Good morning America!

Recently I checked this out on Snopes and it’s true.  I want you to pay especially the difference between 2013 and 2014.

The per person Medicare insurance premium will increase from the
present monthly fee of $96.40 to:

2012 – $104.20
2013 – $120.20
2014 – $247.00

These provisions incorporated in the Obama care legislation, are purposely being delayed so as not to ‘confuse’ the general public in the 2012 re-election campaigns.  

We must pass this around to every senior that you know, so they will know who’s throwing them under the bus.

Thought you’d  might like to know.  Please share with everyone you know.

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By Walt Miller

Recently we sent this to Mr. Rand who is the Executive Director of AARP.

Dear Mr. Rand,

Recently you sent us a letter encouraging us to renew our lapsed membership in AARP by the requested date.

This isn’t what you were looking for, but it’s is the most honest response I can give you. Our coverage gap is a microscopic symptom of the real problem, a deepening lack of faith.

While we have proudly maintained our membership for years and long admired the AARP goals and principles, regrettably, we can no longer endorse its abdication of our values.

Your letter stated that we can count on AARP to speak up for our rights, yet the voice we hear is not ours.

Your offer of being kept up to date on important issues through DIVIDED WE FAIL presents neither an impartial view nor the one we have come to embrace.

We do believe that when two parties agree all the time on everything presented to them, one is probably not necessary.

But, when the opinions and long term goals are diametrically opposed, the divorce is imminent. This is the philosophy which spawned our 200 years of government.

Once upon a time, we looked forward to being part of the senior demographic. We also looked to AARP to provide certain benefits and give our voice a power we could not possibly hope to achieve on our own. AARP once gave us a sense of belonging which we no longer enjoy.

The Socialist politics practiced by the Obama Regime and empowered by AARP serves only to raise the blood pressure my medical insurance strives to contain. Clearly a conflict of interest there!

We do not understand the AARP posture, feel greatly betrayed by the guiding forces that we expected to map out our senior years and leave your ranks with a great sense of regret.

We mitigate that disappointment with the relief of knowing that we are not contributing to the problem anymore by renewing our membership.

There are numerous other organizations which offer discounts without threatening our way of life or offending our sensibilities and values.

This Obama Regime scares the living daylights out of us. Not just for ourselves, but for our proud and bloodstained heritage. But more importantly for our children and grandchildren.

Washington has rendered Soylent Green a prophetic cautionary tale rather than a nonfiction scare tactic.

I have never endorsed any militant or radical groups, yet now I find myself listening to them. I don’t have to agree with them to appreciate the fear which birthed their existence.

Their borderline insanity presents little more than a balance to the voice of the Socialist mindset in power.

Perhaps I became American by a great stroke of luck in some cosmic uterine lottery, but in my adulthood I

CHOOSE to embrace it & nurture the freedoms it represents as well as the responsibilities.

Your website generously offers us the opportunity to receive all communication in Spanish.

ARE YOU KIDDING???

The illegal perpetrators have broken into our ‘house’, invaded our home without invitation or consent.

The President insists we keep these illegal perpetrators in comfort and learn the perpetrator’s language so we can communicate our reluctant welcome to them.

I DON’T choose to welcome them, to support them, to educate them, to medicate them, or to pay for their food or clothing….American home invaders get arrested…Please explain to me why foreign lawbreakers can enjoy privileges on American soil that Americans do not get?

Why do some immigrants have to play the game to be welcomed and others
only have to break and enter to be welcomed?

We travel for a living. Walt hauls horses all over this great country, averaging over 10,000 miles a month when he is out there. He meets more people than a politician on caffeine overdose.

Of all the many good folks he enjoyed on this last 10,000 miles, this trip yielded only ONE supporter of the current Regime. One of us is out of touch with mainstream America.

Since our poll is conducted without funding, I have more faith in it than ones that are driven by a need to yield AMNESTY. (Aka – make voters out of the foreign lawbreakers so they can vote to continue the government’s free handouts).

This addition of 10 to 20 Million voters who then will vote to continue Socialism will OVERWHELM our votes to control the government’s free handouts. It is “slipper slope” upon which we must not embark!

As Margret Thatcher (former Prime Minister of Great Britain) once said “Socialism is GREAT – UNTIL you run out of other people’s money”.

We have decided to forward this to everyone on our mailing list, and will encourage them to do the same… With several hundred in my address book, I have every faith that the eventual exponential factor will make a credible statement to you.

I am disappointed as all get out …I am more scared than I have ever been in my entire life …I am ANGRY…I am MAD, and I’m NOT going to take it anymore!

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By: AMS

Corporate peer review is an opaque process created by the HCQIA statute with no evidentiary safeguards.

As such corporate health care attorneys use it frequently to destroy the careers of physicians they deem ‘undesirable’, ‘disruptive’, or threatening (e.g., those who report fraud or errors to outside entities).

Corporate peer review differs from traditional peer review with respect to transparency and the legal, evidence-based safeguards provided by full judicial review.

Corporate peer review carries with it the obvious moral hazard of making the corporation the sole and final judge or arbiter of its own actions with respect to the public health.

This allows corporate attorneys to use corporate peer review as a mechanism to conceal acts of fraud and malfeasance within the hospital system.

There should be a strict separation between legitimate physician credentialing and corporate peer review. Self interested and subjective viewpoints arrived at through corporate peer review must not be used to impair physician careers.

AMS is opposed to corporate peer review because there are no evidentiary safeguards in the process. We oppose the National Practitioner Data Bank (NPDB) because its rules have disproportionately promoted fraud against independent physicians. 

AMS supports the passage HR 2472, and any reforms that will increase procedural transparency and protect the professional rights and legitimate credentials of all physicians.

The AMA functionally opposes evidentiary safeguards in corporate peer review by their complete silence on the matter; AMS calls on them to support our position on ethical grounds.

