10/17/2024    Allen Jacobs, DPM

Medicare Advantage in the News (Paul Kesselman, DPM)

With regard to the denial of services by MCR Part
C providers, there is a practical aspect which
cannot be denied. Dr. Kesselman notes that in
theory, by the "letter of the law", Medicare
Advantage plans are obligated to provide services
normally provided to a patient as defined by the
local LCD or national directive. However, many in
private practice rely on referrals from physicians
and physician-extenders for practice survival.

Increased podiatric costs are considered a loss of
profit to the referring health care provider. The
referring Medicare advantage plan healthcare
providers monitor payments to providers to whom
they refer. Sadly, unethical referring healthcare
providers will remove or discontinue referrals to
those whom they perceive to be excessively costly,
depriving the referring provider of profit (e.g.:
bonus). The result is a conflict faced by the
podiatric physician: do what is in the best
interest of the patient, or risk loss of referrals
and potentially the financial viability of the
practice.

This is reality, particularly to those whose
practice encompasses a large number of Medicare
advantage patients. The result is an altered
"standard of care " for those with Medicare
advantage plans, e.g.: inability to utilize
preferred wound care products such as grafts,
denial of secondary referrals, limited office
evaluations, denial of rehabilitation.

As many PM readers, I have faced such problems
when the patient has a Medicare advantage PCP who
places personal profit over patient needs. Frail
diabetic patients with extensive external/internal
stabilization following surgery for
neuroarthropathy denied admission to rehab for
assistance. Denial of expensive skin substitutes.
Denial of elderly diabetic patients to
interventional cardiology in the face of screening
studies demonstrating hemodynamically significant
disease.

Denial of needed diagnostic studies such as MRI or
guided US therapy. The result is denial of needed
care, an ethical crisis for the podiatric
physician, and potential medical-legal liability
concerns. There is no question that in many
circumstances, the care of a Medicare advantage
plan patient is not equal to that of a straight
Medicare patient. However, doing the "right thing
" can be costly to those who are actually in
private practice. While the advice and direction
of consultants is appreciated, as Einstein noted,
in theory the theoretical and practical are the
same. But in reality, they are frequently not.

Allen Jacobs, DPM, St. Louis, MO

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