Medicare: Communication or confusion?

Although many physicians complain about Medicare's reimbursement practices, this federal program has done a splendid job of ensuring that elderly Americans have access to affordable medical care.

However, in the area of communicating information to patients about the care provided, there is a lapse—a failure that confuses a great majority of these retirees. Even as a fairly knowledgeable professional, I have great difficulty with the "information" Medicare provides and often do not understand it. And the less-informed understand less. Let me give you a few examples (obviously, the names have been changed, but the facts are real).

As a patient, you have heard good things about Dr. Sam Jones. You look up his number in the phone book—under Dr. Sam Jones. The physician's office answers the phone with "Dr. Sam Jones' office." The only physician (maybe there are one or two others) in that office that you see is Dr. Sam Jones. Your prescription and your appointment card say "Dr. Sam Jones."

Yet you study your explanation of benefits (EOB) from Medicare, and Dr. Sam Jones never seems to get paid—at least as far as you can tell. But, then, there was that unknown bill paid to West Union Medical and Surgical Services (a fictitious name) Could that be Dr. Jones? It probably is, but Medicare provides little help in finding out.

Or did Dr. Jones forget to bill Medicare? Or did Medicare fail to pay him? Is some sort of hanky-panky going on? Forget that we are medical professionals (and that doesn't always help either). What about that poor migrant worker with a fourth- grade education? Medicare should not allow fictitious or corporate or confusing names for payees without identifying the actual individual performing the service. The patient must be clear about which physician performed which service in order to verify the claim.

Much of the reporting is confusing, not communicating. Every patient should know the physician who is being paid. If a corporate entity must be paid, why not something like "West Union Medical and Surgical Services for Sam Jones, DO."

Making the situation even worse is when a charge comes through with a corporate or fictitious or unfamiliar name indicating a service rendered a long time previously, like the one my wife and I received: Florida Universal Radiology for "X-ray/Radiologist" (no further explanation), 10 months after the service. Was that for taking the X-ray? Or interpreting it? In the radiologist's office? In our doctor's office? Or a hospital outpatient facility? Who? What? Not just confusing, but totally confounding!

When my beloved late wife was a patient at Aventura (Fla.) Hospital and Medical Center, Medicare paid a bill to Miami Beach health care Group I (Miami Beach is nowhere near Aventura) with the Aventura Hospital address. After investigation, I found out that it was an old billing entity for the hospital—yet no other charges from them used that identity. What gives? What confusion!

Then, there's the question of what services were being paid for. When I received an EOB listing a corporate name for four separate instances of surgery in one visit and finally identified the physician and the date of service, I remembered that four small office diagnostic tests had been performed—no surgery, no cutting, no sewing. There is no reason, given the complex computer records the Centers for Medicare and Medicaid Services is able to maintain, that the exact service should not be listed. How is a patient to know? What's a patient to think? Again, confusion not communication.

The EOBs confuse me even further—as they must all laypeople. A physician I know of billed a patient $3,600 for a single visit, during which several minor diagnostic tests were done. According to the EOB, the physician was paid about $350 (possibly a more realistic fee for what was done). But what does that lower payment say to the average layperson (or to me)? It raises some questions: Did he overbill? Did Medicare devalue his services? Why the discrepancy? Was the large amount billed necessary for the physician to get his reasonable fee (the smaller amount)?

It was easier in the old days when patients paid their bills. They'd call the office, ask the price of Procedure A, and make an appointment. When it came time to pay, the price quoted was the fee paid—no confusion. Why cannot the fee billed and the fee paid be the same? Or vice versa?

Why can't Medicare billing be simplified as in the following (fictitious) example?:

Arnold Melnick, DO
Florida Associated Physicians
Pediatric Office Visit—or Hospital Visit—or appendectomy or, or, or … 
Date(s) of service
(Then the other pertinent information)

This clarifies who is getting paid for what service performed when.

But there are many more examples of conflict and confusion than of clarity in Medicare reporting. Unfortunately, senior citizens baffled by the reporting simply say, "Oh, well, I don't understand it. But I'm satisfied as long as my care is paid for." How much does this create a proclivity to dishonesty?

Perhaps there are reasons for some of these situations. I suspect that some problems in the past made someone try to solve them and, in the process, created more obstacles and greater bureaucracy. But the patient must be considered in all changes! Many more of these situations bother retired patients—especially those who are unknowing or too frightened to say anything.

Just imagine this: With an estimated 40 million Medicare beneficiaries, if half of us discovered merely a $20 error (not considering possible fraud) on our Medicare EOBs once a year, the savings would be nearly a half-billion dollars annually. But such savings are only possible if the billing communication from Medicare is understandable. Patients could well be the watchdog for Medicare expenditures—if they understood them.

Medicare is providing a great service to the American people. It could do better—and tighten the financial reins (a goal espoused by Republicans, Democrats and the U.S. president) and eliminate potential fraud—by improving communication with patients, not confusing them, and by having better control over what is and what is not happening.