To learn more about HR 2472:

Bill Text112th Congress (2011-2012) H.R.2472.IH

“To amend the Health Care Quality Improvement Act of 1986 to prohibit health care entities from reporting certain professional review actions against health care professionals before adequate notice and hearing procedures are afforded to such professionals, and for other purposes.”

Source: Americas Medical Society

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By Dr. Richard Willner

Various stressors have been correlated to physician suicide, including: personal, financial, and profession.

[i] Anyone who has been under pressure from a legitimate review process will readily tell you that it can be stressful.  If the review is a sham, the stressful nature of the review increases dramatically. 

This unnecessary stress may increase the risk of depression and suicide in the physicians exposed to sham peer reviews.

Generally, suicide results from depression, which is either untreated or inadequately treated and accompanied by the “knowledge of and access to lethal means.”[ii] 

 Interestingly, a study of 47 physicians who were followed for a 30-year period “concluded that long hours, demanding patients, and ready access to narcotics were not problems for physicians who did not have preexisting psychological difficulties evident at college entry.”[iii] 

Although the two major risk factors for suicide are mental disorders and substance use disorders, because most individuals with these disorders do not commit suicide, other risk factors are involved, such as “stressful events and predisposing factors (eg, impulsivity).”[iv]

Certainly, experiencing any peer review can be a ‘stressful event,’ but a sham peer review poses an inordinate amount of stress because it is difficult for the provider under review to use definable defenses in the review process.  

For example, in a typical morbidity and mortality conference an adverse surgical or clinical outcome is openly discussed, and the provider in question may have considerable answering to do regarding the care rendered in that case. 

In that situation, at least the provider knows the object of the review, how to respond, and how to improve his or her understanding to better approach similar situations in the future. 

However, in the case of an adverse sham peer review action, the provider would not know what was coming, why it was coming, or how to prepare. 

He or she is socked with an adverse action with little to no ability to honestly be heard.  This results in enormous levels of stress that may be a trigger to developing psychological squeal, and in the most extreme cases, suicide.

Factors that tend to be protective against suicide include: “effective treatment for mental and physical disorders, social and family support, resilience and coping skills, religious faith, and restricted access to lethal means.”[v] 

Effective treatment for physicians has similar barriers as to the general populations as evidenced in a study involving medical students, including: “lack of time (48%), lack of confidentiality (37%), stigma (30%), cost (28%), and fear of documentation on academic record (24%).[vi] 

Herein lies a major problem, as the protective factors are not as effectively available for physicians. 

Practicing physicians with psychiatric disorders often encounter overt or covert discrimination in medical licensing, hospital privileges, health insurance, and/or malpractice insurance. . . [I]t is not known whether medical boards use the information to covertly discriminate against a physician who was treated or previously impaired but does not report current impairment.[vii]

An expert panel noted that in some states, “licensing boards conduct investigations if physicians seek psychiatric treatment, a process that can lead to sanctioning regardless of whether there is any evidence of impaired functioning.”[viii] 

As the admission of any psychiatric problem could end their medical careers, many physicians “suffer in silence.”[ix] According to one surgeon who has suffered with depression, “You just would rather take a risk with your health than your career. 

It’s not like you get a second chance with it.”[x] Sadly, it has been estimated that approximately 400 physicians die each year from suicide.[xi] Another sad statistic is the suicide completion rate for physicians is significantly higher than the general population.[xii]

If sham reviews could be entirely eliminated and the ability for practitioners to receive effective treatment without the negative ramifications noted above, it is possible that the many physicians who “suffer silently” might be reduced. 

However, the present situation is that sham reviews do occur and the stigma of seeking appropriate psychological and psychiatric care is real. 

Likewise, defending against sham peer reviews and spurious board actions through the legal system is fraught with many difficulties at great monetary costs to the victim practitioner.  It is important to understand that addressing the problem of sham peer review through an organization with vast experience will afford a level of comfort, reassurance, and hope. 

One of the protective factors against suicide comes in the form of “support.”  While the article cited above mentioned support in the form of “social and family support,” additional support from an organization that offers genuine solutions to a seemingly impossible situation obviously comes within the realm of support that most would need to aid them in coping with the unnecessary burdens of stress due to sham peer review.

The Center for Peer Review Justice specializes in helping those Physicians and Surgeons who are going thru the Sham of a Peer Review or State Board Abuse.  It offers excellent Sham Peer Review defense as well as free excellent advice 24-7.  

The Doctors of CPRJ genuinely listen and genuinely help as “No Doctor is left behind”.  The hotline that is answered by a real caring doctor is  504-621-1670.

[i] American Medical Association Council on Scientific Affairs, Physician Mortality and Suicide: Results and Implications of the AMA-APA Pilot Study. 50 Conn. Med. , 37-43 (1986).

[ii] Louise B. Andrew, et al. Physician Suicide. Medscape Reference. Updated May 26, 2011.

[iii] Claudia Center, et al. Confronting Depression and Suicide in Physicians. JAMA, Vol. 289, No. 23, 3163 (June 18, 2003).

[iv] Id.

[v] Id.

[vi] Id. At 3164.

[vii] Id.

[viii] Tracy Hampton, PhD. Experts Address Risk of Physician Suicide. JAMA, Vol. 294, No. 10 (Sept. 14, 2005).

[ix] Lindsey Tanner. Medical Know-How Raises Suicide Risk for Doctors. USA Today. May 8, 2008.

[x] Id.

[xi] See note 2.

[xii] Id.

Source:  Richard Willner     America’s Medical Society

Editor’s Note:  Richard Willner is President and CEO of the Innocence Project of the Center for Peer Review Justice http://www.peerreview.org/ or at info@PeerReview.org 504-621-1670

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By AP

COLUMBUS, Ohio Voters in Ohio have approved a ballot measure intended to keep government from requiring Ohioans to participate in any health care system.

The constitutional amendment passed is largely symbolic, coming in response to the 2009 federal health care overhaul, a provision of which mandates that most Americans purchase health care.

