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Originally Posted by nightowlrn  I worked for CMS, not some claim company. I am one of the ones who interpreted rules and regs. I find it a great program. (with the exception of Part D -- talk about scammers) I could have thrown a few attorneys against the wall because of the whining they are hired to do for medical facilities, but overall the program is run very well considering the ever increasing numbers of very ill seniors. There are scammers out there, but deciding to catch them is often a cost analysis exercise. If catchng them costs more than just paying the claim, then not much effort is going to go into $$ to prosecute scammers.
--- An ingrown toe nail becomes infected and leads to potential amputation. Of course we want to take care of something cheap and easy rather than wait until it is going to cost 20K, a foot, and all the therapy after. Podiatry is of great importance to our elders due to decreased sensation for many reasons.
--- Medicare doesn't pay for non-emergency ambulance service generally. There has to be bright lines and this is one of them. Medicare doesn't pay for the convenience of a patient or a doctor. It does pay if a person cannot get out of bed without help, is not able to walk, and cannot sit in a wheelchair.
I don't know the specifics of your scenarios, but I don't want false information out on the board.
And - Medicaid is a state run program and every state differs. Medicare and Medicaid are in no way comparable. Medicare is an entitlement program and Medicaid is needs based.
ETA -- if you were in Montana and involved in Medicare Advantage --- let's just say that program was brought to us by the sam bunch who also brought us that fine boondogle Part D. |
Actually, no, I worked for MT Blue Cross/Blue Shield prior to them losing the contract with CMS. FYI: We interpreted the same rules and regs you did. We weren't a bill processing center. We actually took calls from beneficiaries and providers---you know, worked in the trenches.
We disagree, but you don't have to be condescending. I saw things there that made me realize that while it (Medicare) is a good program there are areas for improvement.
The amounts paid for some CPT codes, but not others made me wonder.
When administration of oxygen during an ALS ambulance run is paid, but the code for supplies (oxygen and IV tubing) is "disallowed"? Doesn't make a lot of sense. Further, I found it disconcerting that (at the time) Medicare would not provide pre-authorization for procedures, thus if someone had a surgery and Medicare decided it wasn't necessary AFTER the fact---then the person ended up being charged. Also, at the time, Medicare (CMS) did not require medical notes to pay bills--it was based solely on Diagnosis codes and CPT codes. So, you saw a lot of MDs upcoding. They knew what CPT codes paid the highest.
There's a room for improvement.
1) Utilization review (which could help to make sure that all conserative measures had been tried, or if not there was a medical rationale for not...)
2) providing pre-authorization
3) requiring chart notes to substantiate all medical treatment.
Things may have changed--and I hope they have. But don't kid yourself--you may have actually worked for the Fed. Govt (CMS), but I did too (all my letters, voicemail message ID'd me as BC/BS of Montana FOR Centers for Medicare & Medicaid Services).