Payments for Ambulatory Surgical Center Services Provided to Beneficiaries in Skilled Nursing Facility Stays Covered Under Medicare Part A

Ambulatory surgical center (ASC) facility services, such as nursing, recovery care, anesthetics, drugs, and other supplies, provided to SNF residents are subject to consolidated billing and must be billed to the SNF rather than Medicare Part B. Physicians’ professional services are statutorily excluded from consolidated billing and may be billed to Medicare Part B.

The nationwide audit covered 20,906 Medicare Part B ASC facility services valued at $7,113,542 with dates of service in calendar years (CY) 2006 through 2008 that matched 14,192 Part A SNF stays and that thus represented potential overpayments. GAO sampled 100 services provided by 88 ASCs.

Full GAO Report

TIME GOES BY | GRAY MATTERS: The Downside of Medicare

by Saul Friedman

Those of us of a certain age sing the praises of Medicare which, thanks to the recently passed health reforms, according to the latest report of the trustees, has a new lease on life. It will serve the needs of upwards of 45 million disabled and people over 65 for longer than some banks and businesses will be around.

That is to say, the life of the Hospital Insurance Trust Fund has been extended 12 years to 2029. That fund, if you don’t know, pays for Medicare Part A, which includes hospitalization, and rehabilitation or skilled nursing care after, say, an accident or surgery, and for some home care.

In addition, the Obama administration’s bean counters estimate that the new health care overhaul, Medicare Part B – which pays part of the cost of labs and physician visits – will save $8 billion by the end of next year and a whopping $575 billion over the next ten years.

That’s something people over 65 and those approaching retirement to celebrate. Medicare will be there when employment benefits run out.

But Medicare, which was passed 45 years ago, is far from the universal health care that we one day hope to have. Unless a beneficiary has supplementary coverage from a former employer, Medicare’s deductibles and premiums or the Medigap policies to cover those costs have gotten expensive.

If you don’t yet qualify for Social Security (or haven’t had 40 or more quarters of Medicare-covered employment), Part A’s premium (normally free) can cost from $254 to $461 a month. A hospital stay will cost $1,100 for up to 60 days, $275 a day for days 61-90 and $550 a day after that.

Part B, as you know, costs most beneficiaries $96.40 a month, but much more if you are a bit affluent because Medicare under George W. Bush instituted means testing for the first time. It also carries a yearly deductible of $155, which goes up every year.

Part B covers 80 percent of the bills, with those out-of-pocket costs going up. And Part D is an added expense if you need prescription drugs and fall victim to the doughnut hole. Medicare is saving that $8 billion a year mentioned above by cutting Medicare Advantage for 10 million beneficiaries. That’s the right move, in my view, but it’s an indication that Medicare penalizes some people who were hoping to get more coverage.
We could have done better than Medicare or the cumbersome health reforms, most of which won’t take effect until 2014, if the nation wasn’t so stuck in an ideological rut.

One great alternative is called socialized medicine and it’s practiced right here in the U.S. - the Veterans Administration hospitals and health services. And its beneficiaries, non-socialists all, have included the four star generals now running our wars as well as Senator John McCain and many members of Congress.
Although they are not run by the VA, among the socialized institutions that have tended to the needs of presidents as well as lawmakers, are Walter Reed Hospital, in Washington, D.C., run by the Army, and the Bethesda Naval Hospital in the Maryland suburbs.

A few years ago, millions of Americans and I were beneficiaries of the VA health system when it developed, along with Merck and California researchers, an effective vaccine for the dreaded shingles. That was just one of the innovations credited to the VA in a new edition of a book, The Best Care Anywhere, with the subtitle, “Why VA Healthcare Is Better than Yours.”

Written by Phillip Longman, a professional demographer, and a fellow at the New America Foundation and the Washington Monthly, the book tells the story of the quality revolution launched by Dr. Ken Kizer when he took over the VA health system in 1994.

