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Medicare Dropping The Ball on Investigations

Medicare Dropping The Ball on Investigations

As a program, Medicare has a lot of responsibilities on their plates. They handle a lot of different tasks throughout the year to ensure that enrollees are getting the best coverage possible. Regardless of what you think about the quality of your service, nobody can deny that they are working with dozens of different areas, but unfortunately, they have neglected some of those areas, which could be very costly.

In 2013 – 2014, 96 different hospitals submitted data which should have been investigated by Medicare. This data reflected possible dangerous infections that patients could have been contracting while they were at the hospital. Typically, Medicare is supposed to review around 200 cases of hospital reports when there are suspicion infection results.

When looking at the data, which show very low infection rates or statements which suggest that the infections almost always occurred before the patient arrived at the hospital. The problem with this is that hospitals can receive bonuses if they meet specific goals, and one of those goals is infection rate. The idea is that these hospitals could be falsifying their records to make it appear as if the patients are getting the infections before they come in, so the hospitals are not to blame, which gives them better results.

The reward system is a part of Medicare’s Hospital Inpatient Quality Reporting program, and the reward or possible penalty if the hospital doesn’t before well, could amount to millions of dollars. Once hospitals started getting graded on these different categories, it became necessary for the agency to investigate the records to ensure that hospitals were achieving these goals, or just altering the records to make it appear so.

A lot of experts think that the main problem is the fact that there is no standard for how the data is reviewed after it’s sent to Medicare. Dr. Peter Pronovost, who is the senior vice president for patient safety and quality at Johns Hopkins Medicine had some strong words on the lack of investigations, “There are greater requirements for what a company says about a washing machine’s performance than there is for a hospital on quality of care, and this needs to change,” Pronovost said. “We require auditing of financial data, but we don’t require auditing of [health care] quality data, and what that implies is that dollars are more important than deaths.” Pronovost is spreading light on what could become a major problem, and will need a solution fast.

The longer that hospitals are required to submit this data to meet goals, the more creative they are going to become when reporting the data. There are dozens and dozens of ways that you can alter data to help reach goals and avoid penalties. Not only will it cost Medicare as they are paying out bonuses, but it’s also going to hinder the quality of care that Medicare enrollees are receiving.

Medicare reviewed the results from 400 random hospitals, which is only 10% of the nation’s hospital system, and they also looked at the data of 49 specific hospitals that had shown underreported infections. After rechecking the information that was sent in, it showed that only six of the hospitals failed the review. For any hospital that fails the review, they are punished with a 0.6% reduction in how much they receive through Medicare payments. While this may seem like a tiny slap on the wrist, when you look at a large number of patients that pay through Medicare, this small reduction will easily equal millions of dollars that the hospital will not receive.

The data that Medicare is getting from the hospitals can play a major role in understanding the quality of care that patients are receiving, and it can help us improve any areas that are falling through the cracks, but if we aren’t getting truthful reports, then those papers will not be worth the paper that they are printed on. Medicare is dedicated to fixing this problem, but currently, no solution has been submitted to ensure that hospitals are honest with their numbers and reviews.

As a Medicare enrollee, you may be worried about the quality of care that you’re going to receive when you go to the hospitals, and while it’s true that these numbers are shocking, you shouldn’t be worried about getting sub-par care. As a whole, patients are receiving excellent care, and regardless, it’s more important that you go to the hospital instead of skipping the treatment.

As Medicare professionals continue to review the standards systems and the reports that they are getting from the hospitals, we hope that we will see a more efficient system which will reflect the actual quality of care and patient numbers. Because the comparison system is new, it’s expected that there are going to be some hiccups in the process, but it’s important that the professionals behind the program continue to improve the system. We will give you updated on any changes or developments that are made in the future.


MedicareWallet.com is an unbiased, online resource for individuals turning 65 or already on Medicare. Our utmost goal is to provide information in a way that is user-focused, informative and ethical. With a combined 40 years of experience in the Medicare market, we can answer any questions about Medicare and Medigap insurance. Feel free to reach out to us at 800.376.0824 or by email atinfo@medicarewallet.com.

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