To: The Community
From: @theinsurancedoctor
Re: Introduction

• I am a physician who practices medicine and works to help physicians, nurse practitioners, physician assistants and hospital billing and utilization review staff understand how the largest health insurance company in the world makes decisions about payment for healthcare. And that insurance company is the Center for Medicare and Medicaid Services, which is abbreviated C.M.M.S, but it is often referred to simply as C.M.S. .
• CMMS has policies and procedures covering the payment of literally thousands of items, and services.
• It is not practitcal to teach people the thousands of rules and policies created by the Center for Medicare and Medicaid.
• It is possible to teach people how the system works and where to go to get specific answers to specific questions. This is vital, it's all boring fine print until it affects you and what you want, then your motivated and then you call me.

How big is the insurance program operated by the Center for Medicare and Medicaid Services ?

• The Center for Medicare and Medicaid, operates in all 50 of the United States of America and it's Territories., like Guam, Puerto Rico, American Samoa, US Virgin Islands and the Islands of Micronesia.
• Medicare provides health insurance to people 65 years and older, and currently provides health insurance to over 60 million Americans.
• Medicaid covers low income Americans, from conception to age 65, and Medicaid currently covers over 80 million Americans.
• Dual Coverage Medicare and Medicaid; about 12 million Americans are covered by both of these insurance plans.
• So the Center for Medicare and Medicaid services provides healthcare insurance for over 150 million Americans or almost one half the United States population of 330 million, according to the last published US census.

What do I teach them?

• Although I am an experienced physicians with two board certifications, I don't teach them medicine or surgery. I explain the criterion which determine whether they get paid. So in simpler terms: I am teaching them how to get paid.
• CMMS creates the criterion, and they are derived from scientific studies and from patient outcome data on the medical outcomes of millions of patients a year, whose care is paid for by CMS.
• CMMS pays for the healthcare of over 150 million people each year.
• So their payment criterion are important to every healthcare provider and every healthcare faility because providing healthcare to one half the nation means someone has sort through the patients who have a legitimate needs for medical services and differentiate them from the fraud, waste and abuse.
• We must remember that every institution, even our churches and heathcare system, have bad actors, and the responsibility for policing them falls on CMMS.
• But as you can imagine, that's a very ig job, so CMMS needs help from people who understand medicine, billing, fraud, waste and abuse. If you guessed that would be insurance companies, you guessed right. But depending on how the insurance compnaies get paid, that could be like the fox guarding the chickens. So there are other institutions who police the insurance companies, and this creates layers of administration.
• So, the bottom line is it can't be as easy as paying all insurance claims without oversite and conditions, that would not only bankrupt the payment system, but also encourage fraud, waste and abuse. And believe me, people committing fraud, waste and abuse don't need any encouragement.
• FInally, the different insurance companies have different performance records and different mission statements, so that's where government oversight and consumer complaints come into play; the squeaky wheel gets the grease. If concumers don't find out what their rights are and complain when they think they are being taken advantage of, then nothing will be done.

What are those criterion?

• In a startling example of how a government can do something right, the Center for Medicare and Medicaid does two things incredibly well and is an example to the world.
• First, CMS publishes the criterion they use to determine whether they will pay for surgeries, durable medical equipment, drugs, physical therapy, speech therapy, diagnostic tests and various types of x-rays, all on their website.
• Second CMS bases their decision to pay for care on both scientific evidence and proof of benefit for the patient.
• CMMS bases approvals and reimbursement upon scientific evidence, or what is commonly called Evidence Based Care. CMS convenes meeting with specialists in medicine, pharmacy, surgery, social workers, therapists and statistics. These people review both scientific studies and policy statements from Academic Organizations from various medical specialities who establish standards of care for their respective specialties. The scientific studies CMS uses have to be critically reviewed, and the both the process and conslusions reviewed and replicated by others before CMS will place it on their regular reimbursement list.
• Lastly, CMMS looks at benefit to the patient.
  For example a patient may meet the scientific criterion to need a wheelchair, but CMMS asks an additional question: Can it benefit the patient? This means wheelchair payment criterion include has a physical therapist examined this person to see if they are strong enough to propel or push the wheelchair themselves? Do they have someone in the home who can push the wheelchair? Medicare also requires the Physical Therapist actually go to the home and make sure it has large enough doorways, a ramp or access point for a wheelchair. It doesn't have to be a ramp, it just needs to be a physical structure that the patient or their caregiver can push the wheelchair over to access the home, and once the wheelchair is in the home, it has to be passable by a wheelchair. Thats a lot of details and it seems like a bunch of work. But when you think about it, if you give a person a wheelchair because they are to weak to walk, they still have to be strong enough to push themselves in a wheelchair, or they need a caretaker who can do it. And they have to be able to get the wheelchair into the house and through the doorways between the rooms. Otherwise the wheelchairs just become expensive places to stak clothes or newspapers.

