Medical Necessity... To Fix A Problem There Cannot Be Two Standards

Health Care Reform... 21.5% reduction in payments to providers... possible shifting of reimbursement to favor primary care physicians... possible reducing payments to physical therapists to increase payments to cardiologists and oncologists. 

It seems to me to really resolve any problem there are always various considerations.  In the case of health care reform... there are at least 3 entities to consider.  1)  Medicare - its processes:  the inefficiencies, strengths and weaknesses  2)  Providers -  their processes:  how clinical decisions are made, the risk/benefit of the decisions and 3) Patients - their behaviors:  when they seek services, their responsibility in taking care of themselves, when they make poor choices.

I am so ready for a primal scream when I see something like the above and then read the details.  The government can't have it both ways... their audits in clinics capturing money paid inappropriately due to lack of "medical necessity" basically based on review of records yet the allowance of $60 billion in fraud to people who easily scam Medicare!  Medicare is paying for that fraud annually (of course, these are just the ones who got caught)!  In all honesty, providers should not take such a hit in reimbursement yet.  Medicare should have its own work cut out to clean house and ensure someone really needs an electric wheelchair or an electric prosthesis.  Amazing to hear Medicare will easily pay for 2 lower extremity prostheses and an electric upper extremity prosthesis on the SAME person!  Now come on, how many people 65 and older do you know who are THAT bionic?? 

I have no clue how powered mobility devices are billed.  I do know if a patient received any kind of prosthesis concurrently there would be claims sent for physical therapy and maybe occupational therapy.  I would think a darn computer system could process durable medical equipment claims for defined durable medical equipment items 20-30 days after receiving the claim and only pay if inpatient services or outpatient physical therapy services were provided within the same time frame.  I'd highly doubt anyone receiving a prosthesis would know how to function and be safe without some level of education and training.  Even if the prosthesis was a replacement, Medicare can just make a rule that rehabilitation services are required. 

If 10-12% of claims are for physical therapy services, does it seem strange to anyone else that OIG will be focusing on outpatient physical therapy services provided by independent physical therapists?  I highly doubt that physical therapists in independent practice are exploiting the Medicare system intentionally or unintentionally at the magnitude the guy in the video was.

~Selena