The Incredible Shrinking Opposition To Health Care Reform
The big news of the day, obviously, is the health care powwow that’s scheduled to take place today at the White House. Goups once opposed to health care reform — hospitals, drug makers and insurance companies — will stand alongside Obama and announce their commitment to scaling back health care spending in order to help Obama realize reform at long last.
Whatever you think of the industry’s motives, what’s striking here is how marginalized the remaining opponents of reform are right now, how disoriented the GOP opposition is on this front, and how much more likely reform suddenly looks.
Anyway, I thought I’d outsource the job of explaining this to people who know more about the topic than I do:
* Jonathan Cohn says this shows how fractured the opposition to reform has become, and argues that it’s good news, even if the groups are trying to buy some good will to perhaps try and kill a public insurance option later.
* Paul Krugman, a major Obama-skeptic on health care during last year’s campaign, says that the fact that major industry groups are trying to shape rather than block reform is some of the best policy news he’s heard “in a long time.”
* Marc Ambinder says the meeting means the White House will get reform “this year.”
* Ben Smith observes that the meeting is a mark that the argument is no longer over whether there will be reform, but over whether it will include a public option.
Another key thing to watch: The virtual absence of organized Republican opposition to reform, which is dismaying some conservatives. There’s probably no clearer sign of this than that memo by Frank Luntz telling Republicans how to discuss reform by rehashing the same language opponents used in the 1990s, as if nothing has changed since then.
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Forcing everyone to buy private health insurance would be a bigger boon to Republicans than doing nothing – especially if they put up mock resistance like they did with the stimulus and the TARP. It will be a disaster for people put at the mercy of insurance companies.
The problem will be in the details. The major plus of having a public option was that it would bring down costs because of the competition. If the insurance industry is trying to block any attempt at a public option then what assurances do we have that they will actually lower prices? Their word? Sorry but if that’s the case it won’t be good enough. I don’t think there should be any reform that doesn’t include a public option just to keep them honest.
Hey, I’m still in sticker shock over the stimulus, the budget and the deficit. What’s a drop in the bucket like health care? When you aim for bankruptcy, max out all your credit cards and go for broke. Bring on the entitlements and while we’re at it maybe we can send troops to Pakistan. I’m sure all those rich people out there can be taxed to pay for it.
actuator
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Do you even have a point with all of your ramblings?
SG — OT, but what was your idea for nailing down precisely what Pelosi was free to discuss about the torture briefings?
I am still dismayed that a single payer system is not, by design, “on the table.” Any reform that excludes consideration of this option is not meaningful reform.
Reform of health care payment will have to happen in stages-we cannot get to single payer all at once for a variety of ideological and pragmatic reasons.
However, I believe, as someone who has worked in health care financing, that it is ABSOLUTELY ESSENTIAL that there be a publically funded option.
For profit firms will NEVER reform unless and until there is a publically financed plan against which their outcomes can be measured.
Not their costs-their public health outcomes.
When we change the discussion to public health rather than cost and profits-then we have a platform on which true progress toward single payer health care can be made.
Which is why the idea so panics the for-profit health care industry.
Boadicea, I don’t disagree. But it seems to me (and I’m far from knowledgeable) that having single payer off the table, and opposition to a publicly funded option, makes getting to meaningful reform much less likely. The big players are still very much at the table. Where are the voices for the other side?
I see the opposition going on in the DC metro markets. Both anti and pro public health care commercials are airing.
Greg
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I would imagine if you reached out to Pelosi’s office she might want to provide you with the actual details of what the actual rules are or point you in the direction of where you could find them. If she doesn’t then I would say maybe reach out to Jello Jay or Harman to see if their offices could point you in the right direction. Another avenue would be I suppose Harry Reid’s office since as someone who wasn’t briefed but would have knowledge of those rules he might have the answer. I wonder if the ACLU might also have knowledge of the rules since they have had to deal with the states secrets issue over the detainees so much. Perhaps Leon Panetta’s office could provide you with whatever instructions they would have to give in case they ever had to brief the Gang of 4 or Gang of 8 in the future. Its almost assuredly something they have to be prepared for and hopefully they have some knowledge of what can or can’t be discussed outside of the briefing. Maybe the biggest nugget you could get would be to find out what the penalty and or punishment would be for one of the Gang of 4 or Gang of 8 breaking the rules of secrecy. What would they be facing if they spoke out. I think thats an aspect that has totally been overlooked so far. I imagine DOJ could tell you that.
sgwhiteinfla, I am in total agreement that we must have a govt-sponsored option – for the very reasons you state @10:14. To my mind that’s the important fight we MUST win!