The Final Product the criterion upon which reimbursement is based.

• All of this brainpower and all these scientific studies result in what are called National Coverage Determinations; as in what CMS will pay for anywhere in the nation. And Local Coverage Determinations; what CMS will only pay for in some states, based on historical and demographic issues I believe. This reflects in my mind some flexibility on the part of CMS. Below these in the hiearchy of rules lay the InterQual and MCG guidelines, which are software constructs with vast databases, and they attempt to cover any areas where CMMS NCDs and LCDs don't cover.
• It's a pretty complicated attempt to use evidence guidelines for healthcare reimbursement, based on patient outcome data, from the largest patient outcom database in the world.

Research Studies

• Additionally CMS pays for the care of patients receiving therapies which have reached the stage of human trials, as long as these studies are being conducted at large research centers around the contry and their research follows commonly accepted research and evidence gathering standards.
  their website.

Quality Assurance and Utilization Review

• I think my job and the job of people who work for CMMS can be summarized by saying we work to insure that patients get the medicines and therapies they need, which are scientifically proven to work and represent the best plan of care for them. Which is a complex task, and there are one size fits all solutions, just items to use the data, evidence of outcomes, to guide medical care, through reimbursements.

• The Quality assurance part of my job is to insure that the drugs, therapies and surgeries work, and the benefits outweigh the risk. What this means in general is that Medicare always wants the patient to try the least dangerous therapy, which has been shown to work in most patients, before they are treated with more dangerous therapies.

• The utilization review part of my job is to make sure that all requests for payment for a service are reviewed using these CMMS criterion faithfully, so that we only pay for the best and most effective care for each individual patient. An our decisions to pay or not to pay are both objective and consistent.

For example : If the patient has a condition which can be treated with a brace, a splint, a pill and some physical therapy, and 30% of the patients get better with these measures, Medicare will pay for surgery for this condition, only if the least dangerous therapies where tried first. This is important to understand because surgeries have two sets of outcomes: the first set is the surgery may make you better, the surgery may make you worse, and the surgery may have no effect on your condition. The second set of outcomes from surgery is complications; you may have no complications, you may have mild complications and you may have severe complications. If you take a long hard look at these two sets of outcomes, you must also realize your outcome will be a mixture of these outcomes. For example you could have your condition get better, and you have no complications. That's the goal or ideal outcome. But that is only one of six possible outcomes; you could be made better by surgery but have mild complications or be made better and have severe complications. For example you could have surgery on your blood vessel to restore blood flow which is successful, but during the surgery the surgeon accidentally damages the nerve to this leg. The nerve damage paralyzes the muscles, so you can no longer move the leg, or iyou can move it, but it's to weak for you to walk, so you have to use a wheelchair. So the surgery was a success, but the leg is paralyzed. This a terrible example of two possible outcomes.

Another example:
A surgery to straighten the legs of a patient, which is scientifically proven to work, and has very few complications is great. But not of any benefit to a patient who is paralyed from the waist down, bedridden and never goes outside their home. This scientifically proven surgery is of no benefit to this patient, and exposes this patient to risk of surgical complications for no benefit. An unacceptible tradeoff. Or a test which has been shown to pinpoint where all a patient's cancer has spread to, is wonderful, unless the patient has decieded to refuse treatment. In that case, this test, is of no benefit to the patient, and doing it exposes the patient to pain and complications, with no benefit.

Now if you look at these examples, you might think they are uncommon, but in reaity, suttle variations of these cases are the bulk of denials , that a QA/UM driven review company will deny. The other companies may deny cases with a more profit driven motive. And that is why providers and facilities need to be informed about the rules, and just like any good business, they will need to hire experts for marketing, accounting, facility maintenance, and insurance reimbursement.

Quality Assurance and Utilization Review

Summary

• We must remember that Medicare and Medicaid is the largest insurer in the world. And most patients, physicians and hospitals have signed all the paperworks and agreements called Medicare Conditions of Participation, which determine what criterion are used to determine what services will be paid for and under what conditions.
• The system which determines whether hospitals and physicians get paid is really a big quality assurance and utilization review project.
• This project accidentally also serves as a cost control project. The rules of reimbursement / payment created by the Center for Medicare and Medicaid Services reduce un-necessary treatments, and optimize medical care.
• Furthermore, as a business man, I am still surprised to find out how little effort is expended to understand the Conditions of Participation of most Healthcare Insurance policies by the patients, the physicians and the hospitals. Despite the fact they are required by law to read them and sign a statement that they understand their rights and responsibilities under the Medicare or medicaid Conditions of Participation.
• However, I am not complaining, as I understand there are more interesting things to read, and it is difficult to become an expert in this field.
• So it's only natural to hire a specialist for such a complex task. And thats where I come in...
• And fortunately patients have access to Patients Advocate Services for Free.