According to the Century Foundation’s Health Beat blog, Longman’s book includes “eye-popping evidence” based on peer-reviewed research

“...that when it comes to everything from outcomes to patient satisfaction and patient safety, the VA out performs. Most people don’t associate the VA with innovation. But a majority of its doctors have faculty appointments at academic institutions, one reason that the VA is on the cutting edge of evidence-based, patient centered medicine.”
Over the years, Longman reports, “the VA has been responsible for developing the CT-scanner, the first artificial kidney, the cardiac pacemaker, the first successful liver transplant, the nicotine patch,” and the shingles vaccine.”

The VA installed the VistA software program, the centerpiece of the VA’s electronic medical record system, which is now used elsewhere. With the use of the software, Longman writes that the VA system, in which everyone - doctors, researchers, nurses and technicians who work for the VA -

“...is the only health care provider in the U.S. whose cost per patient has been holding steady in recent years.”

Dr. Donald Berwick, the new head of the Centers for Medicare and Medicaid Services wrote on the back cover of Longman’s book,

“The improvement of the VA health care system in the past decade is one of the most impressive stories of large-scale change.”

Who says government can’t do anything right?

In this case (as in many civilized nations), socialized medicine works, but it’s doubtful that the VA system will serve as a model for health reform in the U.S. We blindly reject “socialism”without knowing what it is. But we veterans know how it can be helpful in obtaining good treatment and cheap prescription drugs. Unfortunately, budget cuts over the last eight years have forced the VA to sharply limit eligibility for its health system.

While searching for alternatives to Medicare and the inadequate health reforms, I came across a paper published earlier this month on “the impact of universal national health insurance on population health” in Taiwan, of all places, a successful bastion of free enterprise on the doorstep of communist China.
Taiwan established its National Health Insurance in 1995, which covers more than 98 percent of Taiwanese, at the cost of small co-payments. In the years after the system became effective, the paper reported, deaths from

“...causes amenable to health care” declined by nearly six percent a year. The decline was highest among the young and the old and was “associated with substantial reductions in deaths from circulatory disorders for men, whilst an earlier upward trend in female cancer deaths was reversed.”

The U.S. might have had something similar to Taiwan’s NHI, Medicare For All, except for the timidity of Barack Obama, who did not have the courage of his own convictions, and the ignorance of conservative Republicans and Democrats who worried more about their political futures than the health care of their constituents.

Republicans would have had trouble attacking “Medicare For All.” It’s easier to call for the repeal of the confusing “Obama care.”

We pay for this ideological narrowness with lives; in contrast to the good news of Taiwan’s NHI, the U.S. has the worst rate of amenable mortality among 19 industrialized nations, with more than 100,000 deaths per year from disorders amenable to health care.

Write to saulfriedman@comcast.net
TIME GOES BY | GRAY MATTERS: The Downside of Medicare

TIME GOES BY | GRAY MATTERS: Medicare Anniversary

by Saul Friedman
It’s not too late to observe and celebrate the 45th anniversary of Medicare, for it’s a good occasion to wonder, in this time of economic distress, what life would have been like without it for the 45 million of us who are eligible because we are disabled or over 65.

One reason I ask is I suspect those deficit crazies have not thought about the consequences for Medicare if, as Republicans suggest, the Social Security retirement age is raised from 66 to 70 on the grounds that we’re all living longer.

It does not occur to these loonies that Social Security and Medicare are among the reasons for the increase in longevity. But then members of Congress will always have all the coverage they need for themselves and their families, subsidized by your taxes and mine.

Nevertheless, by putting aside the human issues for a phony bottom line and a deficit that matters little to most of us, it would not be long before these lawmakers on Barack Obama’s deficit commission would raise the Medicare age eligibility. That, of course, would sharply increase, by at least a few million, the nearly 50 million Americans under 65, including 10 million children and babies, who are without adequate health coverage and are dependent on emergency rooms or free clinics.