I think everyone is “for” health care reform. Will be curious to see what the details of the various proposals will be.
Of course everyone is for reform, whatever that may mean. I’d like to see a poll that asks what people are willing to give up/pay for “reform”.
That would be interesting and a little more to the point.
thx SG. I think that’s a good idea. Will pursue.
Ezra Klein isn’t impressed by the proposal.
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http://www.prospect.org/csnc/blogs/ezraklein_archive?month=05&year=2009&base_name=is_the_health_care_industry_on
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I think this sums up best what I agree with him on as being the potential drawback.
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We seem destined either to have new or increased healthcare expenses or taxes. Physicians and healthcare facilities have been paid reduced fees by a few percentage points annually since the 90’s or earlier. The result has been increased retail costs to finance healthcare for the indigent and illegal members of the society.
Since the government has posed that there is a crisis which is unsustainable now, why doesn’t the government propose a way to repay some or all of the monies removed from the US Government Healthcare Trust Fund which has so successfully raided for other purposes? Taxpayers will still be paying twice but the effect should be lowered health care costs and preservation of a proven system.
sgwhiteinfla,
It just seems to me that when the government gets involved in issues such as health care someone outside the government (e. g. taxpayers) is going to pay, others outside the government (special interests) will profit, and someone inside the government is going to gain power (new voting constituents). If healthcare could be reformed in a way that contained costs while not increasing taxpayer burden I’d be all for it. Call me a skeptic (cynic, perhaps?) but with a History degree, an MBA and 40 plus years working for the federal government I have no confidence whatsoever in government to effectively accomplish this. My references to runaway spending were appropriate for not only this administration, but the 3 or 4 that preceded it. But much ado was made about the less than 1 percent savings the admin’s budget cutters could find. Some day the piper is going to require payment. Therefore the Bankruptcy reference.
I am TOTALLY against the government running the health care system.This is AMERICA and we should have freedom of choice on our medical insurance. After all. It does pertain to OUR lives – NOT congress, Senate or the president. Mark my word, if this passes, you will be sorry. Read the proposals of these documents and you will see that you will not longer have freedom to go to the doctor or hospital when you need to, without getting permission from a committee. I will willing to bet that all the members of congress and the senate will NOT hvae this type of insurance coverage.
If anyone thinks the government option will bring down health care costs by improving competition, need only look to the Walmart business model. IN that model, they go into an area and drop prices till the competition can no longer compete and are run out of business. Then they raise prioces. You’re at their mercy. This will be the same thing for America. The government will run all the insurance companies out of business and you will be forced into the government option. Then they will dictate your health care costs and eligibility for certain procedures and medicines. That is exactly how Canada started their “health care reform”. Look at the lousy system they have! Anyone in Canada that wants real care, comes to the US and pays it out of their own pocket!
Wake up America, Obamacare is a bad idea!
I develop appeals for claims that are denied by Medicare on behalf of providers.
I do not believe the average beneficiary is aware of what medicare is currently doing
The article below is a cut and paste from my blog.
I am one of those little guys nobody listens to but I do have thousands of these types of letters in my possession from Medicare
Visit the Blog and the website for more…….
the denial below was done in the name of “Fraud Prevention”
Immediately below the introduction is an appeal letter and the result from the appeal.
To me it is CLEAR AS MUD! (Medically Unbelievable Denial)
I am glad to say that most of you reading this have never been in a position to see correspondence as is shown below. Yet just this week in Nebraska an agency who is $130.00 over the average per episode wound up triggering a probe edit of forty charts which a minimum of 95% must be overturned after denial of the claims take place. $130.00 can you believe that!
