The sickest patient

ISSUE: Medicare reimbursements to HMH

OUR VIEW: The first of many

Let’s pretend you are a business owner who provides a variety of services to your consumers. In return, your consumers pay for your services using an assortment of agreed upon compensation methods. One of these methods involves payment of a portion of the bill by a third party.
Now, consider this circumstance in the scenario. The third party fails to reimburse you for the service you have provided to your end consumer. You’ve exhausted all available avenues to hold the third party accountable for payment, including using available mediators, without success. You can’t repossess the services you’ve provided to the end consumer, and they’ve paid you the portion of the bill for which they’re responsible.
What do you do? One option is to take the issue before the appropriate court of law in hopes of getting proper restitution. This is just what Hardin Memorial Hospital has chosen to do.
Last month, HMH filed a federal lawsuit in U.S. District Court against Secretary of Health and Human Services Kathleen Sebelius. The suit claims her department has failed to reimburse the hospital for Medicare payments HMH says it’s owed for providing hyperbaric oxygen therapy to a Medicare participant patient in 2008.
In the suit, HMH claims that it followed established standard practice and treatment protocols for dealing with such cases as outlined in the Medicare National Coverage Determinations Manual. Following the hospital’s treatment using a variety of therapies over a period of time, the patient eventually improved. Medicare reimbursement, however, was denied.
This is a single suit that, no doubt, will be accompanied by hospitals across the country as the federal government flexes its muscle to cut waste from the Medicare system.
These suits will be costly for the hospitals and stakeholders involved, whether private or public. They’ll require enormous amounts of time, energy and money to litigate. And in many cases, the litigation expenses will likely out-weigh the payments denied.
But as HMH CEO David Gray alluded when commenting on the suit, not all Medicare filings are fraudulent. For every bad apple provider in the health care industry barrel that seeks to take advantage of Medicare money inappropriately or illegally, there are hundreds of others that are above board and beyond reproach.
While it’s critical that fraud and wasteful spending are cut from the health care system, it’s equally critical that private and federal insurance and benefit programs pay what they’re responsible for paying.
This suit, and the myriad to follow here and nationally, can play a role in the possibility of striking this balance. The question is, will such balance ever be established in a health care system as sick as the patients it seeks to serve?

This editorial represents a consensus of The News-Enterprise editorial board.