I remember the Headlines

Anyone who stands to judge me needs to know and understand many things about the situation I was forced to deal with.

I saw the headlines:
“Annual Medicare award goes to Nevada Doctor” and “Medicare assists country doctors in helping rural homebound disabled”, and “Medicare lauds local physician at banquet for saving millions”.
Then I wake up from the dream. Of course, Medicare has no such assistance programs, awards and accolades; only punitive actions.


In my medical practice taking care of homebound disabled I did not recruit my patients; they were abandoned on my doorstep by social services, concerned citizens, relatives and caretakers of chronically ill people. I discovered an invisible and previously unknown world of suffering and hardship in these people. This apparently is not acknowledged by anyone in Medicare or Medicaid. I can only interpret the attacks from the government as part of this denial. Their actions have shown me that they consider my work to be on the same level of a carpet cleaner or dog groomer; unnecessary, unwanted and the subject of fraud,

It is impossible for me to imagine anyone participating in these government attacks having the slightest familiarity with the grave problems suffered by my patients. I can see no way that any of them have ever visited a homebound disabled person who has received scant and improper medical care for decades. The patients I accepted in my practice were mostly frail with multiple, interacting conditions requiring months or years with frequent visits to stabilize and hopefully improve. Suffering, anguish and hopelessness were almost always alleviated. These things apparently do not tit into the equations at Medicare. According to my “Discovery Documents” 97% of my visits were unnecessary. But they were not on the scene; In fact they were calling the shots for 3000 miles away. The stated attitude in Medicare is that monitoring a frail homebound person for worsening has no value. You may compare it to the local fire department. A citizen calls in alarm. Medicare asks for proven evidence of structural fire. The citizen answers that there is only the smell of smoke and the carpet is soaked in gasoline. Medicare answers “Wait for the flames to appear (you must send us documentation of this, which we will review and decide on a proper form of action) and we assign someone to look into the matter. Unfortunately, the only one in your area who does such work is being put behind bars, for your protection, of course. So good luck and tell us what happens!”

This way of handling such problems in our society is not only primitive and inhumane; I believe it to be the product of insane minds! I accepted only needful and neglected people into my practice. After stabilization, I assigned them to one of two groups: people that needed a minimum of at least one monthly visit, and those people that needed twice weekly visits. Of course, all my patients were on ALWAYS on the verge of destabilization, and ended up needing visits more frequently. So, who is a more appropriate person to decide what kind of care a person gets. A physician on the scene or a bureaucrat 3000 miles away? Some of these visits were, indeed, false alarms, Apparently Medicare thinks it more appropriate that a high school student perform the visit, Indeed, I would have trouble recruiting a high school student at the Medicare suggested payment for such services. According to Medicare, when a medical practitioner decides nothing needed to be done or changed, it is worth so little that you can’t even make financial ends meet doing so. Heroic measures, such as putting out the proverbial house fire, are rewarded much better. It’s much sexier that way. Preventive care and monitoring of the frail has little panache.




In illustration, primary care physicians have always objected to the heavier weight (in payment and importance, one must assume) given to heroic interventions, such as surgical operations. The practice of psychiatry, which requires considerable more time, effort and subtlety on a physician’s part, is automatically discounted 50% by Medicare.



I would like to describe in some detail the method I developed to keep both billing and treatment records in my practice. When I started this task I almost completely computer illiterate but was convinced that their use would streamline the process and allow me to not use ancillary staff for these purposed which were a standard expense of medical practice. I also could not afford to do otherwise. There was no guide or blueprint for doing this. Proprietary software was in the process of development but far too expensive for me to afford. I used what software I had: “Microsoft Word”.

When I accepted a new patient I made an MS WORD file with the pertinent patient information. This information would be duplicated on any document or correspondence associated with the patient. This save much time in having to duplicate information. It looked like this:

Blow, Joseph/ DOB: 01-01-1901/Gender: male/
Address: Phone:
Special directions to home:
Caretaker
Home Health Service:
Pharmacy:
Medical Supply Company:
SS#
Medicare #:
Medicaid #
2nd Insurance ID:
Date of Visit: CPT Code:

Diagnosis 1
Diagnosis 2
Diagnosis 3
Diagnosis 4
Diagnosis 5
Diagnosis 6
Diagnosis 7
Diagnosis 8


For billing purposes I made a separate, permanent MS WORD file with new pages for each patient. Since I generally knew what patients were to be seen on a weekly basis, this list would grow and shrink slowly, but be generally the same. At the end of the week, all I had to do was open the file, Change the date and submit the file electronically to my billing agent. The level of service was usually the same, so if a field worker thought the level was different, I could easily overlook it. I will discuss substantiation for level of service elsewhere. This technique I developed on my own, and as I have noted, was prone to errors, but it worked efficiently and was the best I could do. IT definitely allowed me to pursue more valuable patient care issues.

I really could have done without a billing agent. When I first stated the practice, I was completely ignorant of billing practices and had to rely on contract services of so called professionals, who, it turned out, were just as incompetent as I was. On my third agent I contracted with Gordon Clarke, who admitted he was new to the business of insurance billing and had had little idea how to proceed. He was trying to work at home in order to care for his father. As the years passed Gordon became almost completely incapacitated with arthritis, requiring around the clock powerful narcotics for pain relief. After his father died, I continued using his services in order to keep him off the street.

At no time during my medical practice did anyone, including State or Federal government agencies offer help or advice. I had to do it all alone. I thought I was doing a good job with the paperwork. I knew that I was helping my patients attain a better state of health, comfort and dignity. And regardless of what the Government’s rules and regulations were, I was going to continue doing the same thing until the patient’s death or they found alternative health care services.

That’s all for now…………