If not this article really is meant for your eyes…..
I have seen over a thousand denials and written as many appeals. Currently I have 171 bankers boxes (those folding cardboard things) full of charts from the past six years of doing appeals work in storage.
I see the way claims and appeals are denied, and the rationale for denial is constantly changing as is the approach taken, which leaves many of these cases not worth appealing.
Medicare has successfully curbed the practice of numerous agencies nationwide through financial sanctions. Sound familiar in todays world?
BASIC TYPES OF DENIALS
The Therapy downcode Denial: Downcode the therapy threshold by two or tree visits multiplied by 60-70 patients. This one is very popular with all reviewers as your left high and dry. A tough road to haul at best.
The Clinical down code denial: They take all visits away leaving you with a LUPA payment. Ugly but rather workable and financially necessary when you get 30-40 of them at a time.
The MUD Denial: As you read below you will se first hand the work that has been done to deny this agency money due for hard work performed. This denial is one out of forty similar claims that will be litigated next week.
Do not bury your head in your hands and feel helpless as this stuff is easily prevented. However very few consultants will take you down the path you need to go; most will tell you what you want to hear as these are the sweet words of profitability. You can still make a good living and almost never get touched,the choice is yours….
It is far easier to make it than keep it when three years worth of your charts get called for and then get placed under a microscope with the person on the other end of that scope getting paid to deny not to approve. Remember these folks survival depends on your demise…
As the average overpayment is close to three million dollars.
Please realize it costs $16,000.00 per month per million dollars assessed over the course of five years. So $32,000.00 to $48,000.00 per month.
or 72K total damages as some of my folks have experienced.
The message here is: BE PREPARED AND KNOW YOUR STUFF!
A VERY NORMAL EVERY DAY DENIAL
The Name Bugs Bunny has been inserted in any “agency””Physician” or “Patient” identifiable information to protect the PHI.
THE PROVIDERS RESPONSE TO NGS
PATIENTS PERSONAL MD LETTER TO SUPPORT THE NEED OF CARE SENT WITH THE APPEAL
Certification Period: 08/02/2008-09/30/2008
Bugs Bunny is a 61 year old female alert and oriented who was admitted to Home Health from Bugs Bunny Convalescent Hospital on
2/4/2008 for wound care/management on buttocks, heel, low back and toes decubitus ulcer. Patient was referred by myself Dr. Bugs Bunny her primary physician. Referral to home health was for treatment and management of complicated medical problems, such as: Multiple Sclerosis, DM 2 and Anemia Numerous Decubitus ulcers stage III and Stage IV. Patient lives with her spouse who helps with ADL’s/IADL’s. Spouse was trained to check blood sugar levels, and 2 times a day flushing of supra-pubic catheter/care, but is unable to do wound care due to the numerous wounds and its complexity of treatment. Patient is fully bed bound with contractures on both upper and lower extremities requiring maximum assistance .
Daughter-in-law and a sister help with .A.DL’s/IADL’s, to relieve spouse intermittently but refuses to do wound care. I ordered Bugs Bunny Home Health to assist with personal hygiene and bathing. Patient’s daily skilled nursing visit is necessary for wound care treatment due to
patient being diabetic, has bowel incontinence and has a supra-pubic catheter which makes her prone to infections.
“Bugs Bunny Home Health has tried to persuade patient/family to go to a higher level of care but she keeps refusing. She wants to stay home with spouse all the time and says that staying at home would make her feel better and more energetic than in a hospital. She has stayed in a convalescent hospital for more than 2 years due to 2 surgical flaps procedures on her decubitus ulcer that failed and reopened.
The patient was on wound VAC as ordered by her surgeon Dr.Bugs Bunny,.from 3/22/08 to 7/7/08 but with little improvement. Another flap surgery at this time is not possible due to the 2 previous failed flaps and skilled home health care is the only other option at this moment.
