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Medicare and billing

Physicians writing on KevinMD about Medicare payment, the relative value unit system that sets it, coverage and authorization rules, and what the program pays for time and thinking against procedures. Three maintained records draw on this archive: Primary care: what physicians say, in their own words, Prior authorization: what physicians say, in their own words, and Direct primary care: what physicians say, in their own words.

Policy

Why doctors shouldn’t worry about MACRA

I’ve had the chance to present the changes being brought by the Medicare Access and CHIP Reauthorization Act (MACRA) to audiences of hundreds of physicians -- at ACP’s Leadership Day on Capitol Hill, ACP’s Board of Governors and Board of…

I’ve had the chance to present the changes being brought by the Medicare Access and CHIP Reauthorization Act (MACRA) to audiences of hundreds of physicians — at ACP’s Leadership Day on Capitol Hill, ACP’s Board of Governors and Board of Regents meetings, several educational sessions and a news briefing at the College’s Internal Medicine 2016 Scientific Meeting, and to the California Medical Association’s Leadership Academy.  I’ve also had chats with …

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Why doctors shouldn’t worry about MACRA

Physicians

Naturopaths have weaseled their way into the health care system, and they want more

Naturopaths are currently engaged in an intensive lobbying effort at the Capitol in order to gain recognition as medical practitioners and inclusion in Medicare. As a retired naturopath who was licensed in two states, I want to offer a primer…

Naturopaths are currently engaged in an intensive lobbying effort at the Capitol in order to gain recognition as medical practitioners and inclusion in Medicare. As a retired naturopath who was licensed in two states, I want to offer a primer to this political maneuver: Naturopaths are not who they say they are.

To be fair, naturopaths (NDs) are no longer obscure practitioners. NDs are currently licensed or registered in 18 U.S. …

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Naturopaths have weaseled their way into the health care system, and they want more

Policy

Why Medicare is not the enemy

With all the changes happening in health care and the increasing weight of federal mandates and requirements, it’s easy to view the Centers for Medicare & Medicaid Services (CMS) as the big, bad enemy. After all, if they just left…

With all the changes happening in health care and the increasing weight of federal mandates and requirements, it’s easy to view the Centers for Medicare & Medicaid Services (CMS) as the big, bad enemy. After all, if they just left all physicians and health care institutions on their own, everything would be OK, wouldn’t it? It’s an occasional line of thinking I’ve heard from many esteemed colleagues and also appears to be …

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Why Medicare is not the enemy

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Policy

How to perform services that increase primary care revenue

CMS states it wants to increase pay to primary care physicians. And while we might quarrel with their strategies or with the speed of achieving the goal, few would quarrel with the goal itself. In recent years, CMS has developed…

CMS states it wants to increase pay to primary care physicians.  And while we might quarrel with their strategies or with the speed of achieving the goal, few would quarrel with the goal itself.  In recent years, CMS has developed HCPCS codes and adopted CPT codes, some limited to primary care and some not specialty restricted but all likely to be reported by primary care practices. Meanwhile, although payment systems …

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How to perform services that increase primary care revenue

Policy

In defense of Medicare’s observation status

A recent article suggested that using observation status for a hospitalized veteran was dishonorable to his years of service to our country because observation would subject him to higher out-of-pocket costs. This post created quite a lot of discussion and…

A recent article suggested that using observation status for a hospitalized veteran was dishonorable to his years of service to our country because observation would subject him to higher out-of-pocket costs. This post created quite a lot of discussion and debate. While I agree with the author and commenters that observation is confusing to all and that there has to be a better way, the premise that observation …

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In defense of Medicare’s observation status

Policy

Inpatient vs. observation: We have created a monster of our own making

A few weeks ago I wrote a piece about my hero patient, a World War II veteran who landed on Normandy beach, and how he had been left in a difficult position by the whole observation versus inpatient situation while…

A few weeks ago I wrote a piece about my hero patient, a World War II veteran who landed on Normandy beach, and how he had been left in a difficult position by the whole observation versus inpatient situation while he was hospitalized.

