One test per year not related to a specific illness under Medicare? So much for preventive medicine.
In recent weeks we have been telling you about a new FDA proposal to increase its control over low-cost laboratory-developed tests—including locally performed custom diagnostics and tests for rare conditions. Tests like these are the future of medicine. People will soon be able to test for and spot cancers long before they manifest themselves using current methods. Testing can already help prevent diabetes, heart and blood vessel illness, prostate cancer, and other diseases.
Now for the bad news: Medicare will not pay for more than one test a year that is not directly related to the illness currently being treated by the doctor. In addition, Medicare rules forbid your doctor to treat (and therefore to test for) more than one ailment per office visit.
In theory, the patient could pay for the additional testing, but if those tests are deemed “medically unnecessary,” your doctor could go to jail for writing that prescription if he or she bills Medicare for the test. And if she or he wants to discuss the results of the test and prescribe a course of treatment, all discussion and treatment must be about that original ailment, even if you’re now sick with bronchitis instead.
It sounds absurd, but when claims for reimbursement are submitted for tests, procedures, or services that Medicare deems “medically unnecessary,” then they’re considered fraudulent “false claims” under the False Claims Act. In addition, what mainstream medicine deems “medically unnecessary” includes many natural treatments.
Yes, we know that doctors are sometimes involved in Medicare fraud, and it’s been growing: wereported on this issue back in 2010. However, it is more often a well-orchestrated ring of perpetrators committing organized theft. On the other hand, because of the complexity of Medicare rules, it is very easy to make a false claim. In one experiment, a researcher contacted five different government Medicare billing advisors about a possible claim and got five different answers about how to handle it. So even if a doctor stopped practicing and instead spent full time supervising each and every bill, the government can easily claim error and thus fraud.
To make it worse, checking with Medicare doesn’t protect the doctor. Even if a Medicare employee approved the billing, it can still be prosecuted. Of course, it isn’t that every error will be treated as fraud. It is just that it could be, and nobody is sure of what the rules really say. This is a very powerful weapon of intimidation and reprisal.
What about nutritional screening and counseling? Medicare will only cover medical nutrition therapy in very limited circumstances: if you have either diabetes or kidney disease, or have had a kidney transplant in last 36 months. (If you live in the Southwest, Medicare allows only one nutritional imbalance screening per year.)
If a product or diagnostic test is new, getting Medicare to create a new billing code for it can take a long time and cost doctors a significant amount of money in lost reimbursements. Even if there is already a billing code, Medicare must agree to pay for the service. In general, Medicare has not been willing to pay for genetic testing (except in screening for compatibility for kidney and bone marrow transplants), and it is certainly unwilling to cover the level of genetic testing needed to do truly personalized medicine.
Medicare keeps the focus on billable hours at the office from beginning to end. They won’t pay for physicians to consult with patients by email or over the phone—even if you’re old, disabled, or too ill to come to see the doc. They won’t pay for doctors to teach diabetics how to monitor their glucose levels or manage their diabetes in other ways. The same goes for other chronic illnesses.
In addition, Medicare requires the American Medical Association’s Current Procedural Terminology Codes (CPT), which healthcare professionals use to report medical procedures and services in patient records. Healthcare providers must use these codes—no other coding systems are permitted—in order to be reimbursed by Medicare. This squeezes out alternative medicine because there are no codes for many commonplace CAM treatments.
It is no coincidence that the coding monopoly is run by the American Medical Association and enforced by government. Fees earned from coding are believed to represent the bulk of AMA funding and make the AMA totally dependent on the goodwill of the Department of Health and Human Services.
Needless to say, Medicare only covers FDA-approved drugs—not supplements. The only fish oil Medicare will pay for is an expensive FDA-approved synthetic fish oil drug such as Lovaza. In theory, the FDA has only approved Lovaza for treatment of one condition. But nobody worries about that.
Is it any surprise, then, that Medicare is projected to be insolvent by 2026, only twelve years from now?