For more than seven months, 24-bed Nemaha Valley Community Hospital in Seneca, Kan., has not filed a single Medicare claim. Not one.
For more than seven months, it has waited for HCFA to make a decision and has spent all its reserves. It has sent countless letters to HCFA, each begging for action and outlining a financial condition more grave than before.
Now, finally, it seems Nemaha Valley's thrill ride through HCFA-land is over. HCFA has decided to do what it could have done all along and grant Nemaha Valley status as a "critical access hospital." That will allow it to move to a cost-based reimbursement system for Medicare.
The trouble started in May 1996, when the Nemaha Valley board voted to seek designation as a "rural primary-care hospital." Under the RPCH pilot program, Kansas was one of seven states that could designate small, rural hospitals to receive cost-based reimbursements from Medicare.
Nemaha Valley was a perfect candidate. It is small, rural and financially struggling, having lost money in four of the past five years, according to its administrator, Michael Ryan. About 65% of the hospital's patients are Medicare beneficiaries. In June 1997, after Nemaha Valley had waited more than a year and spent nearly $50,000 in legal and consulting fees, Kansas designated it as a rural primary-care hospital.
That is when Ryan and Nemaha Valley began to move through the HCFA bureaucracy in much the same way healthcare reform has moved through Congress.
While Nemaha Valley waited for HCFA to approve Kansas' decision, Congress passed the Balanced Budget Act of 1997. That law killed the RPCH program and gave birth to a nationwide successor -- the Critical Access Hospital program. All hospitals that had the RPCH designation as of August 1997 were grandfathered into the new program.
But not Nemaha Valley.
You see, its status hadn't been approved by HCFA, and therefore the hospital was in limbo. Not the fun limbo but the infernal one, where you move from bureaucrat to bureaucrat looking for the one who actually can do something about your problem.
First, Ryan tried to contact HCFA directly. At least, Ryan says he tried to. HCFA seems to think otherwise.
Nevertheless, Ryan eventually contacted the American Hospital Association, which advised him to contact his federal lawmaker. So Ryan contacted Sen. Pat Roberts (R-Kan.), who contacted HHS. Roberts wrote several letters to HHS Secretary Donna Shalala. One included a handwritten note that said, "We are getting pretty desperate -- need your help."
Last month Ryan was promised a call from Shalala. What he got was a conference call. When he picked up the line, the operator told him he was the 17th participant. The other 16 were from HCFA. (Insert your own "How many HCFA staffers does it take to change a light bulb?" joke here.)
According to Ryan, the HCFA folks talked among themselves for a while about the Nemaha Valley situation, kind of the way doctors and nurses talk over a patient on the operating table. A HCFA official promised to give the issue full consideration.
All this time, Nemaha Valley has not had a Medicare provider number, so it hasn't been able to file a single Medicare claim.
HCFA was quick to point out to me that Nemaha Valley has been receiving 70% of its estimated Medicare claims under the "accelerated payment system."
Only HCFA could call holding 30% of reimbursements "accelerated payment." I suspect, however, that the same HCFA officials who came up with accelerated payments would be really, really upset if 30% of their paychecks were withheld until some unspecified future date.
According to Ryan, Nemaha Valley has worked through all its reserves and will have to begin borrowing money later this month. The hospital has continued to pay its 30 physicians in full, even though it is getting less than 70 cents on the dollar from HCFA. Beneficiaries, however, have not been able to file claims with their Medigap insurers because no Medicare claims have been filed.
HCFA claims that to grandfather Nemaha Valley into the CAH program would cost Medicare an additional $100,000. Ryan has no idea where that number came from, and HCFA isn't saying.
Not surprisingly, when I spoke to him last week, Ryan was at his wit's end. "I just want to be treated like every other rural hospital, but for some reason they want to make us a special case," he says.
Now it appears it might all be over.
Roberts' office issued a press release last week announcing an agreement had been reached with HCFA. Ryan, however, hasn't heard anything, and Nemaha Valley still doesn't have a Medicare provider number.
Welcome to HCFA-land.
Thumbs-up To S. Diane Graham, small-business owner and member of the president's Commission on Health Care Quality, also known as the slaughter-of-the-innocents commission. Graham was the only one to vote against the patients' bill of rights and now can be heard in a series of radio ads against managed-care regulation. The ads are bought and paid for by a coalition of business and managed-care groups. The commission was bought and paid for by the Clinton administration.
Thumbs-down To Sen. John Ashcroft (R-Mo.), potential presidential candidate and the only member of the Senate Commerce, Science and Transportation Committee to vote against the tobacco bill. Ashcroft said he doesn't want limits on the future liability of tobacco companies. This package won't fly without it.