Supporters hope it will prompt a challenge of the overhaul before the U.S. Supreme Court.

The tea party and Republican groups backing the amendment say the Affordable Care Act was an overreach by the Obama administration and Congress.

They hope approval of the ballot issue will bar Ohio from instituting a state-mandated health insurance program like that of Massachusetts.

Opponents argued state law can’t trump federal law and that the amendment’s wording could unintentionally jeopardize state health programs.

Source: Fox News

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By Dr. Richard Willner

The America’s Medical Society supports physicians and citizens who fight for the individual liberties of all Americans.

The 13th Amendment to the U.S. Constitution prohibits the government from forcing its citizens to “serve” it (the government); by association it also prohibits the government from forcing doctors to participate in Medicare.

The following (lengthy) document is the superb product of some brilliant American physicians in California who got a resolution passed by the California Medical Association (CMA) to educate doctors on how to ‘not enroll’ in Medicare…it is fascinating reading…there will be much more on this and related topics by America’s Medical Society. THANK YOU to the brave and industrious doctors who crafted the following:

CMA HOD Resolution 202-11 just passed:

“That CMA provide an On-Call document that provides information to members about their options with respect to Medicare status, including options to participate, “non-participate, “opt-out and lawful options to be non-enrolled (i.e. never enrolled or voluntarily terminated).”

PROPOSAL: A physician may choose not to enroll in Medicare. Individual physicians often ask about their options with respect to Medicare, particularly given the uncertainty of Congressional action on the Sustainable Growth Rate (SGR) as well as many uncertainties related to the Patient Protection and Affordable Care Act (PPACA).

An individual physician has four possible relationships with Medicare:(i) An enrolled1 and participating physician agrees to bill Medicare for all services provided to Medicare beneficiaries, accepts assignment of patients’ Medicare benefits, and accepts amounts allowed by Medicare as payment in full for medically necessary, covered services as defined by Medicare.

A physician typically receives 80% of Medicare’s allowed amounts.(ii) An enrolled and non-participating physician also agrees to bill Medicare for all services provided to Medicare beneficiaries, may choose to either accept assignment or not accept assignment of patients’ Medicare benefits, and accepts amounts allowed by Medicare as payment in full for medically necessary, covered services as defined by Medicare.2

The payments that a non-participating physician may collect from patients at the time of service are 9% higher than the regulated prices Medicare allows a participating physician to charge.(iii) An enrolled physician who then chooses to opt out agrees not to bill Medicare for two years, is not limited to any fee schedule and further agrees to require his/her patients to forfeit Medicare benefits and instead pay mutually agreeable fees directly to the physician.

Sec. 1802. [42 U.S.C. 1395a] FREE CHOICE BY PATIENT. (a) Any individual entitled to insurance benefits under this subchapter may obtain health services from any institution, agency, or person qualified to participate under this subchapter if such institution, agency, or person undertakes to provide him such services.Sec. 1866. [42 U.S.C. 1395cc] (a) (1): AGREEMENTS WITH PROVIDERS OF SERVICES; ENROLLMENT PROCESSES ―

(1) Any provider of services (except a fund designated for purposes of section 1395f (g) and section 1395n (e) of this title) shall be qualified to participate under this subchapter (Medicare) and shall be eligible for payments under this subchapter if it files with the Secretary an agreement…‖ (Emphasis added)2The United States Court of Appeal for the Second Circuit in Garelick v. Sullivan (2d Cir. 1993) 987 F.2d 913 addressed anesthesiologists’ payment options who claimed they were compelled to treat Medicare beneficiaries and who submitted bills to Medicare as non-participating physicians.

The Court rejected a constitutional challenge to the limiting charge provision, holding that there was no “taking” prohibited by the Fifth Amendment of the United States Constitution. In reaching its holding, the court reasoned that physicians are under no legal duty to provide services to the elderly and to submit to price regulations.

This holding did not address the circumstance where a physician does not enroll in Medicare, does not submit to price regulations, and does not bill Medicare.

This holding also does not address the circumstance where a beneficiary pays a physician and seeks reimbursement from Medicare after refusing to permit the physician to bill Medicare.Sec. 1802. [42 U.S.C. 1395a] describes opt-out contracts. Claims that § 1395a violates several Amendments to the Constitution, as well as the Spending Clause of Article I, section 8 of both physicians and the Medicare beneficiaries who voluntarily enter into opt-out contracts were dismissed by an appellate court:  A physician who chooses not to enroll is not entitled to bill Medicare at all; a patient may seek reimbursement directly from Medicare after paying the physician a mutually agreeable fee.

Medicare may or may not reimburse the beneficiary. Unlike patients who seek medical care from a physician who opts out, patients typically do not lose Medicare benefits when they receive medical care from a physician who chooses not to enroll in Medicare.

Information regarding the first three physician relationships with Medicare – participating, non-participating, and opted out – is available in CMA’s ON-CALL Document #0151 (January 2011).

This document discusses the fourth relationship – un-enrolled status. There is nothing in the Medicare law that requires a physician to enroll.

 1. Why do many physicians decide to enroll in Medicare?

Many physicians enroll in Medicare because they want to bill Medicare instead of their patients. For instance, some physicians who provide emergent care have difficulty collecting payments from their patients. Many physicians have contracts with entities such as some hospital medical staffs and Medicare Advantage that require Medicare enrollment.

Arguably, the essential reason that most physicians bill Medicare is simply because nearly everyone has done so for decades.

It is perfectly understandable why virtually all physicians enrolled in Medicare for the first twenty years given its substantial economic benefits during that period; but times have changed.