During the episode of 08/02/08 to 09/30/08; wound on left buttock healed on 8/20/08: On 09/08/08 wound on right lateral foot completely healed. Patient had a fever on 9/16/08 and refused to go to the hospital. Primary physician ordered urinalysis and wound culture which was done and showed that the patient had UTI. Patient was prescribed
antibiotic therapy which resolved the problem,
The reason for denial which was received on 12/18/2008 was that there was no need for daily visits: patient’s medical condition at this time is very unstable requiring skilled observation and assessment, and daily wound care due to no available/willing caregiver to perform wound care. Due to daily SN visit, wounds on left buttock and right lateral
foot healed and fever was identified. Wound culture and urinalysis was done and I was notified and resolved the problems with appropriate antibiotic therapy.
Home health care is necessary until patient”s condition stabilizes for another flap surgery.
It is important that wounds will not have any complications and the Stage IV decubitus will be stable, the diabetes will be stable and the wound will progressed to the stage where they will become operable.
Anemia will resolve to endure the above mentioned procedure (flap
Primary Physician
THE RESPONSE FROM MEDICARE
May 21 2009
CENTERS for MED/CAIlE & MEDICAID SERVICES
Medicare Reconsideration Decision
August 2, 2008 through September 30, 2008
Provider Inquiries
l Visit: http://www.q2a.org
Or Call: 484-688-8900
Beneficiary Inquiries :
Call:1-800-MEDICARE
Or1-800-633-4227
Who we are:
We are MAXfMUS
Federal Services.
We are experts on
appeals. Medicare
hired us to review
your file and make an
independent decision
Dear Sir/Madam:
This letter is to inform you of the decision on your Medicare AppeaL An
appeal is a new and independent review of a claim. You are receiving this letter because you requested an appeal for the denied home health
services provided to “an on August 2, 2008 through September 30,
2008, at Home Health.
The appeal decision is unfavorable. Our decision is that your claim ;s not covered by Medicare. More information on the decision is provided below.
You are not required to take any action. However, if you disagree with the decision, you may appeal to an Administrative Law Judge (ALJ). You must file your appeal, in writing, within 60 days of receipt of this letter. For more information on how to appeal, see the page titled “Important Information About Your Appeal Rights.” The amount still in dispute is estimated to exceed the amount required to file an appeal at the ALJ Hearing level.
A copy of this letter was also sent to the beneficiary,Bugs Bunny.
MAXIMUS Federal Services was contracted by Medicare to review your
appeal.
Summary of the Facts
• The provider, Home Health, submitted a claim for horne-health skilled nursing visits (HPCS Code G0154) and home health aide visits (HCPC:S Code G0156) provided to the beneficiary during the period of August 2, 2008 through September 30, 2008, pursuant to the diagnoses of pressure ulcer, lower back (ICD-9 Code 707.03) pressure ulcer, ankle (lCD-geode 707,06), diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled (ICD)-9 code 250.00), pressure ulcer, upper back (ICD-9 Code 707.02), pressure ulcer, heel (ICD-9 ‘Code 707.07), anemia of other chronic disease (ICD-9 Code 285.29), pressure ulcer, buttock (ICD-9 Code 707.05) and multiple sclerosis (ICD-9 Code 340).
• The initial determination of the claim was rendered on December 15, 2008 denying the services because they were not found to be reasonable and necessary.
• The Affiliated Contractor (AC) with jurisdiction, National Government Services (NGS), received a redetermination request from the provider on January 9. 2009. Included with the request were the following documents: home health certification, nursing visit notes,
nursing assessment documents, physician orders, Outcome and Assessment Information Set (OASIS) documents, wound care documents, progress notes and daily route sheets.
• On February 26 1 2009, NGS issued an unfavorable redetermination decision and determined that the record did not indicate that the services provided warranted the skills of a nurse and appeared to be for observation and assessment purposes only. The provider was held responsible for the bill.
• MAXIMUS Federal Services received a request for reconsideration from the provider April 1, 2009. In part, the provider stated that the services provided were reasonable and necessary for wound care and because the beneficiary’s condition was unstable.
Included with this request were the following additional documents: A physicians letter supporting the provider’s appeal.
• This case was submitted to a panel of healthcare professionals for medical review to determine whether the services were medically reasonable and necessary in accordance with Medicare coverage criteria.