If I may get personal, let me tell you what Medicare has meant for me, for my experience has not been unusual, although I’m lucky to have supplementary coverage through my wife’s former employer, which used to be free but now costs a bundle. Most other Medicare beneficiaries have similar secondary coverage through former employers or one of several Medigap policies sold by several insurers to cover some or all of the costs not covered by Medicare.

I don’t mean to get too basic, but Medicare Part A, which pays for hospitalization, has rather high deductibles; Medicare Part B covers 80 percent of the cost of physician and lab services. Secondary insurance covers those Medicare gaps, and some may provide drug coverage.

Anyway, in 2003, I had a serious stroke, which partly paralyzed my right side and necessitated hundreds of hours of inpatient and outpatient rehabilitation at several of the nation’s finest facilities. The stroke was caused by a heart malfunction which was cured with minor surgery.

In 2005, after too many years as a smoker (I had quit in 1976), I was diagnosed with cancer of the esophagus, which is usually fatal. But chemotherapy, radiation and radical surgery at Johns Hopkins in Baltimore saved my life.

For all this, plus frequent checkups, CT scans, routine doctor visits and a recent prostate procedure, I have paid nothing aside from the reasonable Medicare Part B premiums and the cost of secondary coverage. In short, I can say what millions of Medicare beneficiaries say: without Medicare, I’d be broke, bankrupt or dead.

But that, alas, has been the experience of the millions who, because they are too young, have been denied Medicare. Nor do they yet have decent, dependable and affordable health care because a compromising president and a spineless Congress, mostly Republicans and conservative Democrats, have declined to give the rest of the nation what they and the rest of the world have, universal health coverage like Medicare.

The anniversary of Medicare’s adoption, by a liberal Democratic Congress and president (Lyndon B. Johnson), has give advocates an opportunity to list its lesser known accomplishments. While most of the new health reforms won’t become effective until 2014 (the Part D doughnut hole won’t close until six years later), Medicare was serving 19 million Americans a year after passage.



In a paper written by June Eichner and Medicare’s first director, Bruce Vladek, they point out that beginning in 1966, as the nation’s largest purchaser of health care, Medicare desegregated most hospitals as a condition for receiving Medicare reimbursement. Since then, they wrote, Medicare has contributed not only to the improvements to the lives and health of the disabled and older populations, but has gone far in erasing disparities between blacks and whites. More than 25 percent of Medicare beneficiaries were living in poverty in 1965.

The passage of Medicare came just after the Civil Rights Act of 1964. Which is why southern Democrats joined Republicans in resisting Medicare. But because of those two landmark pieces of legislation, the National Bureau of Economic Research found that

“the gains in black access to hospitals (in Mississippi) coincide with a striking reduction in black post-neonatal deaths for causes considered preventable.”

The cost for these improvement were borne by Medicaid, passed along with Medicare to provide care for the very poor.

Another study noted that Medicare played a significant role in the education of today’s physicians. According to an April Wall Street Journal story, there are about 110,000 resident positions in teaching hospitals that rely heavily on Medicare funding.

Medicare pays $9.1 billion a year to teaching hospitals which pays residents’ salaries as well as the higher operating costs associated with teaching hospitals which tend to see the sickest, most costly and uninsured patients. Unfortunately conservative diehards kept out of the health reforms any increase in the number of funded residencies.

There are, too, a few glitches that have shown up lately in Medicare that need fixing. Under current law, persons over 65 who end their employment and employer health coverage must apply for Medicare during a “special enrollment period” up to eight month after that coverage ceases.

But if the workers chooses to get COBRA coverage, which usually lasts 18 months, they may not realize that they will be disqualified from the special enrollment period and will have to wait until the regular open enrollment period, from January through March 31. In that case, their Medicare coverage won’t begin until July 1. This rule is 24 years old but because it’s happening frequently, legislation is pending to permit signing up for Medicare when COBRA runs out.

Here’s another glitch, discovered by Bloomberg News. Under current law, a person (who suffered a stroke or was injured) is entitled to skilled nursing care and rehabilitation after three days in a hospital. But lately some hospitals, to save money, are keeping patients “under observation” and not admitting them, thus depriving them of the rehabilitation they need. Medicare auditors are challenging this practice, which should be reported as fraud to Medicare.

