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BLOG: Three reasons why Medicare is our best payer
The cover story in this issue of Ocular Surgery News addresses the phenomenon of physicians opting out of Medicare. While few in our profession have made this switch (and a few have quietly opted back in), every physician occasionally dreams about going “off the grid” and leaving the nation’s biggest payer.
If a single policy has kept most ophthalmologists participating in the Medicare system, it was the 2005 CMS ruling that allowed separate private-pay billing of premium lens implants and refractive services performed as part of cataract surgery. For many of us anterior segment surgeons, participation in Medicare gives us access to patients who may elect additional services that are separately reimbursed.
To be sure, there are many legitimate complaints about Medicare, such as increasing hurdles to demonstrate “quality measures” that measure anything but quality and odd restrictions such as reduced payment for the second eye in bilateral cataract surgery, but here are three reasons why Medicare may still be our best third-party payer, and why I, for one, am not opting out of the system.
1. Medicare’s rules are clear and mostly fair. Many private payers sometimes require onerous pre-authorizations and sometimes do not. Some require physicians to bill, only to later find out whether a provided service was covered. Others mandate that their covered lives must have surgery performed in a facility that, although inadequately equipped and staffed, is owned by the payer. While making benefits harder to access, private payers are increasing their premiums to patients at an alarming rate. Not so with Medicare.
2. Medicare pays, generally on time. We regularly have to push back against private payers who down-code capriciously or pay less than the contracted amount for the accepted code. Private insurers sometimes change their billing address without sending notice (just a small address change in the fine print on the back of the patient’s new insurance card). This permits them to sit on claims for months until we protest. In short, working with some private payers feels like having a dishonest business partner where we feel the need constantly to watch for bad behavior.
3. Medicare gives patients the benefits they have already paid for. Whatever you can say about Medicare’s future, the majority of today’s beneficiaries did indeed pay into the system. Whether current actual costs exceed what they paid in is really not relevant. For good or bad, it’s our country’s national health care system, and most seniors would prefer to take advantage of what it provides. We at least owe our elders our best effort in working with the system, flawed as it is, designed to repay them for their hard work.
In medicine, one party sells increasingly expensive services, another receives them, and a third pays the bill. These economics are riddled with conflict, and the rules of conduct will forever become more complicated as costs rise. While Medicare’s flaws are numerous, it deserves a lot of credit for being motivated by patient well-being rather than profit.