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Sue Lani Madsen: Lower reimbursement, more bureaucracy not a prescription for good health under Medicare

UPDATED: Fri., Feb. 24, 2017

FILE - Durable medical equipment like home oxygen tanks seem like a straightforward case of medical necessity, but getting the prescribed treatment isn’t easy because of increased paperwork requirements, providers say. (SR)
FILE - Durable medical equipment like home oxygen tanks seem like a straightforward case of medical necessity, but getting the prescribed treatment isn’t easy because of increased paperwork requirements, providers say. (SR)

As long as health care reform is underway, there will always be a column topic.

Barely six months passed between President Barack Obama signing the Affordable Care Act and the first of 70 changes and counting. Six years of implementation have exposed more flaws to fix, whether by wholesale replacement or more years of repairs. And every column on health care generates feedback that leads to another column.

Under Obamacare, more patients have access to the health care system than ever before. But too many of them find they have access to a diagnosis, not treatment.

Gary Rench, owner of Sandcreek Medical in Sandpoint, brought one specific dilemma to my attention: breathing. A doctor’s order for home oxygen seems like a straightforward case of medical necessity. It is, but getting treatment isn’t so easy.

His company supplies what’s known in the acronym-rich health care environment as DME, or durable medical equipment. DME includes major items like hospital beds and walkers as well as small devices like home oxygen concentrators and nebulizers to support breathing. Many of his patients are on Medicare.

The original Obamacare regulations led to rate cuts for DME. Medicaid, as well as private insurance companies, uses Medicare fee schedules as a benchmark for setting rates, compounding the pressure on small businesses like his.

Medicare establishes what it will pay based on national bid averages. In the past, rural rates have been adjusted to compensate for market differences. According to Rench, the ACA changed the wording behind Medicare’s rate setting authority from “may” establish competitive bid pricing nationwide to “shall.” This small change resulted in a 20 percent pay cut for providing oxygen and other devices, followed by another 30-40 percent cut last July.

He now cringes at calls for service for Medicare patients.

The impact of changes to Medicare fee schedules was confirmed by the staff at Buri’s Medical Equipment in Colfax. They described the cuts as arbitrary. Nothing changed in the cost of providing services except additional paperwork.

It’s the paperwork that makes life – and breathing – difficult for patients. Medicare rules require the DME provider have both the doctor’s prescription and the chart notes in hand before providing equipment. The chart notes have to use precisely the right wording in order to avoid claim rejection under audit. Buri’s said they have often wait up to a week for chart notes to be transcribed, meaning the patient has to wait as well. Holding their breath, so to speak, until the paperwork comes through.

And getting the paperwork right is critical. Medicare audits have become more frequent, according to Rench. He admits there is fraud and abuse, but said “government’s answer to everything is one more piece of paper for a doctor to sign.” He pointed out the emphasis on minutiae won’t deter deliberate fraud by forgery.

The more paper, the less attention paid to each one by busy practitioners. If an audit finds something as simple as a missing date or signature, if the chart doesn’t document that all other options were tried and considered first, then the claim will be denied as medically unnecessary and all payments made on that claim will be clawed back.

Outside contractors performing Medicare audits are paid to find reasons to deny payment, but are not penalized if those findings are overturned. Claim appeals that are supposed to be heard by an administrative law judge within 60 days are now backed up 27 months.

Patients wait, and Medicare claims it’s fighting fraud without affecting patients.

Delays put Rench and other DME suppliers in a tough position. Do they gamble on getting paid in order to serve a desperate patient or wait for all the paperwork to come through correctly? Do they withhold equipment from a patient who is a bad credit risk? For clients who can afford it, paying out of pocket is an option, but he sees the inequity in a two-tier system of care.

Medicare for all is an easy slogan but no universal cure. Repeal and replace is an easy slogan but a hard slog. We would be better to adopt Martin Luther’s slogan for the protest movement he started 500 years ago in the Christian church: “Reformed and Ever Reforming.”

Columnist Sue Lani Madsen can be reached at or on Twitter @SueLaniMadsen.

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