WARNING
MEDICARE PATIENTS TAKE NOTICE!
The Health Care Financing Administration (Medicare, a.k.a. HCFA) is
implementing new rules regarding the ordering of laboratory tests on
Medicare patients. Tests may no longer be ordered for screening or
monitoring without a diagnosis code that agrees with the test being
ordered. In fact, most laboratory tests are ordered for general
screening for disease or at a time when a diagnosis has not yet made.
As these new rules are implemented, such testing will no longer be
allowed. There will be far fewer cholesterol testing, urinalyses, and
screens for cancer, among others.
Screening for disease in healthy individuals will be only part of the
problem. For ill patients, laboratory tests are most frequently done
as part of the search to make a diagnosis, not after a diagnosis has
been made. Consider a man who has had weight loss, 2 weeks of fever,
abdominal discomfort and a faint heart murmur. Does he have a type of
stomach flu, an inflamed gallbladder, bacterial endocarditis, or a
malignant lymphoma? How does a physician start testing this man when a
diagnosis need already be established before any tests can be done? It
doesn’t make any sense.
Now there is an inflammatory side to these new rules. Medicare has
determined that failure to comply with these new regulations represents
a serious transgression. Tests submitted with diagnoses that do not fit
will not be paid for. But tests submitted with diagnoses that are paid
for, but do not fit the clinical picture are considered fraudulent
claims, and ordering physicians are subject to fines and even criminal
charges. This means potential losing one’s license or going to jail.
This could mean that blood tests for gall bladder infection,
endocarditis or lymphoma on a man later found to have just the flu,
could be considered as false claims, payment denied and an allegation of
fraud made.
Most physicians do not order tests without good reason. Good physicians
must rely on cultivated intuition, experience and good sense for
ordering tests, to assess for rare but serious diseases. This is simply
good medical practice. But compelling physicians to furnish diagnoses
allowing payment will prove impossible to obey while at the same time
duly looking after the patient’s best interest. Patient care will
suffer. In short, the practice of medicine will be irrevocably
hampered. Ask your physician about this new rule. And contact your
representative in congress. Voice your concern and get this policy
rescinded!
David Young, M.D.
DYo…@fcs.net
>Now there is an inflammatory side to these new rules. Medicare has
>determined that failure to comply with these new regulations represents
>a serious transgression. Tests submitted with diagnoses that do not fit
>will not be paid for. But tests submitted with diagnoses that are paid
>for, but do not fit the clinical picture are considered fraudulent
>claims, and ordering physicians are subject to fines and even criminal
>charges. This means potential losing one’s license or going to jail.
I believe Dr. Young has described the situation accurately. These rules are
very chilling to me. The fine is $10,000 PER occurance with the US Attorney
having the option of criminal prosecution. This puts great pressure on the
physician-patient interaction. There is no evidence yet that the government
intends to carry enforcement to this level of practice (individual blood
tests), but if they do, the inevitable reaction of most physicians will be do
GET THE HECK OUT OF MEDICARE.
I CAN order screening tests, stress tests, etc…but it is not easy. The
patients have to sign an advanced beneficiary notification form attesting that
we have told them Medicare won’t pay, what the cost is, and why Medicare won’t
pay. This sounds fine to the lay person, but it adds 5 to 10 minutes to the
typical patient encounter…and Medicare already reimburses us at below our
cost of doing business. I do this…but it is far, far easier to just not
bring up the subject, delay needed screening tests, or tell the patients they
aren’t needed than spend the time explaining Medicare’s rules. (Which tend to
change every month).
TMann, MD