1. Trapping Patient & Physicians in Medicare
By Accident or By Design?

2. Medicare Part A
Every American is entitled to Part A Medicare at age 65 if paid into system
Medicare Part B and D are optional
SSA Program Operations Manual System (POMS)
Allows individuals to decline Part A benefits
Surprise is that SS benefits will no longer be paid and previous benefits received must be repaid

3. Medicare Traps Patients
Hall et al v Sebelius 2002
Suit began when Hall wanted to use private health insurance instead of Medicare
Informed he would have to give back SS benefits and forfeit future benefits
Fund for Personal Liberty (Martha DeForest)
Shoestring budget
Dick Armey was co-plaintiff

4. Hall et al v Sebelius Heard in DC District Court
Government stipulated rulemaking ignored
Court was incredulous but ruled against
Case failed at Appeals Court Level
Supreme Court did not take the case
Cato Institute wrote amicus
briefs/hall-v-sebelius

5. Permit Patient Choice
Propose statute to separate Part A Medicare from Social Security benefits to preserve Congress' intent
Save money for Medicare system
Allow patients to use coverage of their own choice
Private health insurance
Health savings accounts
Insurance from municipalities / states
Private funding

6. Medicare Physician Disenrollment
Why:
Save millions of dollars as government is unable to keep up with cost of practice
Patient freedom to select providers
Allows patients and physicians to take the time they both want for evaluations
Patient and physician mutually agree on pricing
Allow patients to use their paid-for benefits

7. Medicare Disenrollment-How does it work today?
Physician is not on Medicare's rolls
Physician has no relationship with Medicare
Patient has relationship with Medicare
Patient requests payment and MAC provides reimbursement to patient

8. Medicare Disenrollment
Governement regulations state
Physician must be enrolled in Medicare to see a Medicare patient.
Unenrolled physicians prevalent in FL, NY, CA, TX
Patient uses CMS 1490-S & gets reimbursed
Doctors receive threatening letter

10. HHS Position

11. Letter from CMS to the AMA c. December 2011
HHS Position
“ In order to stay in compliance with Medicare law, a physician who
treats a Medicare beneficiary for a Medicare-covered service must either
1.) enroll in Medicare and submit a claim on that beneficiary’s behalf for those services;
2.) opt out of Medicare and enter into a private contract with the beneficiary for those services; or
3.) furnish the Medicare-covered services for free.”
Letter from CMS to the AMA c. December 2011

12. HHS Position

13. HHS Position

14. HHS Position

15. CMS Manual System-50 Violators
Required to keep list of top 50 violators
Poor record keeping-one request was obviously crafted in response to the FOIA request
Few, if any excluded from Medicare under 1848
Anyone fined for “violating” 1848
Government worried about challenge under 5th 13th or 14th Amendments?

16. CMS Manual System-50 Violators

17. Social Security Act § 1848 (g) (4)
(4) Physician submission of claims.—
(A) In general.—For services furnished on or after September 1, 1990, within 1 year after the date of providing a service for which payment is made under this part on a reasonable charge or fee schedule basis, a physician, supplier, or other person (or an employer or facility in the cases described in section 1842(b)(6)(A))—
(i) shall complete and submit a claim for such service on a standard claim form specified by the Secretary to the carrier on behalf of a beneficiary, and
(ii) may not impose any charge relating to completing and submitting such a form.
(B) Penalty.—
(i) With respect to an assigned claim wherever a physician, provider, supplier or other person (or an employer or facility in the cases described in section 1842(b)(6)(A)) fails to submit such a claim as required in subparagraph (A), the Secretary shall reduce by 10 percent the amount that would otherwise be paid for such claim under this part.
(ii) If a physician, supplier, or other person (or an employer or facility in the cases described in section 1842(b)(6)(A)) fails to submit a claim required to be submitted under subparagraph (A) or imposes a charge in violation of such subparagraph, the Secretary shall apply the sanction with respect to such a violation in the same manner as a sanction may be imposed under section 1842(p)(3) for a violation of section 1842(p)(1).

18. 42 CFR
§ Basic enrollment requirement.
To receive payment for covered Medicare items or services from either Medicare (in the case of an assigned claim) or a Medicare beneficiary (in the case of an unassigned claim), a provider or supplier must be enrolled in the Medicare program. Except for those suppliers that complete the CMS-855O form or CMS-identified equivalent, successor form or process for the sole purpose of obtaining eligibility to order or certify Medicare-covered items and services; once enrolled the provider or supplier receives billing privileges and is issued a valid billing number effective for the date a claim was submitted for an item that was furnished or a service that was rendered. (See 45 CFR part 162 for information on the National Provider Identifier and its use as the Medicare billing number.)
Deleting this regulation or even better, passing a new statute that allows
physicians to see patients outside of Medicare entirely is what is needed.
Preserving the ability of patients to get reimbursement is paramount.