Decision
We have determined that Medicare does not cover the claim for the home health services. We have also determined that the provider, Bugs Bunny Home Health, is responsible for payment for the home health services on August 2, 2008 through September 30, 2008.
Explanation of the Decision To qualify for the Medicare home health benefit under the Social Security Act, 18 U.S.C. §§
SS 1814 (a) (2) (C) and 1835 (a) (2) (A), a Medicare beneficiary must meet the following: requirements: (i) Be confined to the home; (ii) Under the care of a physician; (iii) Receiving
services under a plan of care established and periodically reviewed by a physician; (iv) Be in need of skilled nursing care on an intermittent basis or physical therapy or speech-Ianquaqe pathology; or (v) Have a continuing need for occupational therapy. Whether care is reasonable and necessary is based on information reflected in the home health plan of care,the Outcome and Assessment Information Set (OASIS) or a medical record of the individual patient. You can find these rules in 42 C. F.R. § 409.42 and the Medicare Benefit Policy Manual, Pub. 100-2, Chapter 7, Sections 20.1.1,20.1.2, and 30 .
A panel of licensed healthcare professionals reviewed this case and determined that the health services for the dates of service under review were not reasonable and medically necessary according to Medicare coverage criteria.
The beneficiary was a 61 year old woman who was admitted to home health services from Bugs Bunny Convalescent Hospital on February 4, 2008 for wound care/management on buttocks, heel, lower back, and toes. The beneficiary’s medical history includes multiple sclerosis, diabetes mellitus type two and anemia. The
beneficiary is incontinent of bowel and has a supra-pubic catheter which makes her prone to infections. The affiliated contractor denied the claim at redetermination because the provider failed to submit documentation to support the medical necessity of the services. The appellant argues that the provider submitted the required documentation to support that the services were necessary for this beneficiary.
In this case, the home health services under review were not reasonable and medically necessary and did not meet Medicare coverage criteria. The beneficiary, a 61 year old female, was admitted to home health services on February 4, 2008 with diagnoses of decubitus of the lower back, upper back, buttock, ankle, and heel, multiple sclerosis, diabetes, and anemia. The skilled nursing visits were ordered for multiple decubitus ulcer care, observation and monitoring of vital signs, ongoing assessment of her body systems, knowledge of disease processes, and repetitive teaching . She had a supra-pubic catheter, which was taken care of by her spouse. He was also doing her blood glucose monitoring.
The patient had an elevated temperature on September 16, 2008 of 101 .3, was found to have a urinary tract infection, and was started on oral antibiotics. Her decubitus were described as stage III and stage IV but there was no realistic endpoint to these treatments. She had been
treated for the decubitus since the start of her home health care services. There was no documented change in condition) medication, or treatment regimen. The services provided were not skilled. The visits consisted of ongoing repetitive treatments related to the beneficiary’s chronic condition. The skilled nursing visits were not reasonable and medically necessary. The home health aide visits were dependent on a qualifying skilled service.
Therefore, Medicare win continue to deny payment for these services.
You can receive copies of statutes, regulations, policies! and/or manual instructions we used to arrive at this decision. For instructions on how to do this, please see ‘Other Important Information’ on the page titled “Important Information About Your Appeal Rights.” Medicare requires that all evidence be presented before the reconsideration is issued. On further appear, an ALJ will not consider any new evidence unless you show good cause for not presenting the evidence to the QIC.
This requirement does not apply to beneficiaries, unless a
provider or supplier represents the beneficiary. You can find this rule at 42 Code of Federal Regulations Section 405.966.
Who is Responsible for the Bill?
Because we determined that the services in question did not meet Medicare coverage criteria, under Section 1879 of the Social Security Act, we must determine whether the beneficiary and/or provider knew or could reasonably have been expected to know that the services would not be covered under Medicare.
The case file did not include an Advance Beneficiary Notice or any other documentation that the beneficiary had been given prior written notice that Medicare would not pay for the horne health services. Therefore, we have concluded that the beneficiary in this case did not know, or could not reasonably have known, that any of these items or services would not be covered by Medicare, and the beneficiary is not financially responsible for these non-covered charges.
