The phrase “Medicaid – Medicare Parity” typically draws a blank stare. A recent article by a healthcare attorney, Ericka Adler, described the presumed benefit of Medicaid – Medicare Parity and how one practice got close to going off the edge of a cliff.
The Affordable Care Act contains a provision allowing certain physicians to be paid at Medicare rates for services provided to Medicaid patients in 2013 and 2014. Those physicians practicing in the areas of family medicine, internal medicine, or pediatrics and who provide at least 60 percent of all their Medicaid services within certain E&M codes are eligible for this so-called “Medicare-Medicaid parity.”
So far, so good. In many parts of the country, Medicaid pays far less than Medicare. So, receiving Medicare rates for Medicaid patients would typically add to the bottom line.
Not so fast. Ms. Adler noted one practice received over $100,000 in increased payments in 2013 based on this parity. This sum was quickly spent on bonuses and expenses. Poof. In April 2014, the practice received a letter letting them know that most of the Medicaid payments subject to the parity payment were ineligible. Poof round two. Apparently, only certain Medicaid programs (those funded under Title XIX) were eligible. Those Medicaid programs funded under Title XXI were not eligible. This state had Medicaid programs funded under both Title XIX and Title XXI. And there was no way to easily determine at the point-of-service which program funded which patient’s plan.
$80,000 had to be returned. And two of the physician-shareholders left the practice year-end 2013 just after receiving their bonuses. The practice had to try to recoup some of that bonus.
What can be learned?
With new programs, be careful about spending all new found cash so quickly. Keep some powder dry.
Further, if bonuses are paid from this pool, make sure there’s a written agreement to “claw back” some or all of the funds that may have been paid out. If doctors leave the group, those doctors remaining should not be penalized further.
There are probably several other lessons to be learned.
It comes as utterly NO surprise that a check from the Government for services that you honestly and honorably performed came with a rubber band attached to the grantor. Good heavens! A bonus almost becomes a felony, and it probably would be if Representative Pete Stark were still in office.
This is an extension of the “felonizing” of medical practice, as dictated by a Congress that believes it is immoral for doctors to do anything more than make a “moderate” living and barely be able to pay back their college loans.
I know that this is not a political web site. But I respectfully urge all physicians to think twice about whom they vote for in the coming elections. This Country has changed drastically in the last 6 years.
It’s not just a matter of having to return honestly earned money. It is that other professionals, especially among them attorneys, would NEVER permit the same actions against them that doctors have allowed to slip-in under their inadequate watch.
We squabble among ourselves, specialty vs. specialty, while the political powers in Congress took advantage of our internecine wars. None of this had to happen. A very large cadre of united healthcare workers can still unite together and fight in Congress to abolish the Stark Laws and return us to a modicum of common sense and free markets.
As of now, lobbying and political fighting in Congress is NOT illegal. Damn near everything else is.
The next time you complain that another specialty is “stealing” a procedure that you often do, remember that Congress is laughing at all of us. We’re arguing about the crumbs after they took away the entire corpus.
Michael M. Rosenblatt, DPM
Where to begin? First of all, amen to Dr. Rosenblatt’s comments. On the money. Getting doctors to work together makes herding cats or reaching peace in the Middle East look easy. And he’s right: Congress laughs at us because they don’t even have to exert any sort of direct control. They limit the funds paid and watch the resulting Darwinian scramble. I’ve heard otherwise bright docs talking about this as if it’s motivated by something noble.
But what’s the real root of the problem? Seems to me that doctors took an easy path when we, as a group, allowed a paradigm change when Medicare came along. Until then, the model was a doctor-patient relationship as central, and the patient might or might not have insurance. Graphically: doctor-patient-insurance company pretty quickly evolved into doctor-insurance company-patient, and here we are now insulated from the patient. Third party payers argue that no, it’s really a triangle, not a line. When was the last time patients stood up to insurance companies in any real number? Insurance company says patient isn’t covered for a procedure, but patient hears “can’t have procedure.” Even the term “coverage” is a soft one: I’ve seen companies pay nothing, or insultingly tiny amounts, for “covered” procedures. How about $250 for treating a ruptured intracranial aneurysm? And no billing for what isn’t covered.
It looks like our patients largely have entitlementitis–if someone else isn’t going to pay for it, he certainly isn’t either.
The only ones who are going to survive the death of actually practicing medicine are docs who refuse to deal with insurance companies. To do that and thrive requires a pool of savvy patients who are wealthy enough to play, which will limit the geographic locations where they can practice. And they will have to be able to live with bust times as well as booms.
Government can change that, too, by tightening the screws on hospitals that allow these physicians to practice at their institutions, which I predict will be the next steps. It’s easy to imagine (prima facie unconstitutional) laws passed refusing payments to these institutions in the name of “controlling costs,” but actually merely being punitive. By the time the restraint of trade issues are resolved before the Supreme Court (and it will go that far for sure), those hospitals will be scarred if not bankrupt.
Myself? I think Ayn Rand’s view of our increasingly dystopian world was a pretty rosy one, along with Mr. Orwell’s and Mr. Huxley’s.
I applaud Drs Rosenblatt and Horton and find it pathetic to see colleagues going “an extra mile” – be it crooked or not to increase the number of patients. In the long run that invariably leads to declining quality of care. Rather than quarreling with insurances for every denied crumb, we should have had a lobby and pack of attorneys on the day when the words managed care were first uttered. Our colleagues in EU can serve as an example – they stand united, they can strike and have a lobby at par with the legislation.
THe other side of this–as a corporation you CAN’T hold back money at end of year without paying corporate taxes. Most corporations try to get down to “zero” or as close as possible at end of year. So “keeping your powder dry” comes at a 40% loss of said powder. And if you think the feds will give that back when they ask for their funds back, you are dreaming. If I were involved in the above practice, I would be getting some good attorneys and finding others similarly screwed, and filing a nice class action suit.
Dr. Richardson recommended filing a lawsuit to try to get the funds re-instated. Filing a lawsuit against a corporation is done every day. Filing a lawsuit against the Government is an entirely different issue.
My understanding as a non-lawyer is that you must first “seek permission” from the Federal Government before you can sue it. And that can be denied if they so choose. The complexity of who administers the funds does not necessarily free-up the potential to sue.
It also depends under which if any statute you are suing about. There is an entire specialty of law over suing Government. A class action lawsuit against Government is a tremendously difficult thing to do, and even if successful, has mixed results.
Prisoners sue State Governments over prison conditions all the time and are generally successful. But those are usually based upon Constitutional issues, usually “cruel and unusual punishment.”
Physicians have no Constitutional dispensations over payments for services. Dr. Horton has it right: “They have all the cards.”
Our most logical action is to try to get everyone who does healthcare together for a giant constituency that collects funds for political action. Each participant organization and individual must swear-off their own private goals of re-imbursement for the greater good. That “greater good” would be abolishment of all of the despicable Pete Stark legislation, for starters.
Undoubtedly the cadre’s represented have differing goals: But they also SHARE a hell of a lot of them.
Michael M. Rosenblatt, DPM