Medicare requirements hobble the health care system

Sick for a week, 82-year-old Hedy Moskat was taken to Carson-Tahoe Hospital's emergency room by ambulance with flu-like symptoms. Dehydration made her increasingly disoriented and confused, but the nightmare was just beginning, according to her daughters, Vesna Vigo and Jasna Richmond.

Carson-Tahoe Hospital officials said she couldn't be admitted because Medicare would not pay for her stay, but Moskat's daughters persisted.

"Thank God I didn't listen to any of their so-called doctors, nurses and social services people. My mother was put into a room and three days later had a massive heart attack," Vigo said. "She was then transferred to intensive care, where she remained until her release to Mount View Nursing Home. She passed away one week later."

According to Gayle Larson, manager of Patient Financial Services at Carson-Tahoe, patients are admitted only if they meet certain criteria, a determination made by computer software called the Interqual. Sometimes, people fall through the cracks under Medicare rules.

"It breaks our hearts when patients don't meet the criteria, but Medicare has forced us to become a business," she said. "In the 1980s, we provided the best care without considering any rules. Now, before we make a move, we must be sure the guidelines are followed. We have an agreement to participate in Medicare and if we don't follow their rules, we're out."

In some cases, the problem has been exacerbated by the Balanced Budget Act of 1997. Signed into law by President Clinton, the bill enacted the most significant changes in Medicare and Medicaid programs since their inception 30 years ago.

Outpatients are compensated differently than those admitted into the hospital.

"Payments are determined per test," Larson said. "Medicare only allows this much for one procedure and pays only half of another. From an outpatient perspective, the beneficiary pays more."

Medicare no longer pays for self-administered drugs for outpatients.

"It's one of the complaints we hear the most," Larson said. "Patients don't have to pay for these drugs when administered in the emergency room, but must pay for them once they are outpatients."

Payments to Carson-Tahoe Hospital's Rehabilitation Center have also experienced marked reductions.

Larson said questions concerning Medicare payments are referred to fiscal intermediaries, or companies that handle disbursements and the answers often seem subjective.

"The health care industry is being held hostage by this system. We must work within their parameters and we had to increase our staff to deal with the issues that come up," she said. "In this department alone, we've added two employees in addition to purchasing the software. When we bill, we must be within Medicare's guidelines, or face stiff penalties."

Tests and procedures must be on a Medicare-approved list for any given diagnosis. If not, Medicare won't reimburse for that test.

Carson-Tahoe is required to let a patient know whether the test is Medicare approved. If the hospital doesn't inform the patient and simply pays for the test, Medicare determines that the hospital is providing a free service, which is an enticement and not considered appropriate, according to Larson.

She said informing a patient of this, known as an advanced beneficiary notice, is a cumbersome process that takes health care professionals away from patient care.

Figures vary from month to month, but Medicare reimbursements make up about 44 percent of Carson-Tahoe Hospital's revenues. Even more onerous for hospital officials: the private insurance industry is considering a system that mimics Medicare.

Several calls to Medicare officials and intermediaries, those who handle the distribution of these funds, were not returned.