April 6, 2001
Committee Holds Hearing On Medicare Complexity
The House Energy and Commerce Subcommittees on Health and Oversight and Investigation held a joint hearing April 4 to examine the relationship between the Health Care Financing Administration (HCFA), Medicare contractors/carriers and providers and the complexity of the Medicare program. The hearing reviewed how HCFA and contractors communicate with each other as well as to providers on program and regulatory changes. Discussion also focused on challenges faced by providers in interpreting HCFA/contractor policy regulations and in billing properly in order to receive payments for services rendered. Witnesses, who included representatives from HCFA, the Department of Health and Human Services Office of Inspector General (OIG), and Medicare contractor, physician and practice plan communities, recommended potential solutions to improve the administration of the Medicare program.
HCFA, the OIG and representatives from the Blue Cross and Blue Shield Association (BCBSA) all reminded the committee of payment and benefit changes enacted into law within the last five years. For example, BCBSA Medicare Contracting Officer Harvey Friedman referenced the many new payment systems that have come online as a result of legislation. Acting Inspector General Michael Mangano added that "the development of various forms of managed care and new models for vertical and horizontal integration of providers have led to the need for new Medicare rules and regulations." Together, such changes have caused the Medicare program to grow more and more complex.
Such complexity was described with a series of examples given by the witnesses representing the physician and practice plan communities. Douglas Wood, M.D., cardiologist at Mayo Clinic, said "in my daily practice, not only do I have to understand the myriad of Medicare rules, but I must also be able to translate a local medical review policy and to try to understand the case-by-case decision making of the medical director. If I make a mistake, in addition to not being reimbursed, I face the risk of other sanctions [relating to fraud and abuse]." Such an environment where uncertainty, confusion and fear of sanctions among provider ultimately affects the quality of care to patients, said Dr. Wood.
On behalf of the Medical Group Management Association, Jyl Bradley, administrator of Associates in Surgery and Gastroenterology and Dunning Street Ambulatory Care Center in New Hampshire, cited areas and provided examples where breakdowns occur in the administration of Medicare: lack of organization and responsiveness of the contractor; lack of preparedness of carriers to handle HCFA changes; lack of communication from HCFA to contractors and in turn to providers; inconsistencies between HCFA manuals and Medicare statutes; lack of notice of medical group practices of HCFA's intentions to change billing and payment rules; carrier mistakes unresolved; lack of HCFA oversight and enforcement of requirements over contractors; and lack of provider education tools and recent action in the wrong direction.
Many of the witnesses and committee members expressed their strong interest in improving provider education materials and programs, as well as funding HCFA and its contractors at higher levels so that Medicare can be better managed. The provider community also urged HCFA to develop national payment policies for commonly performed services as well as to improve its oversight of carriers to ensure a uniform application of national policies.
Information: Lynne L. Davis, AAMC Office of Governmental Relations, 202-828-0526.
