MEDI­CARE OUT­PA­TIENTS RISK HIGHER BILLS FOR PRO­CE­DURES

Kuwait Times - - HEALTH & SCIENCE -

WASH­ING­TON: You pay less for out­pa­tient treat­ment than for a hospi­tal ad­mis­sion, right? Not nec­es­sar­ily in the topsy-turvy world of Medi­care billing, ac­cord­ing to a gov­ern­ment re­port.

Peo­ple en­ti­tled to ben­e­fits un­der Medi­care who had heart stents in­serted as out­pa­tients faced hospi­tal bills that were $645 higher on av­er­age than those who had the same kind of pro­ce­dure as in­pa­tients, the Health and Hu­man Ser­vices in­spec­tor gen­eral has found. Stents are tiny mesh cages that prop open nar­row or weak­ened ar­ter­ies. They usu­ally are in­serted through a tube that’s threaded through an artery in either the groin or the arm.

The ben­e­fi­ciary’s share of costs av­er­aged $1,667 for an out­pa­tient stent, com­pared with $1,022 for an in­pa­tient stent, the re­port found. In­ves­ti­ga­tors looked at hospi­tal billing for 2013-2014.

In a for­mal re­sponse to the re­port re­leased yes­ter­day, Medi­care said it has taken steps to pro­tect peo­ple from such dis­par­i­ties. Nonethe­less, the in­spec­tor gen­eral is rec­om­mend­ing that Medi­care take an­other look at how its billing rules dis­tin­guish be­tween in­pa­tient and out­pa­tient hospi­tal stays. Over­all, there’s a gray area be­tween short in­pa­tient stays and long out­pa­tient stays, a prob­lem that the agency has been work­ing on for years, with mixed re­sults.

Not only do hospi­tal billing de­ci­sions af­fect how much peo­ple pay for a pro­ce­dure, they can also de­ter­mine whether pa­tients get Medi­care cover­age for in­pa­tient re­ha­bil­i­ta­tion. Gen­er­ally, Medi­care ben­e­fi­cia­ries must stay in a hospi­tal for at least three nights to qual­ify for in­pa­tient re­hab cover­age. The re­port says Medi­care should con­sider also count­ing the length of time some­one spends as an out­pa­tient. “An in­creased num­ber of ben­e­fi­cia­ries in out­pa­tient stays pay more and have limited ac­cess to (in­pa­tient re­hab) ser­vices than they would as in­pa­tients,” the re­port con­cluded. “Medi­care - and ben­e­fi­cia­ries - may be pay­ing dif­fer­ently for sim­i­lar care,” in­ves­ti­ga­tors added. Ad­vo­cates say ben­e­fi­cia­ries should be aware that how their hospi­tal stay is clas­si­fied can af­fect what they pay and also their ac­cess to cover­age for in­pa­tient re­ha­bil­i­ta­tion. But pa­tients and fam­i­lies may not be able to do much to in­flu­ence such clin­i­cal de­ci­sions.

As the gov­ern­ment’s premier health in­surance pro­gram, Medi­care serves an es­ti­mated 57 mil­lion older and dis­abled peo­ple. Most of the cases cov­ered by the in­spec­tor gen­eral’s re­port stemmed from emer­gency-room vis­its. The billing dis­crep­an­cies stem partly from Medi­care’s com­pli­cated de­sign. Ben­e­fi­cia­ries pay a de­ductible for in­pa­tient care, cur­rently $1,288 per stay. Out­pa­tient care is billed dif­fer­ently, with ben­e­fi­cia­ries re­spon­si­ble for 20 per­cent of the cost of ser­vices, af­ter a small de­ductible.

Some­times 20 per­cent of the cost of a bat­tery of out­pa­tient ser­vices can add up to more than the in­pa­tient de­ductible. Many peo­ple pur­chase pri­vate “Medi­gap” in­surance to deal with Medi­care’s out-of­pocket costs. For most of the pro­ce­dures scru­ti­nized by the in­spec­tor gen­eral, the Medi­care pro­gram and ben­e­fi­cia­ries both paid less when ser­vices were pro­vided on an out­pa­tient ba­sis. But in­sert­ing a heart stent - a com­mon pro­ce­dure - was not the only kind of med­i­cal care for which out­pa­tients wound up pay­ing more. In­ves­ti­ga­tors said the next three most com­mon ser­vice cat­e­gories for which out­pa­tients wound up pay­ing more were car­dio­vas­cu­lar pro­ce­dures with­out stents, car­diac de­fib­ril­la­tor im­plants and car­diac pace­maker im­plants. Heart dis­ease is still the na­tion’s top killer.

In its writ­ten re­sponse to the re­port, Medi­care agreed that the billing is­sue needs more work. The agency ad­vises hos­pi­tals that stays span­ning two mid­nights or longer should be billed as in­pa­tient. Medi­care said it is do­ing what it can within ex­ist­ing laws to pro­tect peo­ple from pay­ing more for sim­i­lar ser­vices as out­pa­tients. It has re­clas­si­fied pay­ment for many pro­ce­dures to limit what out­pa­tients can be billed. Stent pro­ce­dures are on that list. — AP

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