Medicare Compliance & Reimbursement

Plus:  Why medical care visits in the United States have skyrocketed.

Medicare will no longer restrict its bariatric surgery coverage to gastric bypass procedures. But coverage may depend on surgical centers' success rates.

A new Centers for Medicare & Medicaid Services decision expands bariatric surgery coverage beyond a proposal from late in 2005 that would have withheld coverage for beneficiaries aged 65 years or older, according to a Feb. 21 announcement.

Prior to this decision, "CMS' only nationally-covered bariatric surgery procedure was gastric bypass surgery," the agency says. Now Medicare will cover open and laparoscopic Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, and open and laparoscopic biliopancreatic diversion with duodenal switch.

To obtain coverage for one of these bariatric surgeries, a Medicare bene must have received an obesity diagnosis and a diagnosis of either type-two diabetes, coronary heart disease, stroke, gallbladder disease, osteoarthritis, sleep apnea, respiratory problems, hypertension or a certain type of cancer. CMS will also limit bariatric surgery coverage to facilities that the American College of Surgeons and the American Society of Bariatric Surgery recognize as Centers of Excellence.

"While we want to see more evidence on the benefits and risks of [bariatric surgery], some centers have demonstrated high success rates, and we want to ensure access to the most up-to-date treatment alternatives for our beneficiaries," explains CMS Administrator Mark McClellan.

To read the final decision memorandum, go to http://www.cms.hhs.gov/center/coverage.

Managed Care May Be To Blame For Decreases In Visits To Specialists

The annual number of medical care visits reached 1.1 billion in 2001 and 2002--a 10-percent jump from the visit rate in 1999 and 2000, a recent report reveals.

"Fueling the increase was a 17-percent jump in visits to primary care physicians," according to the National Center for Health Statistics. In fact, half of the 1.1 billion visits were to primary care doctors, the Center for Disease Control and Prevention report indicates. Just 16 percent of the visits were to medical specialists, 15 percent to surgical specialists, 10 percent to hospital emergency departments, and 8 percent to hospital outpatient departments, the CDC finds.

"Patients are seeking care more frequently from primary care physicians in lieu of specialists, perhaps as a result of managed care," an NCHS/CDC statement explains. On average, uninsured individuals sought medical care the least--only 1.6 times per year, compared to 3.8 visits per person for the overall population. "The elderly, who are largely covered by Medicare, saw doctors more than any other age group--about 7.4 visits a year for each person 65 and older," the report notes.

Physicians provided or prescribed drugs during nearly two-thirds of the visits, "amounting to 1.7 billion annual prescriptions (not including telephone prescriptions)," the statistics show. Physicians prescribed nonsteroidal anti-inflammatory drugs, antihistamines and antidepressants most frequently, the CDC reports.

To view the report, "Ambulatory Care Visits to Physicians' Offices, Hospital Outpatient Departments, and Emergency Departments, 2001-02," go to http://www.cdc.gov/nchs/data/series/sr_13/sr13_159.pdf.