July 1, 2011 Legislation





The Medicare Payment Advisory Commission has recommended to the CMS that they crack down on physicians ordering expensive radiographs.  They recommend pre-approval for those physicians ordering a large number of MRI, CT or nuclear med exams.  They believe without any proof except notice by the radiologists with a turf war that physicians with the machines in their own office order unnecessary exams. It is doubtful that Congress will redo Medicare at this time.

A Medicare trustee has stated that Medicare must change for all but he prefers to see it done incrementally instead of at once as under the Ryan plan.  He also is in favor of the new Medicare Board.  The trustees also believe against their own actuarial advice that Medicare can be extended an additional 12 years before it begins to pay out more than it takes in.  

The GAO has released an analysis on CMS's waiver policy.  There does not seem to be any policy or procedure as to how to grant waivers from the Obamacare requirements.  They had allowed 95% of the applicants for waivers to get them in full and another few in part.  They only fully rejected 40 out of 1415 applications. 

Soon after the above was released, the feds have determined that in September no more waivers will be given.  Therefore, get your request in early. 

Congress want Sebelius to give more information on the waivers not given or still in process and she remains silent.  One must wonder what she has to hide. 

Former HHS Secretary Leavitt states most states will not be ready to meet the deadline for health exchanges.  This means the feds will be busy doing health exchanges for the states.

If ever a condemnation of Berwick's view of healthcare was written it is by Zosia Chustecka.  She writes and shows that British men with prostate cancer die 50% of the time of the disease in Great Britain and only 15% of the time in the US.  The reason all agree is PSA testing done in the US but not as much in Britain.  

Soon Medicare claims will be open for all to data mine.  This would be for determining physician scorecards.  This law was part of Obamacare that the legislators forgot to read before they signed off on it.  Berwick is all in favor of it.  Glad he will be gone soon.  It should be noted that the AMA is also for the program but only if physicians get to see and correct data prior to release.   

Medicare has finally decided that the commercial carriers have less fraud and find the fraud earlier than they do.  CMS has announced new technology (for them) based on credit card companies ability to catch fraud prior to a claim being paid.  They decided their stupidity of pay and chase was just that, stupid.  They will use predictive normograms based on best practices to decide if a claim may be fraudulent. Knowing the government, they will go overboard and deny too many claims in their zeal.  This is a good step, however.  

Remember when Obamacare was passed and nobody read it.  Obama's Medicare chief actuary just found out that starting in 2014 Social Security will not count as income if one applies for Medicaid.  This means that millions of more people will become eligible for Medicaid and this may help break the bank for the States and the federal taxpayers.  When actuary Foster blew the whistle on this boondoggle, nobody on the Hill was interested especially the Dems who said this is good.  Now more people    (3 million) will have coverage, even though they have money to buy their own insurance. 

CMS is going to rescind its rule that all lab test requisitions must be signed.  It does seen dumb as they want to move to electronic records.

All know that Medicare has financial problems but nobody wants less money.  That includes the physicians who will not accept the impending 30% cut and the hospitals who want their federal money to continue.  The hospitals are taking out ads to press their point.  They have enough money to do this.  The physicians do not.

A reasonable idea on how to save Medicare has come out of the Senate.  Raise the age to 67 from 65 and have those that make more than $150,000 a year pay more for the benefits.  This is too logical and so will be defeated.  Pelosi wants instead to halt tax breaks for corporations. The proposed legislation also keeps the physician pay at current levels for the next three years instead of a 30% decrease on January 1.

HHS has published interim final regs regarding claim appeals.  The agency stated that group health plans and health insurance mandated under ACA (Obamacare) that came into existence after Obamacare was passed must have external review processes that comport with federal rules which are for medical judgment or rescission of coverage.  Also plans must have internal appeals that occur rapidly, 72 hours for urgent cases.  That figure is the longest allowed.  Shorter times are required depending on the circumstances.  

The FDA panel rejected Avastin for breast cancer patients.  This was a 6-0 vote but the final decision will be later this summer by FDS Commissioner Margaret Hamburg.  Some women have been helped with the med but many others have not.  This just proves that any chemo is individual and may help some but not all patients.

Colorado will join 17 other states to end coverage for circumcision for its Medicaid population.  Hope none are Jewish or Muslim.  The state will save about $185,000 per year by this move.  If sued it will cost more than that in attorney fees.          Top


North Carolina is a perfect example of politics and politicians.  As Congress did with Obamacare, the state legislature did with the medical malpractice law enacted.  Nobody read it prior to passage.  The bill was supposed to protect manufacturers from product liability lawsuits.  This was changed to only cover FDA approved drugs and then dropped completely from the bill.  It will now have to come as an additional bill before the legislature, a make work effort. The original bill protected ED physicians from med mal unless gross malpractice.  The final bill that was passed had protection from med mal for all medical emergencies in the hospital.  Also pregnant women would not have to prove gross negligence to sue for med mal.          Top


Physicians again are procrastinating.  Physicians need to implement HIPAA 5010 prior to January 1 or they will not be getting paid by Uncle Sam.  The costs are running approximately $16,000 per physician including hardware, software and staff training.  It is not a reimbursable expense.   

The government says that their data and health tools help physicians achieve meaningful use in their EHR.  Do not believe it. First of all meaningful use means that it is meaningful for the government not the physician nor the patient. It is make work for many physicians and has no benefit whatsoever.  The costs are also high and there is no way the physician will or can be reimbursed.  Some offices have to hire an extra FTE just to enter the requested information into the computer.  The only saving grace is that the physician may not get a decrease in payment for not complying.  Of course, if the SGR continues the physician will get 30% less to see Medicare patients.     Top


DISCLAIMER: Although this article is updated periodically, it reflects the author's point of view at the time of publication. Nothing in this article constitutes legal advice. Readers should consult with their own legal counsel before acting on any of the information presented.