U.S. to Review Medicare Billing Guidelines

Federal health care officials agreed Wednesday to “take a fresh look” at Medicare billing guidelines that have compounded Ventura County’s fiscal troubles by withholding $3 million in reimbursements for county clinics and could siphon away an additional $1.6 million annually.

At a meeting in Washington, Chief Administrative Officer Harry Hufford and other county officials urged Thomas A. Gustafson, director of the purchasing policy group of the U.S. Health Care Financing Administration, to accept the county’s billing and contractual arrangements with 34 county clinics.

The dispute centers on the county’s contention the clinics are outpatient satellites of the Ventura County Medical Center--a designation that entitles the county to higher Medicare reimbursement payments. The county contracts with private physicians to run the clinics.

Federal officials contend the clinics operate independently from the medical center and should not be billing Medicare at the higher rate. They also cited 21 mental health clinics as ineligible because they are part of the Behavioral Health Department, which the Health Care Financing Administration contends is separate from the hospital.

But county lawmakers argued Wednesday the federal billing rules do not make sense and are stifling an effective health care system that ultimately saves the government money. More importantly, they contend, hundreds would be denied care if the county loses the Medicare reimbursement money.

“I feel passionately about this because it’s the people who need the health care who are in trouble here,” Rep. Elton Gallegly (R-Simi Valley) told Gustafson during the meeting. “We cannot and should not deny care to anyone.”

Gustafson conceded the contracts that bind the clinics to the county hospital in Ventura seem to put them under full county control and therefore may entitle the clinics to $1.6 million in annual federal reimbursements.

That could bring much-needed funds to county coffers to help reconcile a projected $5-million budget deficit for the current fiscal year.

“I think everybody left the meeting feeling very positive,” Gallegly spokesman Tom Pfeifer said. “Gustafson said he would meet with his superiors. There’s no time frame. There’s no promises.”

The announcement was applauded by county officials, who have been lobbying their federal representatives for weeks to help resolve the crisis that has jeopardized funding to 34 of 43 public health clinics.

“I’m very happy they’re going to take a more serious look at the issue,” Supervisor John Flynn said. “It gives us a much better chance. And I think we’re on the way to solving that status of the clinic issue.”

Supervisor Frank Schillo said Gustafson’s announcement vindicates a decision by county officials to contract with physicians for clinic services.

“If [the federal government] is not treating those patients, why are we even in the medical business?” he asked. “We’re in the business for the people who can’t pay.”

Schillo and Supervisor Judy Mikels met with Gustafson about three weeks ago to discuss the reimbursement issue.

“His main interest is that [denying the reimbursements] means these people are not going to be cared for,” Schillo said. “That is what I think turned the tide.”

Hufford, accompanied by Health Care Agency Director Pierre Durand, Deputy Director Mike Powers and County Counsel Jim McBride, argued the satellite clinics are an integral part of the county hospital system and therefore entitled to the higher Medicare rate. The meeting was arranged by Gallegly.

Last June, Health Care Financing Administration officials ruled that clinics nine miles or more from the county hospital were too far to be considered hospital-based and therefore ineligible for the higher Medicare reimbursement rates.

But county officials argued that as satellites of the public hospital, the clinics increase accessibility to health care and should be reimbursed.

“We argued against it saying it violated the whole concept of having clinics,” Flynn said. “You put clinics where people are.”

Officials with the U.S. Department of Health and Human Services relented two months ago and relieved the county of the so-called “nine-mile rule.”