Senate Finance Chairman accuses long-term care providers of 'gaming' dual-eligible reimbursements

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Senate Finance Committee Chairman Max Baucus (D-MT)
Senate Finance Committee Chairman Max Baucus (D-MT)

Long-term care providers struck back quickly late last week after the chairman of the U.S. Senate Finance Committee accused them of “gaming” the reimbursement system during a hearing on caring for individuals eligible for both Medicare and Medicaid.

“There's a lot of gaming going on, I suspect,” said Sen. Max Baucus (D-MT) while questioning Melanie Bella, director of the federal Medicare-Medicaid Coordination Office. “What are you doing to help minimize providers gaming the system?” he also asked.

Bella and others detailed several programs that were underway to help determine how costs could be minimized. Officials also outlined how the so-called dual-eligibles use up a disproportionate of healthcare reimbursement dollars.

Bella said her agency is trying to “establish accountability for the dollars” because providers now “might be able to play Medicaid and Medicare against each other.”

“These avoidable hospitalizations can be disruptive, dangerous and costly,” she testified. “Research shows that nearly 45 percent of hospitalizations among Medicare-Medicaid enrollees in nursing facilities are potentially avoidable, meaning they could have been prevented with adequate monitoring and treatment in the nursing facility setting.”

Providers, who were not invited to testify at the hearing Thursday, were quick to respond.

"Today's testimony by [Centers for Medicare & Medicaid Services] officials unfairly characterized the profession as adopting a revolving door for our residents with respect to hospital readmissions,” said Jeff Myers, the lead lobbyist for the American Health Care Association. “To suggest our providers are gaming the system in order to maximize Medicare reimbursements is false and fails to appreciate the deep-rooted challenges of caring for such a medically-frail and needy population.”

In prepared comments, Baucus said the way to increase efficiency in reimbursement programs was threefold: rework payment models to give providers and states “incentives to work toward the same goal” — remove “incentives for providers to game the system”; coordinate care so all providers “work as a team”; and remove “conflicting rules and cut red tape” where Medicare and Medicaid intersect.

Sen. Jay Rockefeller (D-WV) spoke warily of managed-care programs being floated by CMS, calling it a “losing situation” for dual-eligibles' healthcare needs.