My intention was to draw attention to these types of scenarios and how they cause intense anxiety and concern to our elderly. It’s a horrible …

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Inpatient vs. observation: We have created a monster of our own making

Policy

When debating inpatient vs. observation, remember this history lesson

The observation versus inpatient distinction is rightly getting more media and public attention with each passing month. In a nutshell, for anyone reading who is not familiar with what this is all about, it’s essentially a way of categorizing people…

The observation versus inpatient distinction is rightly getting more media and public attention with each passing month. In a nutshell, for anyone reading who is not familiar with what this is all about, it’s essentially a way of categorizing people when they get admitted to hospital.

You are either deemed an inpatient (basically a more complex case) or an observation (a less serious case). The individual reasons and checkboxes that have …

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When debating inpatient vs. observation, remember this history lesson

Policy

Observation status and readmissions: The data may surprise you

Because hospitals are expensive and often cause harm, there has been a big focus on reducing hospital use. This focus has been the underpinning for numerous policy interventions, most notable of which is the Affordable Care Act’s Hospital Readmissions Reduction…

Because hospitals are expensive and often cause harm, there has been a big focus on reducing hospital use.  This focus has been the underpinning for numerous policy interventions, most notable of which is the Affordable Care Act’s Hospital Readmissions Reduction Program (HRRP), which penalizes hospitals for higher than expected readmission rates.  The motivation behind HRRP is simple:  the readmission rate, the proportion of discharged patients who return …

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Observation status and readmissions: The data may surprise you

Policy

The straight face test of our health care system

Health care in America is fracturing right down the middle, and doctors are going to have to figure out if or how long they can straddle the divide between what patients want and what the government and corporate America want…

Health care in America is fracturing right down the middle, and doctors are going to have to figure out if or how long they can straddle the divide between what patients want and what the government and corporate America want them to have.

Up until this point, the momentum has been with the payers, Medicare, and the insurance industry. But the more heavy-handed they become, the more inevitable the public backlash …

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The straight face test of our health care system

Policy

The problem with penalizing poorly performing hospitals

All of us who care for the poor, the illiterate, the poorly educated, the immigrant, the frail, and the abused know this: caring for them involves many challenges that aren’t picked up by Medicare computers or big data. Simplistic calculations…

All of us who care for the poor, the illiterate, the poorly educated, the immigrant, the frail, and the abused know this: caring for them involves many challenges that aren’t picked up by Medicare computers or big data. Simplistic calculations about quality metrics such as hospital readmission rates have been way off the mark at capturing the complexities of caring for these patients.

A recent study from researchers in …

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The problem with penalizing poorly performing hospitals

Physicians

A physician’s open letter to Medicare patients

Dear patients, This is a hard letter to write, but it is important that you know about a major change that is coming for both of us in 2017, just a short year away. As you recall, last year I…

Dear patients,

This is a hard letter to write, but it is important that you know about a major change that is coming for both of us in 2017, just a short year away.

As you recall, last year I left a large hospital group practice and opened my own office, and I want to thank you for your faithfulness in following me to my new location.  With the newfound freedom of …

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A physician’s open letter to Medicare patients

Policy

Transparency in medicine can be misleading, but it’s necessary

Transparency in medicine is a good thing When the Center for Medicare and Medicaid services (CMS) publicly disclosed the 2012 CMS reimbursements to physicians, the response was immediately felt throughout the medical community. As a practicing physician, we were warned…

Transparency in medicine is a good thing

When the Center for Medicare and Medicaid services (CMS) publicly disclosed the 2012 CMS reimbursements to physicians, the response was immediately felt throughout the medical community.  As a practicing physician, we were warned of this day.  Can’t say we prepared for it, but we sure did brace for it.

And sure enough, on April 9, 2014, the New York Times published on their website a …

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Transparency in medicine can be misleading, but it’s necessary

Policy

Readmission penalties: Medicare’s ingenious move

A long, long time ago, hospitals existed to admit patients when they were sick, treat them with medicines or surgery and good nursing care, and discharge them after they became well. Hospital care was at one time a charity, which…

A long, long time ago, hospitals existed to admit patients when they were sick, treat them with medicines or surgery and good nursing care, and discharge them after they became well.

Hospital care was at one time a charity, which evolved into a nonprofit service, before it became a very big business.

In olden days, nonprofit hospitals charged patients straightforward fees for their services. Then, when you were just a young whippersnapper …

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Readmission penalties: Medicare’s ingenious move

Policy

We need full transparency for hospital chargemaster prices. Here’s why.

