With elections upon us, I have been thinking more about the evolution of Medicare and how it affects the doctor-patient relationship. The past few years I have learned much about Medicare Part B, which covers outpatient (non-hospital) physician visits. Unfortunately, the more I know, the more questions I have! Here are some interesting facts you might not know about Part B:
1) You’re in or you’re out : physicians must choose whether or not to participate with Medicare. If they are “in”, they see patients with Medicare, are reimbursed at a set rate for services, and are subject to Medicare rules and regulations. If they are “out” they can see patients with Medicare only after signing a special private contract, and neither the physician nor the patient are reimbursed for services. Physicians who are “out” must submit special forms with Medicare every 2 years and they are not allowed to bill Medicare for any services at any facility through any agency during this time.
2) Expect the audit : if a physician is in Part B they can expect to be audited by the government for their services. Auditors are not medically trained, and they will review a physician’s documentation for services closely. If they find that the documentation does not match the billing, they can hold the physician’s Part B income indefinitely until the case is resolved.
3) Medicare does not pay for most preventative care : except in certain circumstances, Part B does not pay for preventative care. The physician must demonstrate in their documentation of the visit that the visit was “medically necessary” or they will not be paid. So under Part B “routine follow-ups” are not covered, and physicians are not paid to see patients unless it is “necessary”. It is notable that there is little guidance from Medicare on the definition of what is “medically necessary” and that this is a prime target for auditors looking to recover funds. For a list of Medicare-covered preventative care, see http://www.medicare.gov/navigation/manage-your-health/preventive-services/preventive-service-overview.aspx
4) Part B is not mandatory : you do not need to sign up for Medicare Part B! Like any insurer, it has its pros and cons, and has a monthly fee.
So how does this impact the doctor-patient relationship for psychiatrists? In my experience, most psychiatrists will simply refuse to see patients over 65 to avoid the whole Medicare dilemma. Psychiatrists who work with Medicare tend to be underpaid, overloaded with patients, and chronically anxious about their administrative burden and the risk of audit. Patients with Medicare tend to feel rushed and neglected. Psychiatrists who do not work with Medicare are frustrated because they have a smaller patient base and are limited in their career options by the 2-year “out” rule. Their patients are frustrated because they must pay 100% of services.
I do not know what the 2010 elections will mean for Medicare, but I doubt it will solve the current strains it places on the doctor-patient relationship. I strongly urge people approaching 65 to learn more about the pros and cons of Medicare Part B before signing up! For more details, see http://www.medicare.gov/navigation/medicare-basics/medicare-benefits/part-b.aspx