2. Is every physician required to enroll in Medicare?

No. (See below.)Medicare Part B physician enrollment is a process whereby a physician becomes eligible to submit claims for payment to Medicare. In return for the privilege to bill Medicare and to receive payments from Medicare, an enrolled physician agrees to accept Medicare’s fee schedule as payment in full.4 See the attestation on form CMS-855i (―Medicare Enrollment Application for Physicians and Non-Physician Practitioners‖), Section 15, number 9 that clarifies the purpose of Medicare enrollment: ―I further certify that I am the individual practitioner who is applying for Medicare billing privileges.‖

(Emphasis added)4 42 C.F.R. § 424.505: ―To receive payment for covered Medicare items or services from either Medicare (in the case of an assigned claim) or a Medicare beneficiary (in the case of an unassigned claim), a provider or supplier must be enrolled in the Medicare program.

Once enrolled, the provider or supplier receives billing privileges and is issued a valid billing number effective for the date a claim was submitted for an item that was furnished or a service that was rendered.‖ (Emphasis added)

3. Why do some physicians choose not to enroll in Medicare?

Some physicians, for instance pediatricians and pediatric specialists, rarely provide medical care to Medicare beneficiaries. Some physicians want to protect their patients’ privacy.

For instance, many psychiatrists consider production of medical records for third party review an unethical breach of patient confidentiality.

Since Medicare reserves the right to review medical records of physicians enrolled in the system, some physicians choose not to enroll in Medicare. Some physicians do not want their patients to lose their Medicare Part B benefits when seeing them.

A patient forfeits these benefits if an enrolled physician opts out of Medicare Part B in accordance with the narrow provisions of Sec. 1802. [42 U.S.C. 1395a] but does not forfeit these benefits if his/her physician chooses not to enroll in Medicare.

Some physicians want to give patients the extra time and attention they need through home visits and other special services. Some physicians cannot enroll in Medicare in a timely manner.

In order to provide medical care during a protracted enrollment process, some physicians bill their patients and then assist these patients to seek reimbursement directly from Medicare. Some foreign physicians provide care to Medicare beneficiaries who travel internationally.

Some physicians cannot stay in business if they accept Medicare’s regulated prices as payment in full. These physicians choose not to enroll in Medicare so that they can collect their professional fees in an egalitarian manner, without respect to age.

They are also able to provide appropriate discounts to those in need without running afoul of Federal law and Medicare regulations. Access to care is improved since physicians are able to keep their practices viable.

Some physicians fear threats of felony charges, civil monetary penalties, and RACs (recovery audits) that sometimes compel enrolled physicians to comply with Medicare’s coding and billing rules even when these rules jeopardize patients.

Physicians employed by the Department of Veterans Affairs, Public Health Service, Department of Defense, or by Medicare enrolled Federally Qualified Health Centers, Rural Health Clinics, or Critical Access Hospitals do not enroll in Medicare. Physicians in fellowship programs do not enroll in Medicare.

4. Is a physician who chooses not to enroll qualified to submit bills to Medicare for any non-emergent services?

No.

5. Is a physician who chooses not to enroll permitted to submit bills to Medicare for emergent services?

Yes.Complete form CMS-1500 and submit it to Medicare. Write on the form, ―Emergent services. Dr. _____ is not enrolling in Medicare.‖ It is possible that such a claim submission will trigger Medicare to try to begin the enrollment process (Medicare Benefit Policy Manual, Section 40.13: https://www.cms.gov/manuals/Downloads/bp102c15.pdf)

6. May a physician who chooses not to enroll in Medicare provide medical care to a Medicare beneficiary and collect a mutually agreeable fee?

Yes.A physician who chooses not to enroll in Medicare Part B does not have any obligation to Medicare.

7. Will Medicare reimburse a beneficiary who pays for covered medical services provided by a physician who chooses not to enroll in Medicare?

Yes.

5. In order to receive reimbursement from Medicare, a patient must complete form CMS-1490S, write on form CMS-1490S, ―My physician is not enrolled in Medicare,‖ and send the completed5 ―If a beneficiary receives services from a provider or supplier that refuses to submit a claim to the A/B MAC or carrier, on the beneficiary’s behalf, (for services that would otherwise be payable by Medicare), and/or refuses to enroll in the Medicare program, the beneficiary should:

(1) Notify the contractor in writing that the provider or supplier refused to submit a claim to Medicare and/or refused to enroll in Medicare, and

(2) Submit a complete Form CMS-1490S with all supporting documentation. The contractor shall process and pay the beneficiary’s claim if it is for a service that would be payable by Medicare were it not for the provider or supplier’s refusal or inability to submit the claim and/or enroll in Medicare.

Claims shall be adjudicated based on whether the service provided is covered or non-covered/excluded rather than on the provider’s enrollment status. If for a covered service, the claim shall be processed and the allowed amount reimbursed to the beneficiary, if appropriate.

If for a non-covered/excluded service, the claim shall be processed and denied with an appropriate MSN message.‖ Medicare Claims Processing Manual, Disposition, Sec.2 (Approx. Page 203)

(Emphasis added.) form to the local Medicare intermediary. When form CMS-1490S is used, an itemized bill must be submitted with the claim.

Inasmuch as form CMS-1490S has no provision for an ICD-9 code, the ICD-9 code is not required at the time of claim submission.‖6 (Section 70.8.4, Medicare Claims Processing Manual). Further, there is no provision for use of CPT codes. Download form CMS-1490S .

In California, 7 send completed forms CMS-1490S to: J1 MAC-Palmetto GBAP.O Box 1051AugustaGeorgia 30903Medicare will typically forward a CMS 1490S claim to the beneficiary’s supplemental insurer.

If Medicare does not forward a claim, the beneficiary may complete form CMS-1500 and send it to their supplemental insurer, which may also reimburse the beneficiary.

8. How much will Medicare reimburse a beneficiary for services performed by a physician who chooses not to enroll in Medicare?

Medicare contractors typically pay Medicare’s allowable amount if the claim is for a service that would be payable by Medicare were it submitted by a physician enrolled in Medicare. (Medicare Claims Processing Manual, section 70.8.8.6:

Endnotes one is an EOB8 sent to a patient who paid an un-enrolled physician at the time of service and then submitted form CMS-1490S to Medicare for reimbursement.

