Owners and Employees of Houston Mental Health Company, Term Paper Example

It is a common practice for physicians to refuse to accept certain health insurance policies in order to ensure that they are able to profit. However, all physicians are encouraged to accept government issued policies such as Medicare and Medicaid. Although the Affordable Care Act has made partnerships with insurance companies more simplistic, many doctors continue to partner with only certain plans and policies, rather than a broader spectrum. This raises the question of whether it is legal under the Affordable Care Act and other existing legislation to deny healthcare to patients on the basis of their insurance policy. This paper will review the legality of such actions and define when physicians can and cannot deny a patient’s insurance.

Medicare and Medicaid are government funded programs that aim to ensure that elderly citizens and impoverished citizens, respectively, are able to access their right to healthcare. Physicians argue that a large number of patients are on these insurance plans and that they do not reimburse physicians as comprehensively as private health insurance companies. In the past, there has been much dispute over whether doctors should be required to accept these policies and what should be done if they are denied. Although it is legal for physicians to not accept these plans, it is essential for them to treat these patients as equals with those who have private health insurance. Unfortunately, reduced profit occasionally results in reduced care, and many Medicare and Medicaid patients have filed suit to protest these actions.

In two recent cases, Papciak v. Sebelius (2010) and Anderson v. Sebelius (2010), two Medicare patients were denied access to healthcare by the Department of Health and Human Services under the requirement that Medicare beneficiaries must show continued health improvement in order to qualify for continued care. This is particularly problematic in the elderly population because many patients do not expect improvement, but require long term care in order to ensure that their health situation does not diminish. In the first case, Mary Beth Papciak brought action against Kathleen Sebelius, Secretary of the United States Department of Health and Human Services because Medicare had denied her request for occupational and physical therapy. Papciak argued that custodial care was a necessary part of her treatment because she had required hip replacement surgery and was unable to take care of herself. Second, she argued that a therapy’s ability to maintain an individual’s health level should also be considered necessary and therefore covered by the insurance program. Sebelius argued that since Papciak’s health situation would not be improved by the therapy, she was not eligible for treatment. The court granted Papciak the ability to receive the therapy on the basis that interpretive guidelines of an agency’s regulations “do not rise to the level of a regulation and do not have the effect of a law”. This court case directed practice so that a physician and insurance company must consider the condition of the patient as a whole when deciding whether to approve care. In this particular situation, it was shown that physical therapy enhanced the patient’s mental well-being and should therefore be approved.

In the case of Anderson v. Sebelius, Sandra Anderson was denied a variety of medical services because according to the definitions provided by the Secretary of Health and Human Services, her condition was stable. However, it was documented that Anderson had a series of medical problems that required treatment. To alleviate this discrepancy for future cases, the court concluded that Medicare will cover services even when a beneficiary’s condition is stable and unlikely to change. Rather, eligibility determinations should be made based on the patient’s unique situations and medical needs.

The situations that Mary Beth Papciak and Sandra Anderson were faced with are not uncommon and Medicare regularly denies patients for benefits that they were promised. Although this is primarily an administrative issue with Medicare and the regulatory agency, this misperception is shared by physicians, which furthers the stress of the patients. Typically, the physicians themselves are not at fault, and Medicare beneficiaries that are not able to receive coverage are required to contact the government regulatory agency. As these lawsuits demonstrate however, it is not legal to treat Medicare patients differently because they receive their healthcare for free on behalf of the government. To avoid future suits, it is essential for healthcare professionals and the government to treat Medicare patients as they would any individual with private health insurance.

A secondary consideration that is necessary when dealing with Medicare patients is that physicians must uphold the same ethical treatment of these patients as those in different age groups and with private health insurance. However, there have been many situations in which doctors and other health care professionals have taken advantage of the elderly in order to profit. As a consequence, many have scammed Medicare and billed for procedures and treatments did not take place. The elderly are an at risk population for this type of treatment because they are less likely to understand or notice the documentation that they receive at the end of a visit to the doctor’s office.

One of the most significant Medicare scandals occurred in 2012 and resulted in $97 million worth of fraud (Department of Justice, 2012). Several physicians who belong to a company known as Spectrum Care P.A. in Houston conspired together in order to scam both their patients and the government. The scheme had continued for five years before the group was caught and arrested. They carried out the fraud by reporting that they provided partial hospitalization program (PHP) services for their patients, which is a form of outpatient treatment for individuals with severe mental illness. It was found that the individuals who were billed for these services neither qualified for nor requested these services, and they were not provided regardless.However, all five doctors would sign documentation stating that the patients were admitted for PHP. Although many physicians have attempted to scam Medicare in the past, this case initiated an effort to detect and prevent government healthcare fraud. This law is entitled the Health Care Fraud Prevention and Enforcement Act (HEAT) and is expected to help minimize Medicare losses, thereby assisting the population that this healthcare program was intended to serve.

As this discussion has noted, many issues currently exist with the Medicare program, and this has been the case throughout history. As a consequence, there have been several attempts to revise and renew the program so that it can best benefit patients. One of these programs is known as the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 and the other is the Health Care and Education Reconciliation Act of 2010. Both of these laws expanded both the reach and protections afforded by Medicare. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 was significant primarily because it enabled Medicare beneficiaries to have prescription drug benefits in addition to their normal coverage. In addition, it prohibits the government from negotiating discounts with drug companies. Because drug companies are protected under this act as well, they will not need to bargain with physicians in a manner that compromises care of seniors. The Health Care and Education Reconciliation Act of 2010 was created to amend the Patient Protection and Affordable Care Act which allows both Medicare patients and their physicians to be reimbursed more easily. This encourages more doctors to work with elderly patients.

In conclusions, although many issues at present exist with Medicare in terms of patient knowledge and physician acceptance, legal action has helped seniors get the care promised to them and conditions are improving. When seniors are prohibited care, it is necessary for them to call this to the attention of the Department of Health, either in the form of a written appeal, or a suit when necessary. In addition, it is necessary for seniors to be aware of the care that is provided them and to report any errors to their physician. If a scam is suspected, it is important to report Medicare violations to the local government or IRS. Lastly, it is important for seniors to be aware of the amendments and alterations to their Medicare plans to adjust for the gap in knowledge that may be present when the laws are first introduced.

References

Anderson v. Sebelius, WL 4273238 (2010).

Department of Justice. (2012). Owners and Employees of Houston Mental Health Company and Patient Recruiters Charged for Alleged Roles in $97 Million Medicare Fraud Scheme. Retrieved from http://www.justice.gov/opa/pr/2012/July/12-crm-928.html

H.R. 1 (108th): Medicare Prescription Drug, Improvement, and Modernization Act of 2003.

H.R. 4872 (111th): Health Care and Education Reconciliation Act of 2010.

Papciak v. Sebelius, WL 3885605 (2010).