Can a Medical Practice Actually Say No?

By Katie O’Leary.

Many Americans do not know the difference between Medicare and Medicaid. There are a lot of programs our country has created, many of them can be even more confusing and have even more paperwork to trip you up. Just qualifying for Medicare can be a headache: you can be denied multiple times, get the wrong information, and even have go to court to receive the benefits you so desperately need. Medicare is granted 2 years after SSDI is awarded. One cannot apply for it until one reaches the mandatory retirement age, depending on one’s year of birth, or 65, whichever comes first. If you are less than 65 and receive SSDI, one may be eligible for Medicaid depending on state income thresholds. It’s not a guarantee.  Under certain conditions, say dual eligibility gained as an adult disabled child, one may be eligible for both Medicare and Medicaid. Rules and thresholds vary by state. When an American citizen turns 65 years of age, they automatically qualify for Medicare. But, if you have a disability, you can apply for Medicare and receive the same benefits at a younger age.

Such is the case with Sarah[1], a patient who qualified for Medicare after being approved for disability benefits due to her full-body CRPS. (We’ve changed her name so as not to hurt her attempts at finding a medical practice)

Katelyn O’Leary

For those who do not know, CRPS (Complex Regional Pain Syndrome) is a disorder of the sympathetic nervous system, usually triggered by an injury, surgery, accident, etc. The brain becomes confused and believes that long after an injury to a particular part of the body has healed, that the area is in fact still damaged. This results in excruciating neuropathic pain signals being sent to that part of the body, or in Sarah’s case, her ENTIRE body. It started with an injury to her shoulder from a nasty fall at her job. Unfortunately, CRPS is known to spread, and hers has spread to her other limbs and her internal organs as well. She qualified for disability in 2015 after a worker’s compensation case and has been trying to find a decent clinic and doctor to treat her disorder.

On August 22, 2018, Sarah called the Mangrove Medical Group located in Chico, CA looking for a new doctor to potentially treat her. When she asked if they take Medicare patients, they informed her that they only take patients who are 65 and older. She immediately followed up with her Medicare representative who told her this was not true – Medicare patients cannot be discriminated against or denied coverage based on age. When Sarah dug deeper, the administrator for Mangrove asked her if she was a potential pain management patient. When Sarah said yes, the administrator said “We do not prescribe opioids so that is why we do not cover patients under 65.”

I was appalled by this statement. Denying coverage to disability patients because you do not wish to treat their pain? I had to find out for myself what was going on. And what I would soon find out, is that this is happening everywhere. I called Mangrove Medical Group and asked to speak to their administrator Ann[2].

“Do you accept Medicare patients?” I asked.

“Yes we do.” She said.

“What about patients under 65 years of age?” I said.

“At this time we don’t accept patients younger than 65.” She replied.

When I told her that I was a writer she immediately hung up on me and all further attempts to contact her were sent directly to voicemail[3].

I then decided to call Medicare myself and see what they would say about this situation. Could it be true that in this day and age, with the opioid epidemic rising, and with the influx of disability patients – that doctors could deny Medicare patients who are younger? Is this a new way to restrict pain patients from taking advantage?

“I have never heard of that happening before – ever.” This was said by Diana[4], in a tone of shock, a Medicare representative I spoke to and to whom I told Sarah’s story. She informed me that not only was this illegal, but that it violated the list of rights for all covered Medicare patients:

  • Be treated with dignity and respect at all times.
  • Be protected from discrimination. Every company or agency that works with Medicare must obey the law. They can’t treat you differently because of your race, color, national origin, disability, age, religion, or sex.
  • Have your personal and health information kept private.
  • Get information in a way you understand from Medicare, health care providers, and, under certain circumstances, contractors.
  • Get understandable information about Medicare to help you make health care decisions (this list is available via medicare.gov)

Diana went on to tell me, “Notice how it says ‘be protected by discrimination’? It includes age. If a doctor had a MEDICAL reason to deny service or coverage to this patient, they would have to submit paperwork, or an ABN: ‘An Advance Beneficiary Notice (ABN), also known as a waiver of liability, is a notice a provider should give you before you receive a service if, based on Medicare coverage rules, your provider has reason to believe Medicare will not pay for the service (medicare.gov).’”

But Sarah did not receive an ABN. She was told over the phone that because she was under the age of 65, she would not be accepted as a patient at the Mangrove Medical Group. Diana then said, “She needs to file a complaint against this medical office with her local civil rights office: hhs.gov/hippa. They cannot deny her coverage based on her age. That is simply discrimination.”

