The Memory Center

What is Dementia? Dementia involves problems in short-term memory and other cognitive skills such as with language and executive functions–or reasoning/planning ability. There is no blood test, X-ray, or brain scan capable of diagnosing dementia. Instead, neuropsychological tests of memory, language, reasoning/judgment, etc. are used. Once diagnosed, we determine the degree (stage) of dementia and work with the patient's Primary Care Provider (PCP) and/or other specialists to determine the medical etiology or causes of the dementia.

What is done? A home-based assessment typically takes about 2.5 to 3.5 hours of facer-to-face contact. Have all medications (especially over-the-counter drugs, vitamins and supplements–which often contribute to the problem) available, we mean the bottles not any lists. We will review safety and risk factors during the home visit. Testing is painless as we use targeted neurocognitive tests. Immediate feedback is provided to family. Prophylactic strategies to reduce dementia risk are described, as are treatments. Legal implications (Elder Law, Medicaid Estate Planning, driving, etc.) are reviewed. Referrals are made to Day Programs, Elder Law attorneys, assisted living facilities, Geriatric Care Managers, companionship agencies, Elder Services, COA services, Alzheimer's support groups and advocacy, etc. as needed. And, a 5-6 page comprehensive report is sent in a week or two to the family, the PCP and other concerned professionals.

Location: Our main office is at 119 Cedar Street in the medical district near the Cape Cod Hospital, Hyannis for more physically able patients. We often do in-home evaluations as this allows us to see a person in their natural environment. If you come to our office, please bring all bottles of prescribed medications, over-the-counter drugs and any vitamins/supplements with you. Bring the everything you put into your body (other than food or drink), just put it all in a big bag and tote it to the appointment. Do not bring lists–they are of little to no help to us.

Where we travel: We do in-home assessments across Cape Cod. For legal/private work we can travel as far as the Fall River, Taunton, and south shore areas, but we charge for travel. With special preparations we can even go to Martha's Vineyard and Nantucket. Dr. Elovitz is licensed in both Massachusetts and Rhode Island.

How Long? We appear to be the last FT providers in southeastern Massachusetts. More about why it's hard to find a provider for any mental health service in Massachusetts or anywhere else. Consequently, we typically have a 7 to 8 month wait for an insurance reimbursed appointment.

Cash Pay? If you don't have traditional Medicare (e.g., you have a Medicare replacement HMO like Tufts or Pilgrim, or an "Advantage" plan) and we are not on that panel, then we are not obligated to accept that insurance and thus you can pay us directly and then seek reimbursement from your non-traditional Medicare insurer. If you pay cash you will have little or no wait for an appointment, as we reserve time for these appointments–it's how we financially survive as cash pay patients basically subsidize our ability to take Medicare. Sad but true. For the most part we are only obligated to take standard Medicare and BC/BS when primary.

We can also accept private pay for non-Medicare reimbursable services. These appointments are also available quickly–within just week or two. Examples of non-insurance reimbursable services include capacity to: sign documents; drive; alter a Will, assign a HCP or POA, change a trust, live alone, etc. Other non-Medicare payable services include need to: invoke Long-term Care (LTC) insurance; rule-out cognitive problems in order to obtain LTC insurance; help fight with a LTC insurer refusing coverage; etc.

• PLEASE NOTE • If you have traditional Medicare and you pay cash you cannot submit any bill to Medicare in order to seek reimbursement. You will be asked to sign a Medicare document (Advance Beneficiary Notice of Noncoverage, or ABN form) attesting that you understand this, and that you promise not to seek reimbursement. Oddly, Medicare is afraid they may pay you and then later on discover the error and then have to "claw back" the money from you or us. Consider the NYT not long ago reported how Medicare paid a Miami ophthalmologist $21,000,000 in one year. They didn't discover this until several years later via audit (that's how they monitor payments) and tried to "claw back" the money, but he had moved home to Venezuela, which has not extradition with the US, and is reportedly living well.

OK, so what's the cost? If you pay privately, the good news is that you get seen quickly, and the cost is about the same as a root canal and is far less painful. Our charge is at least 50% less than a typical private neuropsychological evaluation, and is far far less than any comparable service in Boston. Call to ask about what cases we must take Medicare for vs. what we can't take Medicare for–as the advantage of paying cash is a fast appointment.

A Primer:

Most transactions in America is straight forward–they involve two parties; i.e., there is a seller and a buyer. Insurance introduces a third party which has its own motivation. The goal of any insurance company is to collect as much as possible from you and pay the provider as little as possible. Medicare is different in that you don't directly pay them, they get a set amount of money from the government (all of us) and the Congress will not increase that amount beyond tiny cost-of-living increases–it's a zero sum game. Thus, to keep primary care providers (PCPs) in the system by increasing their exam reimbursement, Medicare has to decrease some other provider's rate. In our case, Medicare has reduced their allowed rate for neuropsychological testing by about 5% per year for the last 8 years (over 40%) resulting in very few specialists left in New England accepting Medicare for neuropsychological evaluation.