Finally, the biggest necessary fix is the one Obama said he was for before he became president; Medicare For All. It is the subject of a new appeal to the Congress by Representatives Dennis Kucinich (D, Ohio), John Conyers (D, Mich.), and Independent Senator Bernie Sanders of Vermont.

If Congress won’t pass it, they asked that states be permitted to adopt it. It would be better, of course, if Medicare for All was federal law. If Obama led the way, he could be in the same leagues as LBJ. But our president for change, who has yet to speak forcefully against cutting or tampering with Social Security benefits, is too busy to listen. Maybe it’s possible in a second term, if he gets one.

Write to saulfriedman@comcast.net

Medicare Part B Services During Non-Part A Nursing Home Stays: Mental Health

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This report presents findings based on a medical review of Medicare Part B mental health claims provided during non-Part A nursing home stays in 2006.  Non-Part A stays occur in nursing homes when the stay is not paid for under the Medicare Part A posthospital skilled nursing facility benefit. 

We found that 39 percent of claims for mental health services that Medicare Part B allowed during non-Part A nursing home stays in 2006 did not meet the program requirements for coverage.  Specifically, services were medically unnecessary, undocumented or inadequately documented, or miscoded.  These errors resulted in an estimated $74 million in inappropriate Part B payments, of the $211 million allowed in 2006.  Claims for psychotherapy services comprised the majority of these inappropriately paid claims, which is consistent with findings from the CMS 2006 Comprehensive Error Rate Testing report.  Additionally, we found that 71 percent of the sampled mental health claims contained inaccurate diagnosis codes or lacked adequate documentation to support the diagnosis code, although these codes did not directly affect reimbursement. 

Read/Download Report

Legislation Improves Access to Medicare

Many people are misinformed about when they should enroll in Medicare. The Medicare Rights Center receives calls almost daily from consumers, as well as insurers and employers, who are confused by the current enrollment rules. Older Americans and people with disabilities who have mistakenly declined Medicare Part B as a result of innocent errors or misinformation may sometimes find themselves with no health coverage at all. Some have to wait months to over a year before they have coverage.
 
New legislation, The Medicare Enrollment Protection Act of 2010 (H.R. 5588), establishes additional Medicare Part B enrollment periods, which allow individuals to enroll in Medicare without delay. The legislation is supported by the House of Representatives Seniors Task Force and was introduced by Congressman Kurt Schrader, Democrat of Oregon, on Wednesday June 23.   

Read more about the Medicare Enrollment Protection Act of 2010.

Medicare Update: CMS Announces 2010 Medicare Premiums and Deductibles

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On October 16, 2009, the Centers for Medicare & Medicaid Services (CMS) released display copies of Notices announcing Medicare Part A and Part B premiums and deductibles for calendar year 2010.

Medicare Part A

The deductible for a beneficiary admitted as a hospital inpatient will be $1,100 in 2010, which is an increase of $32 from 2009. The Notices also indicate that a beneficiary will have to pay an additional $275 per day for days 61-90 in 2010, and $550 for lifetime reserve days. Further, the Notices indicate that the daily coinsurance for days 21-100 in a skilled nursing facility will increase to $137.50 in 2010.

According to CMS, 99 percent of Medicare beneficiaries do not have to pay a premium for Part A services. However, some seniors and certain other individuals under age 65 with disabilities, who have fewer than 30 quarters of coverage, may obtain Part A coverage by paying a monthly premium. That premium will be $461 per month in 2010. However, a reduced premium applies for individuals with 30-39 quarters of coverage, which will be $254 in 2010.

Medicare Part B

The Medicare Part B deductible for 2010 will be $155.

The 2010 Part B monthly premium rates for beneficiaries who file an individual tax return (including those who are single, head of household, qualifying widow(er) with dependent child, or married filing separately who lived apart from their spouse for the entire taxable year), or who file a joint tax return are:
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