I consulted Terri Lewis, Ph.D., a frequent contributor to the National Pain Report. When I asked Terri about this situation, she said, “The only way they could legitimately deny [this patient] is if they were not contracted on her insurance carrier plan. In this case, age, gender, disability are not involved. They do not have to participate in every Medicare plan.”

Terri then went on to explain something called “capitation.”  In a capitated plan, often called Advantage plans, the insurer strikes an agreement with physicians to limit the numbers of persons they have to serve so as not to overly burden the economic formula for the physician reimbursement.  Most physicians will not disclosure that they have hit their capitation limits when they tell patients they are not accepting new patients.

Furthermore, if they are accepting patients on the Medicare plan in question, then they must accept despite characteristics. If pain is in the equation they can say, “We do not treat pain.” But they must refer, and the insurer must make sure they have qualified providers for pain management on their plans. Unfortunately they can have qualified providers who are working at the limit of their capitation agreements who are not taking new Medicare patients under the plan in question. It’s a form of hidden rationing that remains undisclosed to the public. It harms patients who are complex.

A medical practice does not have to disclose capitation and could instead refer a patient to another practice. But in Sarah’s case, capitation does NOT seem to be present. They did not refer her to another doctor to treat her pain, and the economic burden of the medical practice is unclear given that they were accepting new patients. But the question I have is this: Wouldn’t it make more sense to just say they have too many patients and lie than admit to such discrimination? Most doctors usually shuffle patients to other doctors when they can’t provide a service or provide pain management due to lack of resources or simply from lack of ability. If this medical group is so ignorant and willing to reveal their discriminatory bias towards patients, and are willing to trample on the rights of patients – do they even know capitation is an option?

Ultimately, as a CRPS patient myself, I am appalled by the apparent actions of a medical group that is willing to break the law to deny service to patients with disabilities. If they wished to avoid becoming a pain management clinic, there are ways to do that without infringing upon patient rights. Sarah has already filed a complaint against Mangrove Medical Group. But I encourage every Medicare patient of ANY age to know your rights and to fight for them. You deserve treatment and you deserve to be heard. And for medical groups who are afraid of dealing with pain patients? There are other ways to avoid pain management as a specialty: it’s called not having it.

If you or a loved one feels that you are being discriminated against by a medical group, doctor, hospital, or health plan while on Medicare, please go to this website to file a claim as soon as possible: hhs.gov/hippa

Repeated attempts to further reach the Mangrove Medical Group were unsuccessful.

[1] Her name has been changed to protect privacy of those involved

[2] Her name has been changed to protect the privacy of those involved

[3] All further attempts to reach the Mangrove Medical Group Administration office were unsuccessful and went to voicemail

[4] Her name was changed to protect the privacy of those involved

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Authored by: Katie O’Leary

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Becky

Sadly in the fight to get my daughters overall pain to a level she could minimally take care of herself and maybe hoping one day work part time,we have had so many turn her away.
Try having the extreme nerve, muscle, bone, artery, and everything pain, plus major dysautonomia head pain.
EDS, LYME, RMSF, CHRONIC FATIGUE SYNDROME, BABESIA, BART, EBV , POTS, SICCA syndrome, on on. Cant find docs on Medicare plan. When we do they are states away.
Medicaid doesn’t pick up cost of out of pocket docs. Medicaid said to daughter. “Why dont you go to a doctor in your plan?” Put my daughter into downward spiral like my daughter did something wrong.
We need help. We need docs in Medicare that are good doctors. The rheumatologist said she did not learn about EDS nor LYME nor others in med school. The out pocket pain doc will not prescribe what my daught er needs to take a shower even.
So people like my daughter will cost a lot of tax money as us baby boomers die or spend all our money taking care of sick adult kids. Everyone thinks they will get out alive no chance… lyme will get you if nothing else does. In all 50 states.
Government on America does not care about disabled . Period. Fact.

Christine

refusing to treat a person’s pain should not be an acceptable practice. That in itself is discriminating against a patient based on disability as a doctor would not deny necessary medications for a patient suffering from diabetes, thyroid etc as they are trained to treat these ailments. The same holds true for patients who do not require steroid injections and nerve blocks. BC College of Physicians and Surgeons warned their PCPs about refusing to treat a patient’s pain. They stated that PCP’s treat COPD diabetes, etc and are capable of treating those patients suffering from Chronic Pain. Primary Care Providers are trained on all commonly prescribed medications and have the knowledge, skill and judgement to treat pain using uncomplicated measures including the prescribing of opioids for pain.

