Deciding on the Best Cut

First, a bias laid-out on the plate in full view.

I think healthcare service providers should be paid for their work. Healthcare service providers should be paid in accordance with the level of responsibility and the investment they have made to become credentialed.

What I have learned over the years is that in addition to the service provider, numerous other persons are paid to manage the exchange of funds between providers and patients. 

How many people have to be paid to have a therapist arrive at your door to provide care to your child?

Do you consider it reasonable for a therapist to provide services in the home of any child?

Define reasonable.
Cost effective?
Life-saving?

By what standard is it necessary or beneficial to go to the patient’s home for services?

I call into question the whole premise for delivery of “healthcare” in the home of the patient. For your consideration. To think about. To decide for yourself.

Therapy is not the only in-home service. Nursing care is likely the most – in terms of patients, numbers of hours and amounts billed to Medicaid.

I have been in homes where the child is approved for full-time care, 24-7. These are very sick, medically-fragile children and regulations dictating nursing services have been written to substantiate a cost effective service-delivery in the home over an institution or hospital. I do not have an argument against providing this kind of care. At the same time, in some of the homes I have been in, the whole family receives subsidized housing, income in the form of the child’s SSI, and medical coverage without-copays for everything while the adults are all unemployed.

Very possibly in-home services are life-saving in a home like this.

Inside the black box of healthcare insurance the corner holding Medicaid pays for volumes of regulation to be sure no one takes advantage of Medicaid benefits – seemingly invisible to the patient but all too apparent to the service providers. 

In comments on my last post starrlife noted the poor compensation for dealing with ‘bureaucracy’. I can attest to paperwork demands that often seem unreasonable. I have spent hours writing letters of medical need for equipment and orthotics, talking with other providers, talking with personnel in physician’s offices and physicians – all un-reimbursable work from Medicaid. The specs for how minutes-of-service are to be charged for therapists are based on time spent with the patient with pittance allowance for writing a note.

I am NOT complaining, suggesting nor stating that my the compensation per visit for therapists is insufficient.

I work for a very good company who bills Medicaid based on invoices I generate for the work I do. This company exists to help parents of children get nursing and therapy services in their homes. I have nothing but good things to say about the company with whom I contract.

For this good small company, the regulation is un-mitigating. They are inspected and audited often. Requirements on them for quality control, continuing education of personnel, document keeping and timelines are the stuff of mountains of manuals. In order to receive public money, one must prove public trust.

Going beyond the requirements…. One day this home health agency bought all of the therapists breakfast at IHOP. (They usually feed us at the office if we have to come for a meeting, but this was an optional meeting.) Administrators of this small business are members of some club association for administrators of home health agencies. [Imagine that.] Anywho, they wanted to share with us the prospects of more regulation coming down the pike. Er, more auditing coming down the pike – based on some (few, those found-out) agencies fraudulently billing Medicaid.

In response to fraud against Medicaid, the wisdom of the government (aka your legislators) passed laws authorizing money for investigating fraud in Medicaid. Legal auditing firms could then bid for the government contract to do the auditing. The line of thinking went like this – if we invest million$ auditing everyone we will likely find more million$ in fraud and thus saving the government money. Right. [Didn’t hurt the law firm doing the auditing either. Ahem.]

I am confident that many people are paid to be sure that some people do not receive healthcare insurance from the government when they do not qualify.

I selected just two items to share from my 1-inch-thick-file policies&procedures-manual for this agency.

Offering Gifts and Other Inducements to Beneficiaries concludes with this truly summative sentence: “To the extent that providers have programs in place that do not meet any exception, the OIG, in exercising its enforcement discretion, will take into consideration whether the providers terminate prohibited programs expeditiously following publication of this Bulletin.” 

As I recall the mandatory review of this policy (the company was mandated to review in person – which included everyone signing two pieces of paper to confirm we were there) the discussion mostly revolved around the details of exchanging holiday gifts with the families we serve. You know, this is okay under these circumstances but not that or under those circumstances.

Within the Administrative Policy Manual are 5 pages on Safety and Workplace Violence and this Definition is first: “Workplace can be the Home health office, the patient’s home, a healthcare facility or anywhere business is conducted.” The policy then states that, under OSHA, the providers can be cited for failure to recognize workplace violence.

I cannot.write.how.comforted.I.am by this regulation. [Good thing none of us slipped and got hurt at IHOP – “anywhere business is conducted”. Ahem.]

Medicaid reimburses my agency for an amount that is ~200% more than the agency reimburses me. Believing in the company I contract with, I say that with not-even-a-smidgen of regret or concern.

That is because about two years ago I endeavored to bill Medicaid directly for my services.

I filled-out and submitted MANY forms. I attended HOURS of instruction on how to use the billing software system – that I installed on my pc. I bought forms to use in the beginning until the software system was ramped-up. I spent HOURS on the phone with perfectly polite personnel confirming receipt of items and correcting arcane ‘mistakes’ never instructed or not within the instructions. [Believe me, I am condensing this story.]

