Medicare and Medicaid

iStock_000036113648LargeMedicare — The Past

Since its inception as a government sanctioned public health insurance program, Medicare has been both a bone of contention between political parties and a beacon from which to gauge the changes in American health care as a whole.

Passed as part of the Social Security Amendments of 1965, Medicare had as its focus individuals sixty five years of age and older, with a similar yet state-run program, Medicaid, addressing the medical needs of people with certain disabilities and and those from low income households.

Over time, however, Medicare has grown to be the preeminent standard for our nation’s health care in its entirety, with nearly every substantive change to its core foundation signaling a corresponding restructuring of our overall health care system.

The modifications imposed on Medicare, both by market forces and federal legislation, stand as a series of growing pains from which to mark the evolution of the American health care model. By charting these changes through the decades we can better understand the ways in which health care as a whole has morphed from a cost based system to one of performance evaluation. In turn, this may provide us with a glimpse into health care’s future if certain fundamental issues are not addressed in current reform legislation.

The rise of the government’s role in providing health care to its citizens came relatively late in America’s history. For much of its first two centuries the burden of caring for the sick and injured fell to neighbors, friends and relatives, with additional support from individual communities and religious groups. Visits by an actual doctor were generally limited to the home and dictated by local demographics. Almshouses and charity wards provided a certain degree of medical service, as hospitals were few and far between, and often existed solely upon the largess of the surrounding vicinities. Those who had the opportunity to visit a hospital prior to the twentieth century more than likely did so after an accident or as the result of an unfortunate designation of insanity. Read More…

Medicare — The Future

The Centers for Medicare & Medicaid Services released the final rule for the Medicare inpatient prospective payment systems (IPPS) for the 2014 fiscal year (effective for discharges occurring on or after October 1, 2013).  The final rule revises the IPPS for operating and capital-related costs of acute care hospitals and incorporates certain statutory provisions contained in the 2010 Patient Protection and Affordable Care Act, as amended in part by the  Health Care and Education Reconciliation Act of 2010.

Additionally, the final rule updates the rate-of-increase limits for certain hospitals excluded from the IPPS, as well as the payment policies and annual payment rates for the Medicare prospective payment system (PPS) relating to long-term care hospitals. The final rule changes the ways in which a hospital determines its full-time equivalent (FTE) resident cap for graduate medical education (GME) and indirect medical education (IME) payments.

The final rule also updates the requirements for the Hospital Value-Based Purchasing (VBP) Program and the Hospital Readmissions Reduction Program.

The entire final rule, which will be codified in 42 CFR Parts 412, 413, 414, 419, 424, 482, 485 and 489, can be seen here:

Litigating Medicare

Medicare consists within the following:

  • Title 42 of the United States Code
  • Title 42 of the Code of Federal Regulations
  • The CMS Online Manual System (
  • The Medicare Administrative Appeals Process
  •  Federal Court decisions

Section 1869 of the Social Security Act, 42 C.F.R. Part 405, Subpart I,  contains the procedures for conducting appeals of claims in Original Medicare (Parts A and B). These five levels of appeal in Medicare include:

  • Redetermination by a CMS contractor (carrier, fiscal intermediary or Medicare Administrative Contractor (MAC))
  • Reconsideration by a Qualified Independent Contractor  (QIC)
  • Hearings before an Administrative Law Judge (ALJ) within the Office of Medicare Hearings and Appeals in HHS
  • Review by the Appeals Council within the Department Appeals Board of HHS
  • Judicial review in federal district court

The Medicare Act sets forth very stringent channeling requirements to ensure a proper exhaustion of administrative remedies, which comes at a price.  Nevertheless:

In the context of a massive, complex health and safety program such as Medicare, embodied in hundreds of pages of statutes and thousands of pages of often interrelated regulations, any of which may become the subject of a legal challenge in any of several different courts, paying this price may seem justified.”  Shalala v. Illinois Council on Long Term Care, Inc., 529 U.S. 1, 13 (2000).