A. MacKenzie

As a follow up to my prior comment, I believe the real issue Sarah has is she takes pain medication and is being denied on this basis, rather than a Medicare coverage issue. The fake “opioid crisis”, fanned by the media, is the real culprit.

A. MacKenzie

I was denied access at two clinics in North Idaho simply because I take tramadol for fibromyalgia. I did not have Medicare or Medicaid, but Blue Cross insurance. I was not seeking any kind of pain management treatment (my tramadol prescription was being authorized by a practitioner in my former home town). I tried to make an appointment to see a provider for other medical issues and at both clinics the receptionist looked up my name and birthdate and then told me I could not be seen at their clinic. Presumably they looked up a database that showed I took tramadol. Both told me that was just “their policy.”

So, even before seeing a doctor, I was discriminated against. They made a presumption based on what seems like should be private information, and then denied me access to healthcare, essentially.

I admit I laughed (bitterly) out loud when I read the headline…then it just got more ludicrous. The writer clearly is isolated from reality as a Medicare or a pain patient. A couple of years ago I moved to a new state, and not only lost the pain care I’d had, but I could not get any doctor or practice to accept me as a patient solely to prescribe meds for my hypothyroid condition. They took Medicare patients, but absolutely would not see (literally) a FORMER pain patient, one who only needed a hormone that in no universe can be seen as a street drug…but without which I would slowly stop, like a clock that isn’t wound.

What our theoretical “rights” are has no application whatsoever in the real world.

nana

I agree this is happening but even if you force them to “treat” you- what are your chances of getting good treatment?

The second thing that upset me is the statement “we do not prescribe opioids.” A blanket and upsetting thing to say. What if a patient came in with an amputated finger? They would arbitrarily not offer pain relief? What about a heart attack? Treatment should be based on need. I am appalled too.

I called a medical practice in Idaho when trying to find a provider. They said “we do not accept Medicare.” She gave life coaching treatment. I thought that would be great.

I called around some more without getting help.

I called back again to her office and asked what the charges would be for cash.. Her office told me that if I had Medicare she flat would not see me. Even as a cash patient.

I gave up at that point. Anyone with that attitude would not treat well if they lowered themselves to treat us.

What chance do we have?

Alex

Although completely outrageous, a terrible violation of “Sarah’s” rights as well as a lousy way to treat anyone, it’s not really surprising. The opioid crisis has given many medical practices a real scare. New pain patients are view as “pill shoppers” because “If you already have a CRPS diagnosis, why are you looking for another Doctor”? That’s the response I got from a Practice Manager I know well. The State where I live is one of the “top ten” in the opioid crisis list so many Doctors are scared of the issues that have already happened – Doctors being busted by the DEA for prescribing opioids. This just complicates the issue.

I too am a CRPS survivor, with full body CRPS for almost 20 years now. I have been in “Sarah’s” position more than once. One Doctor – a supposed expert in CRPS and RSD, actually told me he would no longer treat me based on my diagnosis, prognosis and medication needs. This happened at a Meds Visit when I had taken my last dose of pain meds that morning. I was out of meds, facing horrible pain without them, and now looking at withdrawal on top of it. I have never abused my medication, and my records show that by way of call in pill counts, pill counts at visits and random urine tests done at the Doctors office. None of that made a difference. I went through hell for weeks, godawful pain, no sleep, nasuea, vomiting, cramps, swetts – all the lovely things that come of being a pain patient going off meds abruptly. Did the Doctor care? Not a bit. Did he do anything illegal? Maybe. Did he violate his oath? Absolutly! Was he unethical? Of Course!

As a long term user of opioids for pain control, getting proper treatment is not easy, the press is making it worse as are all the medical pundits who decide that a pain patient who needs opioids must be a junky. Lovely label isn’t it. The real senario is that a pain patient with severe chronic pain just might turn to a substance purchased on the street because they cannot function with the pain they endure. This is what practices like the one “Sarah” went to – tried to go to – can actually cause. By breaking the law, and their hipocratic oath they are putting patients at risk. Sad but rue.

naomi

That same thing has happend to me multiple times here in Portland, oregon. After they here im a pain patient and 48 with medicare they tell me no. Which it seems like i have tons of lawsuits! Right.

Rochelle

Good info but I have a couple of questions. With regard to SSDI and Medicare has the law changed since the late 1990’s? I was approved for both in July 1997 and had immediate access to Medicare. I know it seems to be changing on a regular basis which may explain the now two year delay referencec.

With regard to capitation, I thought it referred to certain referrals from your primary care physician referring you to see a sprcialist not requiring medical group approval. Maybe there are different areas with regard to capitation.

Denise

Please keep us posted as to the results of this complaint.