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Why Doctor Opted Out of Medicare

by Robert G. Schwartz, M.D.
June 12, 1998

Part and parcel of a physician's soul is caring for the sick. It's what motivates one to enter the medical profession. Yet, most citizens who have Medicare coverage today are finding fewer physicians who will accept new Medicare patients. In fact, some physicians, including myself, are dropping out of the Medicare program altogether.

Why would a physician who has treated Medicare patients for over 15 years suddenly decide to opt out of the Medicare program?

The federal government, while possibly well intentioned, has now created such a complex maze of Medicare rules and regulations that compliance is practically impossible. By the time the physician figures them out, they have changed. By the time one realizes that they are not in compliance, they are audited.

At this point, the federal government is not concerned that the doctor was not aware of the dynamic rules and regulations. To them, the doctor is committing fraud and will be fined up to $10,000 per fine item error.

To add to the frustration of keeping abreast of ever-changing rules and regulations, when a physician has a problem with Medicare, he does not know where to turn for help. Medicare is run by the Health Care Financing Administration (HCFA). They have regional offices all over the United States. For example, South Carolina's regional HCFA office is in Atlanta.

Since the Medicare program is so large, HCFA contracts with other companies to actually run the program. HCFA calls these companies the Intermediaries. In South Carolina, the Medicare Intermediary is a subsidiary of Blue Cross Blue Shield, called Palmetto Government Benefits Administrators.

Even the intermediary admits that is has a hard time keeping abreast with all of HCFA's rules and regulations. They may make rulings against what would otherwise seem to be obvious HCFA policy. If pointed out to them, don't be surprised if they are deaf to the complaint.

If a physician provides care that he or she believes to be medically necessary and Medicare pays for it, but then later decides during an audit that it was unnecessary, the physician will be penalized. The most common and on-going disagreement between physicians and Medicare federal regulation revolves around the issue of was the care medically necessary.

Every patient contact becomes an encounter with choice: Think first of the patient, or of the system? It has gotten to the point where only in a minority of cases can the two needs be met simultaneously.

I, for one, am tired of honoring the Medicare system more than my patients' needs. I welcome the possibility of establishing and renewing physician- patient relationships that are not invaded by federal rules and regulations. There are few basic truths more fundamental than the belief that preservation of life and liberty also includes the right to unrestricted freedom when it comes to one's own health care. Opting out allows the physician to place patient care ahead of federal rules and regulations. It empowers him to practice medicine once again.

Robert G. Schwartz, M.D., Greenville, South Carolina (A similar version of Dr. Schwartz's opinion appeared in the Greenville News, January 8, 1998.)

If a physician provides care that he or she believes to be medically necessary and Medicare pays for it, but then later decides during an audit that it was unnecessary, the physician will be penalized.
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