Medicare sometimes forwards such claims to any supplemental insurer on behalf of a beneficiary, although in this circumstance the patient submitted form CMS-1500 to a supplemental insurer (United Behavioral Health) and received additional reimbursement. See Endnote Two.ii

9. May a physician who is not enrolled in Medicare refer Medicare beneficiaries for other services such as laboratory tests?

Yes.The American Medicare Association earns significant non-dues revenue from its CPT Code copyright.

Address list:

Although this Medicare EOB claims that a physician who chooses not to enroll in Medicare part B is prohibited from billing the beneficiary more than the Medicare allowed amount, Medicare manuals do not describe penalties or recommend referral to the Office of the Inspector General if a physician charges exceed the amount allowed by Medicare.

10. Will Medicare pay for services ordered by a physician who chooses not to enroll in Medicare?

Yes.A patient who seeks care from a physician who chooses not to enroll in Medicare does not forfeit Medicare benefits, but may give up the convenience of having a third party bill for services ordered by an un-enrolled physician.

There are two ways that a performing facility such as a laboratory or radiology facility might get paid for services ordered by a physician who chooses not to enroll in Medicare.

First, section 6405 of the Affordable Care Act requires that any physician who wishes to enroll in the Medicare program for the sole purpose of ordering or referring items or services for Medicare beneficiaries must complete the following sections of form CMS-855i: Section 1 (basic information) Section 2 (identifying information) Section 3 (final adverse actions/convictions) Section 13 (contact person) Section 15 (certification statement)

Download form CMS-855i :

The physician MUST include a cover letter with this enrollment application stating that s/he is enrolling in Medicare for the sole purpose of ordering and referring items or services for a Medicare beneficiary.9 Mail the completed enrollment application with a letter to the Medicare enrollment contractor:

Alternatively, a physician who chooses not to enroll in Medicare may suggest the patient select Option Two on an Advance Beneficiary Notice (ABN)10 asking the facility performing a service not to bill Medicare but instead to bill the patient personally.

The Medicare beneficiary may then seek reimbursement directly from Medicare by submitting form CMS-1490S with a letter explaining that the service was ordered by a physician who chooses not to enroll in Medicare.

A physician who is not enrolled in Medicare may wish to give form CMS-1490S along with an explanatory letter to a patient who is referred for services.

The referring physician might complete the form for the patient to approve and sign and provide an addressed envelope for the convenience of both the patient and the facility performing the requested study. For more information:

CMS Gov. (1)

CMS Gov. (2)

CMS Gov. (3)

Advanced Beneficiary Notice: (1)

Advance Beneficary Notice (2)

11. May a physician who is currently enrolled in Medicare as a participating provider or a non-participating provider choose to un-enroll?

Yes.Complete the following sections of form CMS-855i: Section 1A (basic information) Section 13 (contact person) Section 15 (certification statement)In Section 1, under ―REASON FOR APPLICATION,‖ check the box that states, ―You are voluntarily terminating your Medicare enrollment.‖

12. May an enrolled physician who has opted out of Medicare choose to un-enroll?

Yes.Complete the following sections of form CMS-855i: Section 1A (basic information) Section 13 (contact person) Section 15 (certification statement)In Section 1, under ―REASON FOR APPLICATION,‖ check the box that states, ―You are voluntarily terminating your Medicare enrollment.‖

13. Is a young physician or immigrant physician entering private practice required to enroll in Medicare?

No.A physician who does not want to enroll in Medicare, i.e. does not want to bill Medicare for services provided to Medicare beneficiaries (either as assigned or un-assigned claims for payment), does not have to complete form CMS-855i.

14. Is a physician who is currently enrolled in Medicare required to re-enroll?

No.A physician who decides not to submit any more bills to Medicare does not need to re-enroll. New Medicare rules will require every physician who wishes to continue to submit bills to Medicare (both assigned and unassigned claims) to re-enroll periodically.

If a physician does not re-enroll, Medicare will revoke his/her billing privileges. Although Medicare typically reimburses its beneficiaries for services provided by a physician whose billing privileges have been revoked, it might be preferable for a physician to resign by completing the relevant sections of CMS-855i.

(Medicare does not reimburse its beneficiaries for medical care provided by a physician who has been sanctioned or excluded from Medicare for things like fraud.)

15. Is a physician who is not enrolled in Medicare and is therefore not qualified to bill Medicare obligated to require his/her patients to sign opt-out contracts?

Physicians who choose not to enroll in Medicare are not prohibited – but also are not obligated – to opt out of Medicare. See Sec. 1802. [42 U.S.C. 1395a (b)]: ―Use of Private Contracts by Medicare Beneficiaries.—(1) In general.—Subject to the provisions of this subsection, nothing in this title shall prohibit a physician or practitioner from entering into a private contract with a Medicare beneficiary for any item or service…‖

Be aware that an un-enrolled physician who also opts out simply forces his or her patients to forfeit all Medicare Part B benefits for the physician’s medical care.

16. Do the Social Security Act Amendments of 1994 apply to a physician who chooses not to enroll in Medicare?

No.

There is no law requiring every physician to both bill Medicare and accept payments from it because the U. S. Constitution, including Amendment 13, as well as Sec. 1802. [42 U.S.C. 1395a], does not grant authority to the federal government to require every physician to serve it.

The Social Security Amendments of 1994 only apply to physicians who bill Medicare. In order for either a physician or a patient to receive payment from Medicare for a bill submitted by a physician, the physician must voluntarily enroll in Medicare.

See Code of Federal Regulations (CFR) title 42, part 424, section 505 (42 C.F.R. 424.505) § 424.505:11 Sec. 1802. [42 U.S.C. 1395a] PROHIBITION AGAINST ANY FEDERAL INTERFERENCE ―Nothing in this subchapter shall be construed to authorize any Federal officer or employee to exercise any supervision or control over the practice of medicine or the manner in which medical services are provided, or over the selection, tenure, or compensation of any officer or employee of any institution, agency, or person providing health services; or to exercise any supervision or control over the administration or operation of any such institution, agency, or person.‖―Basic enrollment requirement.

