When I began writing about the menace of increased federal
involvement in our medical delivery system, I was surprised to
discover that some doctors actually supported it. These misguided
medicos represented only a small minority of practicing physicians,
and most were profoundly ignorant about health care economics, but
the “M.D.” following their names provided them with a façade of
credibility. A number of these people took advantage of their
illusory expertise in health care policy to launch blogs which they
used to promote their notions of “health reform” and extol the
virtues of government-run health care in general.
Among them was an ER physician who writes under the nom de
plume “Shadowfax.” This particular “docblogger” stands out in
my memory because he was peculiarly uninformed about the nuances of
the issue and yet utterly dismissive of anyone, including other
physicians, who attempted to make him understand that he would one
day regret advocating an increased government role in medicine. I
occasionally crossed swords with him myself, but it was an exercise
in futility. Like most soi disant progressives, this
self-satisfied sawbones couldn’t imagine that he might be on the
wrong side of this or any other issue.
This unshakable belief in his own infallibility regarding
government-administered health care was partly due to his
hopelessly naïve view of Medicare, which he
called “the most successful government program ever.” Never
mind that this “success” had produced a $38 trillion unfunded
liability, it was somehow “more efficient than private insurance.”
Imagine my surprise, then, when I looked at the byline for
this scathing piece bemoaning the depredations of that very
program. The outraged author of “Medicare made the rules and now
punishes doctors for following them” is none other than the
redoubtable Shadowfax.
I haven’t read his blog for a while, but it would appear that
the virtues of government-run health care have begun to pall for
the good doctor. He has finally discovered what I and others told
him years ago: Medicare rules are, as he apparently now realizes,
“arbitrary and disconnected from reality.” He has also noticed
that, when a physician runs afoul of these bureaucratic vagaries,
the government is the judge, jury, and executioner. The immediate
cause of his disillusionment is Medicare’s trick of performing a
superficial audit of a doctor’s billing practices and, based on a
hopelessly flawed statistical sampling method, accuses him of
fraud.
Shadowfax querulously explains: “You get a letter from the
Medicare … telling you that you’ve been reviewed, found guilty of
upcoding, and this finding, based on a handful of charts, is
extrapolated back several years.” The term “upcoding” is industry
jargon indicating that a provider has submitted a claim using codes
that produce inappropriately high payment. It’s rarely done
deliberately, assuming it has actually occurred, but that doesn’t
matter. “The result is a large demand for reparations, usually in
the mid-to-high six figures. The physician group can either write a
check or lawyer up and argue it chart by chart.”
Although physicians have been spared this kind of skullduggery
until recently, hospitals have been enduring it for years, and the
amounts involved are much larger. Moreover, as Shadowfax suggests,
it’s a no win situation. Because Medicare uses a sampling method
that makes a mockery of statistical analysis, its refund demands
are often unjustified. But huge expenses are required to prove
that. Either way, a lot of money disappears from the bank account
of the hospital. And it gets worse. The recent “fiscal cliff” deal
changed the rule so that Medicare can now demand refunds for
“overpayments” made as far back as 5 years ago.
The most ironic feature of this program is that it proves our
Beltway masters intend to do what Shadowfax and other advocates of
government-run health care claimed they would never do — tell
doctors how to practice medicine: “Medicare is … reviewing charts
and claiming that the physicians are fraudulently upcoding because
we are documenting complete Reviews of Systems when they were not …
medically necessary.” In other words, the ultimate arbiter of
medical necessity is no longer your doctor. This program means that
the medical need for an examination, test, or procedure is
retroactively determined by the government.
And “medical necessity” is the number one target in these
retroactive chart audits. Why? Because, ultimately, the need to
order a test or perform a procedure is a judgment call. Thus, it is
easy for someone far removed from the situation, years later, to
read a medical chart and claim that some feature of your doctor’s
orders or documentation fails to conform with government standards.
And these retroactive determinations are not made by brain
surgeons. Most of the audits are carried out by nurses under the
loose supervision of a “medical director,” usually some M.D. who
finished medical school at the bottom of his class.
But that’s what you get when you let bureaucrats and politicians
make the rules. Now Shadowfax whines, “What I hate about this is
the underlying dishonesty.… If there’s an argument to be made that
physicians are paid too much, then let’s have that debate on its
merits. But the attempt to save money by harassing physicians and
exploiting the contradictions within the rules that the government
itself wrote is beyond maddening.” Well, dude, this is what you
advocated for years. Government-run health care is — by its nature
— dishonest, coercive, and corrupt. Now you, along with those of us
to whom you refused to listen, are stuck with it.
