to adopt new billing software with ``predictive modeling'' by next year. Such analytical technology enables the credit card industry to detect questionable bills for, say, a flat-screen TV purchased outside a cardholder's immediate area so that companies can notify the customer and stop payment if fraud is a factor.The cost of rolling out the new billing technology would reach an estimated $930 million over the next decade but it may reduce or prevent paying one of every $7 to fraudulent claimants.
Furthermore, the new Affordable Care Act includes tougher penalties for offenders, expanded administrative powers for Medicare and $350 million to combat healthcare corruption over the next decade."

Sen. George LeMieux, R-Florida, who sponsored the anti-fraud bill, said he has been frustrated watching Medicare continue to pay billions to dubious healthcare providers for unnecessary or bogus services. But Senator LeMieux supports the Republican Party platform to repeal the same Affordable Care Act which funds such anti-fraud activities! Does he really believe that the voters are that stupid, or short-term memory challenged, to forget his election antics?
Its time that politicians start collaborating and cooperating to solve the real problems we are facing and to focus on stopping the Medicare fraud gravy train.
But maybe I am too naive to believe that politicians are capable to act and behave rationally.


Wednesday, September 22, 2010

Healthcare Reform

Several very important component of the federal healthcare reform package are going to go into effect tomorrow.
Therefore, we should review the facts (and not fiction) regarding those components which will protect our patients (i.e. our families) from insurance companies. I hope that physicians will finally embrace these reforms, too. There should be no reason to reject them!
I also recommend reading today's Miami Herald editorial supporting healthcare reform. I agree with the authors conclusion:

"But tweaking the law and trying to get rid of it altogether, as a lawsuit filed by Florida's attorney general and others aims to do, are two different things. The law is an investment in the health and future of the American people. It can be improved, but it should become a permanent feature of American society."

Read more:

* Preventive services:
o Based on the theory that inexpensive preventive measures can reduce expensive hospital visits later, the reform act requires insurers to pay all costs for many immunization vaccines and screenings for colorectal cancer (for those over 50), depression, high blood pressure (for diabetics) and autism (for children 18 months to 24 months.)
o Also covered at 100 percent are mammograms for women over 40 and smoking cessation programs. For a full list of preventive services covered go to

* Adult children:
o All new private insurance that offers dependent coverage must allow parents to cover their children until age 26. They can live elsewhere and still be covered, and they must be charged at the policy's prevailing child rates.I
o If adult children can get insurance through their own jobs, they can't switch to their parents' existing job-based coverage if it's grandfathered. But if they don't have work coverage, they can move to parents' plans, even if the employers are planning to continue using their current plans.

* Right to appeal:
o Consumers covered under new, non-grandfathered insurance plans will have a right to appeal to an external party if, for example, their insurer denies coverage of treatments recommended by their doctors.
o Consumers will first have to file an internal appeal with the insurers. If not satisfied, they then can appeal to an impartial reviewer. Details of who will handle reviews and what regulations will apply are being worked out.

* No exclusions for children:
o In the past, insurers can -- and regularly did -- deny children with pre-existing conditions. As of Sept. 23, Thursday, they will be required to accept all kids, regardless of health status.
o This provision has led to spirited debate. Insurers' fear is that parents would wait until their kids got sick to buy coverage. `
o Insurers depend on providing coverage for a broad pool of people -- with the healthy majority paying premiums that fund the sick minority. Their fear with reform is that if only sick people sign up, insurers will lose huge amounts of money or need to raise premiums to horrendously high rates. Starting in 2014, that fear vanishes, because virtually everyone will be required then to have insurance.
o Health and Human Services recently responded to the insurers' fears about kid coverage, allowing insurers in the individual market to have an open enrollment period of, say, one month a year in which families could sign up children under 19 with pre-existing conditions. That means families will be encouraged to enroll healthy kids because they won't be able to automatically sign them up when they get sick.

* Lifetime caps removed:
o Many policies have limitations of $1 million, $2 million or even more. Most people never even have to think about them. But for those with severe chronic illness, their removal could mean a lot, possibly even preventing bankruptcy.