Oh! I failed to mention, the state contracts with a private company to run the Medicaid program. The people I am dealing with are contractors with the state government. In effect, they are the same as private insurance – that is, they exist to collect funds and restrict outflow. To protect the poor patients from fraudulent providers they create a mind-boggling maze of requirements in order to get money.

Oh! I failed to mention, in order to bill Medicaid for my first (trial) patient, I had to bill the patient’s primary insurance first (the patient was on a waiver program). So, billing work was doubled. Several months into the process, I broke the code for billing for my evaluation and was paid everything but something like $2.38 – for which I received a check from Medicaid.

I missed one step in the billing process that eliminated any reimbursement for the weekly therapy visits I provided after the evaluation. My last two claims to Medicaid were for wheelchair evaluations – which require the signature of a PT – as favors to the DME (Durable Medical Equipment) guys I like. I sent in the claims. Absolutely.no.response.

I.gave.up. I decided not to invest any more of my time in trying to recoup money from the behemoth and the behemoth’s guard dog.

I am not smart enough to bill the Medicaid program. I am grateful that some people are smarter than me, and they can have the rest of what Medicaid gives them for my services.

Realize I am not alone. But My Kind are few, and some children are not getting services precisely because of the circumstances I just described. One day I found a business card on my front door. A business card for a case worker for the special Medicaid program. The next day a nice-sounding lady called me on the phone asking me to take a patient. I was sympathetic, but….

Remember the trap door inside the black box? Under there is a huge stash for the recycle bin of bulletins that look like this:

I still get volumes of paper from the state Medicaid intermediary. And I suspect I am not alone. And if I WAS actively billing Medicaid, how much of each of these bulletins do you think would be applicable to me? Because Medicaid pays for way-more stuff than home health - hospitalizations, surgeries, out-patient treatment, dental care, medications.  [Frankly, I cannot even fathom contacting them to try to get them to stop sending the bulletins.]

Everything I have said here may be acceptable to you ~ just the cost of doing business. Perhaps jaded was too mild a term for what how my experiences with healthcare insurance have done to me influenced my opinions. [In a way, I have posted today what many of you post occasionally – frustration.]

So, where do we go from here? There’s another back corner I will show you - (parts of) government healthcare insurance for the military, their dependents and retirees. (Not to be confused with Veteran’s Administration healthcare. I cannot responsibly go there; do.not.know.the.way.)

   

In complete sobriety I again question increasing public money into this system. If you are considering advocating for more money into BIGgovernmenthealthcareinsurance, I respectfully suggest you spend your time exploring ways to improve the current system towards providing more services to more people over adding money in trust of the same outcome.

I would really like for someone to answer my first question at the top of this post. It would be nice if some news sleuth would do that for us, eh? Instead of exploiting reporting on some poor family with medical expenses and no healthcare insurance I would like to see a report of how government money is spent that is not spent on medical care.

Now that would be news.

Comments

[Stephanie Nance]

I cannot answer your question! I guess one can be thankful that the PT does, in the end, get paid. That's the problem with a centralized system. The layers of fraud protection act as layers of discouragement to those who are not willing/able to make a career of learning the ropes.

BTW, this week I have an appt. with our county's developmental disability organization. They offer case management services and, I believe, will help me navigate the medicaid waters.

[starrlife]

yep- there are layers of baloney in there- a veritable Dagwood sandwich!We have very few dentists in the whole state to provide services to Medicaid clients just for the reasons you describe, along with the low reimbursement. I have a lot of mixed feelings about it. The Auditing is just absurd, what about JCAHO accreditation Barbara? Another layer!I feel fortunate that we are out of the bill for individual services racket- at the end of the year the agencies will push for more services to meet the fee for service cap- it was barbaric.

[Barbara who lives here]

I hate to think my question was only rhetorical, Stephanie, but thanks for responding as if I was serious. "A centralized system" indeed. I will show some of the effects of a system that tries to take care of everyone in the next post on insurance (not the NEXT post).

I am pleased to see you are getting some response from your state's Medicaid system. While Medicaid for persons with disabilities is a small portion of Medicaid in general, it exists for those individuals.

Thank you, Stephanie, and thank you, starrlife, for adding to this post.

For those that do not know JCAHO, the credentialing agent of the government for hospitals, ignorance is bliss.

Your comment regarding dentists also applies to physicians and optometrists. Providers refuse to provide services to persons whose insurance DOES NOT PAY.

Tying into my post on the poor - I will mention also, the providers that do take Medicaid patients suffer greatly from missed visits. Every missed visit in a scheduled day at the dentist's office is money lost.

Each provider can show statistics that Medicaid patients are no-shows at much higher rates than anyone else. Guess what happens when a therapist arrives to a home and no one is there? No pay for that visit.

Life is definitely harder for the poor. But this highlights the problem with equating free-public-insurance programs with medical care. The patient has to participate.

The "if you build it they will come" attitude is a crock. This seems to be part of the thinking for drawing EVERYONE into a required system.