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U of M study: Medicare lacks tools, incentives to enforce evidence-based coverage policies
Date:10/31/2007

policy. Policymakers should convene experts to redesign claims forms and coding, or other mechanisms to acquire supplemental information.

Align incentives: Contractors are rewarded for efficient low-cost claims processing, not for enforcement of coverage policies. Policymakers need to modernize the role of contractors to incent them to pay only for value.

Invest in compliance: Contractors need additional resources to request and review patient charts in the absence of information on the claim. A highly effective and visible effort is necessary to inform providers that policies will be enforced.

Improve education: Contractors must educate providers on the importance of coverage policies. Patients need better information so they know how the science affects them as well.

Foote concludes, Public and private payers are often reluctant to second guess doctors and other professionals. We have seen abuses where payers deny needed and necessary care. When Medicare was passed in 1965, professionals were assured that the program would not interfere with the practice of medicine. But Medicare is also directed not to pay for procedures unless they are reasonable and necessary. Theres an inherent tension between these goals. However, in an era of rising costs and questionable quality, we must refine tools to ensure that patients get care based on scientific evidence.


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Contact: Nick Hanson
hans2853@umn.edu
612-624-2449
University of Minnesota
Source:Eurekalert

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