Americans believe that Medicare is going to cover their medical costs after the age of 65.  That Medicare is an entitlement program. Wrong.  First of all we Americans have paid for the Medicare premiums through withholding so it isn’t an entitlement.  Medicare will only pay under Part A if the following rules are met:

1. Must have a qualified 3 day stay in an accredited hospital
2. Must be medically necessary
3. Must be certified by a licensed physician or Doctor of Osteopathy
4. Must be coverable by needing skilled nursing or therapy services seven days per week
5. Must be reviewed by the physician and therapist(s) every 30 days for recertification
6. Must be for reimbursable expenses related to the skilled care, including equipment
7. Must have a deductible of the current amount after the first 20 days of skilled care
8. Cannot exceed 100 days of coverage for each spell of illness (a break in the spell will be for a 60 day break in the stay without being re-hospitalized).  A new spell of illness requires another 3 day qualifying hospital stay.  Re-hospitalizations are screened closely for further qualifying coverage
9. Claims are generally denied for not meeting the above qualifiers … denials are subject to complicated rules for submission, documentation and are reviewed by non medical government officials (administrative law judges) who want the appeal to be rejected … thereby saving the Government money and hurting the provider who has incurred the cost and will loose the reimbursement
10. Providers typically don’t appeal due to the time and money it takes to submit let alone to win (which is rare) … currently there are 800,000 appeals backed up due to lack of money

Medicare Part A (for), B (for non inpatient care), C (HMO administered Medicare) and D (coverage of medications for Medicare and Medicaid) are being withheld from our pay checks.  So, in fact Medicare isn’t an entitlement program and the government is using our money.  The problem is they loan that money to the general fund through treasury notes for paying bills and fighting wars.  then claim the providers are committing fraud and abuse by wanting their claims paid.

See the next blog for the Medicaid political guise.