To receive payment for covered Medicare items or services from either Medicare (in the case of an assigned claim) or a Medicare beneficiary (in the case of an unassigned claim), a provider or supplier must be enrolled in the Medicare program. A physician who chooses not to enroll in Medicare does not submit bills to Medicare or receive payments from Medicare.

Before the issue of ―participating‖ or ―non-participating‖ is reached a physician must have already voluntarily enrolled. To be clear, there are two general categories of physicians:

1. those who choose not to enroll in Medicare Part B and therefore are forbidden to submit claims to Medicare or receive payments from Medicare (except for emergency services).

2. Those who choose to enroll in Medicare Part B and are required to submit claims for payment to Medicare on either a participating,12 non-participating13 basis, or while remaining enrolled, have formally opted out.

Ambiguity arises because Medicare laws uses variants of ―participate‖ in two very different ways: 1. Sec. 1866. [42 U.S.C. 1395cc] (a)(1) 14 defines a physician as ―qualified to participate‖ in Medicare and ―eligible for payments‖ if he or she voluntarily chooses to file ―with the Secretary an agreement…‖

This is the fundamental ―Enrollment Process.‖Sec. 1848. [42 U.S.C. 1395w–4] (g)(4)(A) 15 ―Physician Submission of Claims‖ can only apply to an enrolled physician (―qualified to participate‖ under Sec. 1866. [42 U.S.C.12 Sec. 1842. [42 U.S.C. 1395u] (b)(6)(A) ―The term ―participating physician‖ refers … to a physician who at the time of furnishing the services is a participating physician (under subsection (h)(1)); the term ―nonparticipating physician‖ refers, with respect to the furnishing of services, to a physician who … is not a participating physician … (as defined in subsection (h)(1)).‖ ―(h)(1) Any physician … may voluntarily enter into an agreement with the Secretary to become a participating physician …. For purposes of this section, the term ―participating physician or supplier‖ means a physician … who … enters into an agreement with the Secretary which provides that such physician … will accept payment under this part on an assignment-related basis for all items and services furnished to individuals enrolled under this part during such year.‖

(Emphasis added)13 Sec. 1848. [42 U.S.C. 1395w–4] (g)(1)(A) ―Limitation of actual charge.—In the case of a nonparticipating physician … or other person (as defined in section 1842(I)(2)) who does not accept payment on an assignment-related basis for a physician’s service furnished with respect to an individual enrolled under this part, the following rules apply: (I) Application of limiting charge.—No person may bill or collect an actual charge for the service in excess of the limiting charge described in paragraph (2) for such service. (ii) No liability for excess charges.—No person is liable for payment of any amounts billed for the service in excess of such limiting charge.‖ (Emphasis added) 14 Sec. 1866. [42 U.S.C. 1395cc] (a)(1) AGREEMENTS WITH PROVIDERS OF SERVICES; ENROLLMENT PROCESSES ―(1) Any provider of services (except a fund designated for purposes of section 1395f (g) and section 1395n (e) of this title) shall be qualified to participate under this subchapter (Medicare) and shall be eligible for payments under this subchapter if it files with the Secretary an agreement…‖

(Emphasis added) 1395cc] (a)(1)) who is eligible to ―submit a claim for such service on a standard claim form specified by the Secretary to the carrier on behalf of a beneficiary…‖2. Sec. 1842. [42 U.S.C. 1395u] (h)(1) Defines a “participating” physician as one who agrees to accept payment from Medicare on an assignment-related basis for all items and services.

Although Sec. 1842 is silent on the prerequisite enrollment requirement, Sec. 1866 makes it clear that only a physician who chooses to file ―with the Secretary an agreement…‖ is ―qualified to participate‖ in Medicare and is ―eligible for payments‖ from Medicare.

Although still silent on the prerequisite enrollment requirement, Sec. 1842 further defines a “non-participating” physician as one who does not agree to accept payment on an assignment-related basis for all claims paid by Medicare. Sec. 1842’s specific definition of ―non-participating‖ is confusing, and some may apply it erroneously to describe a physician who does not enroll in Medicare and thus is not obligated to Medicare at all. Sec. 1848(g) (1) (A) ―Limitation of Actual Charges‖ can also only apply to an enrolled physician “qualified to participate‖ under Sec. 1866. [42 U.S.C. 1395cc] (a)(1) who must ―submit a claim to the carrier” but is “non-participating” under Sec. 1842. [42 U.S.C. 1395u] (h)(1).Before the issue of ―participating‖ or ―non-participating‖ is reached a physician must have already voluntarily enrolled. Medicare acknowledges that ―mandatory claim submission provisions of Sec. 1848(g)(4) apply to a physician who ―must submit a claim to Medicare‖ and ―must be enrolled in the Medicare program‖16 but may sometimes overlook the choice that physicians have to either enroll or not enroll in the program.

15 Sec. 1848. [42 U.S.C. 1395w–4] (g)(4)(A) ―Physician submission of claims.—In general.—For services furnished on or after September 1, 1990, within 1 year after the date of providing a service for which payment is made under this part on a reasonable charge or fee schedule basis, a physician, supplier, or other person (or an employer or facility in the cases described in section 1842(b)(6)(A))—(I) shall complete and submit a claim for such service on a standard claim form specified by the Secretary to the carrier on behalf of a beneficiary, and (ii) may not impose any charge relating to completing and submitting such a form.‖ (Emphasis added)

16 See ―When a physician … furnishes a service that is covered by Medicare, then it is subject to the mandatory claim submission provisions of section 1848(g)(4) of the Social Security Act (the Act). Therefore, if a physician … charges or attempts to charge a beneficiary any remuneration for a service that is covered by Medicare, then the physician or supplier must submit a claim to Medicare. In order to receive payment for Medicare covered items or services from either Medicare (in the case of an assigned claim) or a Medicare beneficiary (in the case of an unassigned claim); a provider … must be enrolled in the Medicare program.‖ (Emphasis added.

