In case you haven't figured it out yet, HCFA has been robbing physicians blind via various bureaucratic schemes for the past decade or so. After instituting fee freezes, Maximum Allowable Actual Charges (MAAC) and Limiting Charges, HCFA implemented the Resource-Based Relative Value Scale (RBRVS). RBRVS was nothing more than a complex numerical scheme designed to reduce payment to physicians for services rendered. This was followed by bundling initiatives, "correct coding" initiatives ("correct" according to HCFA's definitions), prepayment reviews, postpayment reviews, focused medical reviews, Physicians At Teaching Hospitals (PATH) reviews, E&M Guidelines, site of service reductions (even though fixed costs are often little affected by the site where services are rendered) and various secret schemes which utilize frequency of services, bundling of unrelated services, ICD-9CM-linking and other quasi-"medical necessity" criteria to snipe at physicians.

To enforce these payment reduction provisions HCFA created an environment of fear for physicians via such programs as Operation Restore Trust (which many physicians have referred to as Operation Destroy Trust), offering your senior patients bounties and Qui Tam riches for taking a few free shots at their doctors. Physicians have become the balloons on the board at the carnival, and HCFA is encouraging all government-entitled players to step up to the booth and throw as many darts as they wish, no charge. Pop a balloon, and the player wins a prize. All because government has promised an entitlement that it cannot pay for. Government must thus rob physicians to fulfill its promise to its dependents.

Despite the ruling in United Seniors Association v.Shalala that Advanced Beneficiary Notices (ABNs) can now be used routinely for services which are "medically warranted" but which HCFA considers to be not "reasonable and necessary" (if you can figure out the difference between the two please tell me), HCFA has yet another trick up its sleeve to overcome your ability to protect yourself from financial loss. I refer to HCFA's new scheme as "covered but included in." If the pattern of attack in recent years is any indication, it can be predicted that within the near future, there will be very few "non-covered" services under the Medicare program. Most, if not all services will be "covered but included in" some other service. This will insure HCFA's goal of totalitarian control over all aspects of medicine for Medicare dependents. This will entitle physicians to provide as many services to their patients as they wish at the physician's own expense. HCFA will dictate that all other services are "included in" a designated low-paying service and must be provided free of charge to the patient under penalty of sanctions. In effect, HCFA is aiming to side-step the provisions forbidding involuntary servitude (slavery) as set forth in the 13th Amendment to our Constitution. Physicians will thus be given the choice of being a target balloon at the fair, or a slave. This is what I call "green collar" crime-criminal acts committed by government bureaucrats using bureaucratic tools. As Bastiat said, "see if the law takes from some persons what belongs to them, and gives it to other persons to whom it does not belong. See if the law benefits one citizen at the expense of another by doing what the citizen himself cannot do without committing a crime" (The Law by Frederic Bastiat, c. 1850). This is the very definition of legalized theft, legalized plunder or green collar crime.

The solutions are clear: Don't participate in Medicare, opt out if you can, and if you can't opt out, FIGHT BACK! Don't let the bureaucrats take a single shot at you for free. Contest all wrongful actions. Obtain the names and addresses of your regional HCFA bureaucrats, and write letters of complaint to them citing the wrongful and/or illegal actions of your Medicare carrier. Send copies of the letters to central HCFA bureaucrats and to your Congressmen (with patients' names blacked out) for each and every wrongful thing they do to you. Demand that they respond to each and every piece of correspondence. Demand that they write letters to patients to explain what wrongful action was taken against you. Show these tyrannical bureaucrats that you are neither a target balloon nor a slave! Show them that you are a Medical Warrior to be reckoned with, a member of the AAPS-the Delta force of Medicine!

Pamphlet No. 1068, October, 1999