If she had been eligible for Medicare, the hospital would have charged the government $10,000 for the services it provided to her, with Medicare picking up most of the tab. But lacking insurance, she was billed directly from the hospital,…

If she had been eligible for Medicare, the hospital would have charged the government $10,000 for the services it provided to her, with Medicare picking up most of the tab. But lacking insurance, she was billed directly from the hospital, and not for a mere $10,000. The total charge: $120,000!

That 1,200 percent markup is extreme. But out of the 50 U.S. hospitals with the largest price markups, 49 are for-profit …

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We need full transparency for hospital chargemaster prices. Here’s why.

Meds

Blame the system, not Martin Shkreli

Toxoplasma gondii is a parasite that causes opportunistic infection in helpless people. It may have met its match. The cost of treating toxoplasmosis, a rare but extant infection, just shot up exponentially. Drug-resistant strain, you ask? Have physicians in infectious…

Toxoplasma gondii is a parasite that causes opportunistic infection in helpless people. It may have met its match. The cost of treating toxoplasmosis, a rare but extant infection, just shot up exponentially. Drug-resistant strain, you ask? Have physicians in infectious disease gone mercenary, you wonder? No. A change in ownership.

Daraprim (pyrimethamine) is a nifty drug that kills parasites. It’s been around for eons. I still recall its name from my …

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Blame the system, not Martin Shkreli

Policy

Bundled payments means the death of quality medical care

A recent CMS proposal to bundle payments for doctors and hospitals for hip and knee replacements in 800 model centers has hit a roadblock. The five-year program would have begun January 1, 2016, and nearly 300 comments were received by…

A recent CMS proposal to bundle payments for doctors and hospitals for hip and knee replacements in 800 model centers has hit a roadblock. The five-year program would have begun January 1, 2016, and nearly 300 comments were received by CMS earlier this month. Apparently most of the comments were not, shall we say, favorable. Even the Federation of American Hospitals protested

For those who are unaware, “bundled payments” means that …

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Bundled payments means the death of quality medical care

Policy

Innovation in health care: Too much, too little, or just right?

I was recently discussing all the changes going on in healthcare at a summer cookout with a few doctors in private practice. The topic of accountable care organizations (ACOs) came up, and the group started debating the pros and cons…

I was recently discussing all the changes going on in healthcare at a summer cookout with a few doctors in private practice.  The topic of accountable care organizations (ACOs) came up, and the group started debating the pros and cons of them.  At one point in the conversation, I brought up Medicare’s Innovation Center (the organization leading efforts like ACOs) and asked the group what they thought of it. No …

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Innovation in health care: Too much, too little, or just right?

Policy

How Medicare benefits doctors: A complicated history

Fifty years ago, President Lyndon Baines Johnson signed Medicare (and Medicaid) into law. Medicare’s relationship with physicians since then can best be described as a complicated one. First, recall that Medicare became law notwithstanding the American Medical Association’s fierce opposition…

Fifty years ago, President Lyndon Baines Johnson signed Medicare (and Medicaid) into law.   Medicare’s relationship with physicians since then can best be described as a complicated one.

First, recall that Medicare became law notwithstanding the American Medical Association’s fierce opposition to it. Three years prior to its enactment, AMA President Ed Annis warned that, “We doctors fear that the American …

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How Medicare benefits doctors: A complicated history

Policy

What running an lawn service taught me about health care today

Years ago, I owned a lawn service. I ran the company. Actually, I was the company. The only worker. Then, a buddy of mine joined up. It became our summer gig for many years. We prided ourselves on quality. We…

Years ago, I owned a lawn service. I ran the company.

Actually, I was the company. The only worker. Then, a buddy of mine joined up. It became our summer gig for many years.

We prided ourselves on quality. We were good at what we did. And, we were fast, too.

Jump ahead a few years. OK, more than a few.

I now work in …

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What running an lawn service taught me about health care today

Policy

Medicare is paying for chronic care management! Here’s what you need to know.

The Medscape Physician Compensation Report puts primary care physicians at the bottom of the heap, with a median earning of less than $200,000 per year in 2014. What if the largest insurer of older Americans took those numbers to heart…

The Medscape Physician Compensation Report puts primary care physicians at the bottom of the heap, with a median earning of less than $200,000 per year in 2014. What if the largest insurer of older Americans took those numbers to heart and decided to give primary care a pay raise of 25 percent, in recognition of and better support …

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Medicare is paying for chronic care management! Here’s what you need to know.

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