Note: this is Medicare’s response to a question, not a quote from the law. It confuses un-enrolled status with enrolled.)

17. Where can physicians and their patients find complete information explaining reimbursement for services provided or ordered by a physician who chooses not to enroll in Medicare?

Since Medicare does not qualify, privilege, or regulate a physician who chooses not to enroll in Medicare, there are limited federal policies pertaining to such physicians.

Medicare beneficiaries may find some assistance in the Medicare Beneficiary Manual:

(quoted in Footnote 6, above).

SUMMARY

Most physicians enroll in the Medicare program Part B and are thereby eligible to submit bills to Medicare.

Reasons for physician enrollment may vary and include contractual obligations with other entities such as Medicare Advantage and some hospital medical staffs.

There is no law that requires every physician to serve Medicare. Physicians who choose not to enroll in the Medicare program Part B may bill their patients who are Medicare beneficiaries; these patients may seek reimbursement from Medicare.

This proposal demonstrates that Medicare can function now the same way that medical insurance used to work when patients paid for their own medical care and recovered some of their expenses from insurance policies intended to limit risk and protect from catastrophe.

Source: Richard Willner     America’s Medical Society

Editor’s Note:  Richard Wilmer is President and CEO of the Innocence Project of the Center for Peer Review Justice http://www.peerreview.org/ or at info@PeerReview.org 504-621-1670

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By Dr. Richard Willner

Medical students have always incurred a huge debt to finance their education, but currently this debt is at an unmanageable level.

The prohibitive cost of a medical education has reached a critical point where the integrity of the entire medical profession is threatened.

The combination of exponential increases in medical tuition, the current legislative changes governing loans, and stagnant physician income will eventually leave medical students with educational debt so great that their earnings may be insufficient to even meet debt payments.

While the government continues to increase the cost of practicing medicine, decrease reimbursements, and increase the costs of regulatory compliance, physicians are left to deal with these financial constraints.

As a result of the downturn in the economy, federal and state budget cuts have compromised funding for medical education. According to AAMC data, the price of public medical education has increased by a staggering 312% over a twenty year period.

The average medical student will graduate with $157,000 in student loans. With the price of a medical education at an all time high, the AAMC reports that “in recent years, physician incomes have increased only slowly, and in constant dollars, the amounts have trended slightly downward.” Thus, while salaries fail to increase, the expenses continue to mount.

The increasing cost of medical education is partially due to a lack of a “standard” cost for attending a medical school. These costs can vary widely even between schools in the same city.

With institutions using medical student tuition to fund expansions and institutional projects that only indirectly affect the students, it is difficult to even put a price on the actual cost of medical student education.

Though the increasing costs of a medical education are concerning, the recent change in legislation is one of the greatest issues plaguing medical students today.

In 2007, Congress passed the College Cost Reduction and Access Act (CCRAA) (P.L. 110-84), with the intent to help students manage the increasing costs of education.

This legislation benefitted undergraduates by increasing the maximum Pell grant awards, lowering the eligibility requirements, and offering $5,000 in loan forgiveness to those employed in areas of high need.

However, this legislation adversely impacted residents by abolishing the 20/200 government pathway. This pathway qualified residents, based on economic hardship, to defer loan repayment for up to three years during residency based on the following criteria: full time employment, debt > 20% of income, and income not greater than 220% of the poverty level.

Thus, residents could defer their loans, not be responsible for repayments during this low salary time, and could avoid accruing interest on their subsidized loans during residency.

As of July 1, 2009, the 20/200 pathway was replaced by the income based repayment (IBR) system. The rationale behind this new program was to encourage immediate payment on loans and prevent the large accumulation of debt upon completion of training.

However, the implications to medical residents are astounding. Instead of deferment, those entering medical residency are now forced to begin loan repayments during their first year of residency; a time of minimal income.

During residency, the government will only pay the interest on the subsidized loans if the resident is making monthly payments towards their debt.

Monthly payments in the IBR program will be capped at 15 percent of monthly discretionary income. (Approximately $350/month for residents). After 25 years of consistent payments, any remaining debt is forgiven.

Those who cannot afford to make these monthly payments during residency will be forced to place their loans in forbearance, during which interest accumulates rapidly on ALL loans.

In addition, interest may be capitalized under forbearance, making this a more expensive option for borrowers.

Another grave concern facing medical students is President Obama’s budget proposal for 2012, where he seeks to eliminate the government payment of interest on subsidized loans during medical school.

Instead, he encourages reallocating this money to Pell grants for undergraduate students. Starting July 1, 2012, this bill will take effect.

A student can borrow up to $8,500 a year from subsidized loans where the federal government pays the interest while the student is in school. Over the course of their training, students can accrue up to $65,500 from subsidized loans.

A student who borrows the maximum of $65,500 in subsidized loans would owe $207 a month just in interest payments over the course of 10 years.

Currently, the government pays that $207 each month the student attends school until six months after graduation. Eliminating the interest payment on subsidized loans will further increase the debt one is facing upon completion of medical training.

The challenges facing current medical students are astounding. This is a call for action.

Contact your congressman and let them know how you stand on these important issues. Without a united voice, the medical profession will not prevail in this fight.

Source: Richard Willner    Medical Student Loans

Editor’s Note:  Richard Wilmer is President and CEO of the Innocence Project of the Center for Peer Review Justice http://www.peerreview.org/ or at info@PeerReview.org 504-621-1670

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By Elizabeth Harrington

First Lady Michelle Obama said yesterday that the government can affect who kids “will be forever” if it can shape their “habits and preferences” during the large part of the day they are at school.

Mrs. Obama was speaking on the South Lawn of the White House at a reception to honor schools that met the goals of the U.S. Department of Agriculture’s Healthier US School Challenge (HUSSC).

