Negotiating The Medicare Labyrinth

Have you ever had that nightmare where you are stuck in a maze, and you keep hitting the wall only to have to turn around and start over... You wake up exhausted, scared and in a cold panic that you could be stuck in that maze forever...

Welcome to the world of negotiating medicare payment for services, procedures and care.

I recently lived this nightmare in regard to a treatment option that my care team felt would benefit a resident. The problem? We live in the wrong state and our Dr. is assigned the wrong fiscal intermediary to bill for services in our building. If this resident lived in Virgina the treatment would have been done at bedside in her room by her Dr. who could bill for it and receive payment. Unfortunately for my resident the only way she can receive this treatment is to experience a van ride to a clinic 35 miles away where she would have to see a new Dr. and deal with the trauma of leaving her environment, and riding in the back of a health care van for over an hour. By the way, she suffers from dementia, and the transfer trauma would be very painful for her.

I am being told that our Dr.s' fiscal intermediary does not recognize us a "service provider for such treatment", yet they will allow me to bill for transporting this resident, paying a driver and staff member to go with her and the treatment supplies once the treatment is completed. I am not the brightest person with financials, but even I can figure out that this is the more expensive option....

This scenario irks me greatly...First for my resident/elders. Why is there not a par/par coverage system for medicare? Why do the fiscal intermediaries get to determine what services get covered and in what setting? Why is this not a universal service program? Secondly, as a taxpayer and perhaps someday medicare recipient how do I know what services are covered and where I can get these specialized services? As a provider who deals with reimbursement issues daily, this was a new encounter. I can only imagine the lack of consumer awareness of these scenarios that play out daily all over America.

I think of the millions of dollars that companies such as the one who provides this treatment option, Dr.'s, facilities and other providers spend simply negotiating payment for services. I can only imagine the impact this additional cost has on the goods and services that we all provide to Americans.

In fact, obtaining reimbursement for health care has become an occupation in high demand. I would imagine that becoming a reimbursement specialist would be a lot like completing a new sudoku puzzle each day...You finally get the numbers in the right places, and wham...a new puzzle appears for you to figure out.

So we continue to run the maze, occasionally we make it out, but usually we spend thousands of hours and dollars running into walls....Only America could make health care a game..