Since we have found that the beneficiary is not liable, we must next determine whether the provider should be held liable for any of these non-covered items or services. The provider has received or has access to CMS notices, including manual issuances, bulletins, of other written guides or directives from Medicare contractors, describing the basis for excluding certain services from Medicare coverage. Similarly, the provider has access to Federal Register publications containing notice of national coverage decisions or of other specifications
regarding non-coverage of an item or service. Therefore, we have determined that the provider is responsible for payment of the home health services because it knew, or could reasonably have been expected to know! that Medicare payment for the service or item would be denied.You can find these rules at 42 Code of Federal Regulations Section 411.406 and the CMS Medicare Claims Processing Manual, Publication 100-4, Chapter 30, Section 40.1 .
If you have any questions please call the phone number on the front of this letter. For information on how to appeal this decision, please see the page entitled “Important Information About Your Appeal Rights. t1
Sincerely,
Barbara M. Yakimowicz, J.D., M.H.A., PMP
Project Director .3 ..
IMPORTANT INFORMATION ABOUT YOUR APPEAL RIGHTS
It is Your Right to Appeal this Decision. IIf you do not agree with this decision, you may file an appeal. An appeal is a review performed
by people independent of those that have reviewed your claim so far. The next level of appeal is called an Administrative Law Judge
(ALJ) Hearing. At this hearing, you or your representative may represent your case before an ALJ.
up the right to get a decision in the gO-day time limit that usually applies to ALJ decisions. If you want to file an appeal, you should send
your request, along with the first page of this decision to:
HHS OMHA Western
27 Technology Drive, Suite 100
Irvine, CA 92618-2364
866-495-7414
If you need more information or have any questions, please call us at the phone number provided on the front of this notice.
MAXIMUS Federal Services
OIC Part A West
P.O. Box 62410
King of Prussia, PA 19406
If you want copies of statutes, regulations, policies, and/or manual instructions we used to arrive at this decision, please write to us at the
following address and attach a copy of this letter:
Other Important Information
If you want someone to act for you, you and your appointed representative must sign, date and send us a statement naming that person to act for you. Call 1-800-MEDICARE to learn more about how to name a representative.
1-800-MEDICARE (1-800-633-4227),
TTY/TOO: 1-800-486-2048
IOther Resources To Help You I Help With Your Appeal If you want help with an appeal, or if you have questions about Medicare, you can have a friend or someone else help you with your appeal. You can also contact your State Health Insurance Assistance Program (SHIP). You can call 1-800-MEDICARE (1-800-633-4227) for information on how to contact your local SHIP. Your SHIP can answer questions about
payment denials and appeals. I Who May File an Appeal If You or someone you name to act for you (your appointed representative) may file an appeal. You can name a relative, friend, advocate, attorney, doctor, or someone else to act for you. You must have at least $120 still in dispute. This appeal can be combined with others to reach this total, if the other claims were appealed and decided within 60 day of this new request for an appeal, and involve similar or related services.
In your request you must include: (1) The name, address, and Medicare health insurance claim number of the beneficiary, (2) The name and address of the person appealing, if the person is not the beneficiary, (3) The name and address of the representative, if any, (4) The appeal number listed on the front page of this notice, (5) The dates of service, (6) The reasons why you disagree with the decision, (7) Any and all evidence you wish to submit and the date it will be submitted, (8) A
statement that you have sent a copy of this request to the other parties to the appeal, and (9) If you wish to combine claims to meet the
$120 amount, include a list of the claims. ALJ hearings are usually held by video-teleconference (VTC) to make sure you get a hearing and decision as fast as possible. VTC hearings reduce travel time for you, ALJs, and witnesses. If you do not want a VTC hearing, you may ask for a hearing in person, which will be granted for good cause. Your request must be in writing. Your request must give a good reason why you don’t want a VTC hearing . If your request for an in-person hearing is granted, a hearing will be held and a decision Issued as soon as possible. To exercise your right to appeal, you must file a request in writing within 60 days of receiving this letter. Under special circumstances, you may ask for more time to request an appeal.