* High risk pools:
o For the truly desperate, the new high-risk pools can be a lifesaver -- but not a cheap one. They're intended for uninsured patients who have pre-existing conditions and can't get coverage elsewhere. They will serve as a bridge until 2014, when there are new government-regulated insurance exchanges accepting virtually everyone who can't get coverage elsewhere.
o Florida has had a high-risk pool for years, but because of the expense, it has been closed to new patients since 1991 and has only 250 members left.
o The Legislature opted not to re-open it in response to the reform act, meaning that the state's residents can sign up for a federally sponsored pool, known as the Pre-Existing Condition Insurance Plan.
o Under the plan, Florida residents will pay monthly rates ranging from $363 for those up to 34 and as much as $773 for those 55 and older, according to . That's with a $2,500 deductible and maximum out-of-pocket of $5,950 a year. Those payments cover only part of their insurance costs. The feds have allocated $351 million to Florida to pick up the rest of the expenses till 2014. Critics fear that's not enough.
o The program is only for those who are legally in the United States, have been uninsured for at least six months and have been denied coverage because of a pre-existing condition. Applications are available at or by calling (866) 717-5826.

* Limiting insurers' profits:
o Starting Jan. 1, insurers of large groups will be required to spend 85 percent of premiums on healthcare. For insurers of small groups and individual policies, it's 80 percent. In 2012, if insurers fail to meet these requirements, they must offer rebates to customers.
o Should money spent on converting to electronic records be counted as a medical expense or an administrative one? What about monitoring infectious disease rates in hospitals or money spent managing chronic conditions?
o The National Association of Insurance Commissioners has been working on draft guidelines. The U.S. Department of Health and Human Services says it has not yet received them.

* Other changes:

* About one million seniors have already received $250 rebate checks because of high prescription drug costs that were not covered by Medicare Part D.

* About 70 South Florida organizations -- including the Miami-Dade and Broward school systems -- will get funds to help pay for healthcare for retirees aged 55 to 64 who are not eligible for Medicare.

* Starting this year, businesses with no more than 25 workers with average annual wages under $50,000 can get tax credits of up to 35 percent of the costs of premiums.

For further information, is the government site for the reform act. The Kaiser Family Foundation (, the Commonwealth Fund ( ) and Families USA ( are three Washington nonprofits that provide details and analysis of the reform act.

Monday, September 06, 2010

Shifting Healthcare Costs

According to a recent editorial published in the New York Times (Shifting the Health Cost Burden, September, 2nd, 2010) "the latest annual survey of employer health benefits contains good news for the employers but bad news for their workers."
What are the good news? The average total premium for employer-sponsored health insurance (typically paid partly by employers and partly by their workers) rose only a modest 3 percent this year for family plans, reaching $13,770 in 2010.
What are the bad news? The employee share of their premium soared by 14% reaching almost $4,000, while the amount employers contributed did not increase.
Whats are the results?

* Employers shifted virtually all of the increased premium costs to their employees , who were in a weak position to resist in an economy where there were few other jobs to jump to.
* Since 2005, while wages have increased just 18 percent, workers’ contributions to premiums have jumped 47 percent, almost twice as fast as the rise in the policy’s overall cost.
* Meanwhile insurances are getting stingier and less comprehensive.
* Workers face higher deductibles, forcing them to pay a larger share of their overall medical bills. The Kaiser survey found a significant increase in the number of employees who had a deductible of at least $1,000, to 27 percent this year, from 22 percent in 2009. Almost half of workers who are covered by a small employer with fewer than 200 workers have an annual deductible of that amount.
* Increasing out-of-pocket expenses will almost certainly reduce the number of medical office visits, will force staff to collect deductibles at the point-of-care, or bill the patients and write off the increasing amount of unpaid bills. This will further decrease the margins in family medicine offices and force doctors to see more patients for less money!

What can we do? Facing very tight profit margins doctors must improve the efficiency of their offices, teach their staff to work as teams and advertise their medical services to those seeking cheaper medical services.
Instead of working harder we must work smarter. Yelling and screaming will not help us to move forward. We must learn to run our offices as small businesses and adapt quickly to the rapidly changing market place.