The USDA Web site describes HUSSC as “a voluntary initiative established in 2004 to recognize those schools participating in the National School Lunch Program that have created healthier school environments through promotion of nutrition and physical activity.” The program has since been rolled into Mrs. Obama’s “Let’s Move!” initiative.

Read more CNS News

Source: Fox Nation

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By Wesley J. Smith

The AMA News has an article out about how Obama care is looking increasingly to bust the bank. 

It gets into the supposed need to restrict access to treatments based on”evidence based” medicine, the propriety of which, it seems to me, depends on how that term is defined in the law.

But that’s not what I want to get into here.  Rather, I contend that by seizing national control of health insurance, the Feds have all but guaranteed that insurance will not be affordable.  It all gets down to what constitutes “essential health benefits” under the law. 

From the story, “IOM Panel: Insurance Exchanges Will Fail Unless Cost Factor is faced:”

The health reform law requires HHS to establish a minimum health benefits package — known as essential health benefits — to be offered by health plans in the exchanges, set to begin operating in 2014.

HHS Secretary Kathleen Sebelius asked the IOM to propose methods for creating and updating the benefits package.

The IOM-convened committee said HHS should choose an essential health benefits package that costs about the same as an average small group health plan, provides a range of services backed by evidence of their medical effectiveness, and balances the competing needs of health plan affordability and covered benefits.

“If that package of benefits is too narrow, health insurance might be inadequate to ensure access. If it is too expensive, insurance might become too expensive,” said John R. Ball, MD, chair of the IOM essential benefits committee and former executive vice president of the American Society for Clinical Pathology. The IOM committee did not suggest specific benefits to be covered because that was not part of its mission.

But the Feds have already demonstrated that they can’t be trusted to create a package that is truly limited to “essential benefits.” 

Remember Secretary of HHS Sebelius bragging about the “free birth control” that all policies must provide?  As readers of SHS will recall, that was just the tip of the iceberg, that the new regulation actually threw in the kitchen sink under the “reproductive health” benefit–including services such as domestic violence screening that aren’t medical at all. 

From my blog entry, “Obama care: Lard on the Goodies! Destroy the System!

The pattern is set.  Special interest constituencies will continually demand ever more; e.g. coverage for illegal aliens, coverage for abortion, coverage for IVF, etc. etc. etc. 

At the same time, powerless people will be offered ever less, e.g., imposition of futile care theory and health care rationing against the morbidly elderly, the dying, and people with severe disabilities. 

See, these groups have no powerful political constituency groups grabbing pieces of the pie for them.  They will matter little in the emerging corrupt system of exchanging health care benefit spoils in return for political support, which is the essence of Obama care.

Government leaders have traditionally bought votes or rewarded special interest constituency loyalty by handing out jobs and government benefit goodies. 

But the American Government is beyond broke, so Obama cairns are now using their stranglehold over the health insurance industry to lard pork on the insurance companies’ dimes. 

That will either make insurance unaffordable or break the industry in two (or both).  Given the utter irresponsibility of our current governance, the Feds are the last people to look to as effective controllers of health care costs or regulators of what constitutes “essential health services.”

Source: First Things

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By MDHD

Miami, FL Miami-Dade County Health Department Administrator Dr. Lillian Rivera, RN, MSN, PhD has issued a mosquito-borne illness advisory for Miami-Dade County.

After a human case of West Nile virus (WNV) was confirmed in a 27 year-old male resident of Miami-Dade County.  The individual has fully recovered.

Officials from the Miami-Dade County Health Department and Miami Dade County Mosquito Control Division, was available yesterday to answer media questions.

Miami-Dade County Health Department reminds residents and visitors to avoid being bitten by mosquitoes that may cause West Nile Virus. 

Miami-Dade County Mosquito Control Division and the health department continue surveillance and prevention efforts and encourage everyone to take basic precautions to help limit exposure by following the recommendations of the Department of Health.

Symptoms of West Nile virus disease may include headache, fever, fatigue, dizziness, weakness and confusion. 

Physicians should contact their county health department if they suspect an individual may meet the case definition for a mosquito-borne illness.

The easiest and best way to avoid WNV is to prevent mosquito bites. The best preventive measure for residents living in areas infested with mosquitoes is to eliminate the places where the mosquito lays her eggs, primarily artificial containers that hold water.

To prevent mosquitoes from living and multiplying around your home or business:

DRAIN standing water:

• Drain water from garbage cans, buckets, pool covers, coolers, toys, flowerpots or any other containers where sprinkler or rainwater has collected.
• Discarded old tires, drums, bottles, cans, pots and pans, broken appliances and other items that aren’t being used.
• Empty and clean birdbaths and pet’s water bowls at least once or twice a week.
• Protect boats and vehicles from rain with tarps that don’t accumulate water.
• Maintain swimming pools in good condition and appropriately chlorinated. Empty plastic swimming pools when not in use.

COVER your skin with:

• CLOTHING – If you must be outside when mosquitoes are active, cover up. Wear shoes, socks, long pants and long sleeves.
• REPELLENT – Apply mosquito repellent to bare skin and clothing. Always userepellents according to the label. Repellents with 10-30% DEET, picaridin, oil of lemon eucalyptus, and IR3535 are effective.
• Use mosquito netting to protect children younger than 2 months old.

COVER doors and windows with screens:

• Keep mosquitoes out of your house. Repair broken screening on windows,
  doors, porches, and patios.

DOH continues to conduct statewide surveillance for mosquito borne illnesses, including West Nile virus infections, Eastern equine encephalitis, St. Louis encephalitis, malaria, and dengue.

Residents of Florida are encouraged to report dead birds via the web site . 

For more information on mosquito-borne illnesses, visit DOH’s Environmental Health web site , or call the Miami-Dade County Health Department at 305-324-2400 begin_of_the_skype_highlighting, 305-324-2400 end_of_the_skype_highlightingor

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