Allowed Rates and Secondary Insurance: Medicare sets an "allowed" rate for every service and then pays 80% of that rate to the provider, leaving a 20% copay to the patient. There is also a yearly $100 deductible for out-patient services. This was to make sure patients has "some skin in the game" so as to discourage them from frivolously doctor shopping over every ache and pain. Much to Medicare's dismay, private insurers starting selling policies to cover Medicare's deductibles and 20% copayments as those copays can get quite high. Medicare does not like this since once you buy such a "secondary" policy (often called a "Medigap" plan), you have no incentive to not go to as many doctors as possible. Don't make the mistake of thinking if Medicare doesn't pay, you can just bill the secondary insurance and see if they will pay. Secondary insurance will only pay if Medicare (the primary insurance) pays, after all if AARP's Medigap plan pays 20% and Medicare pays $0.00, then 20% of $0.00 is zero. Some secondary insurances (notably United Health Care products) won't even pay if Medicare does, having their own rules which second guess Medicare.

What Medicare Pays for:

Medicare's allowed rate is per hour of professional time, which pays for time spent preparing (reviewing medical records sent to us by your doctor) before we see you, interviewing patient and family for problems and historical information, testing, test scoring & interpretation and report writing. It will pay for consultation (feedback) to the patient and family right after the testing.

Medicare allows up to eight hours per neuropsychological testing, but we only bill four to five hours, and rarely as much as six. Keep in mind that only 2–3 hours may be spent working with the patient and family, but we also bill for the additional time before-and-after your visit to prepare, score and interpret and write the five-page report and letters to you, the doctor and other involved parties, etc. So don't be surprised if you receive a Medicare EOB (Explanation of Benefits) saying we billed Medicare for 5 hours, but you recall we were only in your home for 2.5 hours.

Who Pays for What?

With a physician's referral and a diagnosable condition, Medicare will "almost always" pay for 80% of their allowed rate, leaving a 20% copay for you–around $120. In the beginning of the year, Medicare has a $100 deductible for outpatient services so if we are the first doctor to see you, so there could be an additional $100 out-of-pocket charge to you for that deductible. Don't get mad at us, you'd be charged that deductible for any professional you saw early in the year! An exception is that no deductible is charged against your annual wellness exam with your PCP.

Medicare Advantage Plans will also usually pay the Medicare allowed rate and the deductible, with a small co-pay for you. Other such "replacement" products like Harvard-Pilgrim or Tufts HMO's often will not pay us directly, but you can submit our bill to them for possible reimbursement. As noted above our total billed is usually between 4 – 6 hours.

Most secondary insurance (like BC/BS Medex, Banker's Trust, etc.) will cover the 20% copay and yearly $100 deductible. AARP pays the copay but NOT the $100 yearly deductible. HMO products and high deductible plans like some offered by Aetna, Cigna, UBH, etc. not so much... Rarely, are out-of-pocket expenses more than $130 for insurance-based work, but you should check with your insurance provider.

We cannot access your private HIPAA protected information at your insurer for you. In other words, we can verify if you "have" Medicare, but it is impossible for us to check if you have a replacement product or if it is in force. They will not tell us if you have not paid your premium and it was cancelled. Nor, will any insurance tell us how much you have used, etc. as that is private information. We manage our own billing and are over 98% successful in getting the maximum allowable payment from Medicare, but remember third party secondary insurances and Medicare replacement products are purposed to pay us as little as possible from their pocket, which could leave you with a balance.

Why Can't I find Another Provider to see My Sooner?

Medicare is difficult to work with. For those who care, the National Association of Neuropsychologists (NAN) compiled by Dr. Robert Barth (here) in providing advice to neuropsychologists considering working with elders and accepting Medicare. Their advice follows:

"Quite unfortunately, Medicare is an extremely problematic reimbursement system which should probably be avoided if at all possible. The primary problem with Medicare is that it involves numerous regulations which are counter-intuitive and which are are not readily accessible, but which, when violated, will render the doctor vulnerable to accusations of "fraud" (Medicare does not simply accuse people of failing to know the rules, it always uses the word 'fraud') when Medicare discovers that the regulation has been violated.

The risk of being accused of "fraud" is essentially intolerable, and should not be accepted by neuropsychologists. This is the basis of my recommending that neuropsychologists try to avoid Medicare reimbursement. However, this situation is especially intolerable given the fact that most doctors are reimbursed by Medicare at 60 or 70 percent of usual and customary [rate], but neuropsychologists are reimbursed by Medicare at approximately 20 percent of usual and customary [rate]. The rate of reimbursement by Medicare in most states does not even cover the cost of providing the patient with neuropsychological services. When combined with the vulnerability to "fraud" accusations, seeking reimbursement through Medicare is essentially unsupportable from a business perspective.

The situation is made even worse by the unreliability of reimbursement through Medicare. Even though the system claims that some minimal reimbursement is available, is some states the Medicare administrators have demonstrated a concerted effort to avoid ever paying any of the bills. The burden for such failure to pay cannot legally be passed on to the patient, so there is no motivation for the patient to assist the doctor in efforts to gain reimbursement.

This set of circumstances could potentially create a crisis within geriatric service delivery, because of the high need for neuropsychological services in that population, coupled with the almost universal coverage of geriatric patients by Medicare. I have no solutions to offer for this problem at the current time, but I am hopeful that solutions may be developed/proposed as we work to heighten general awareness of the problems. In our practice, when we are asked to see a patient who is covered by medicare, we have found it more economical to provide services on a charity basis rather than to waste time interacting with the Medicare administrative systems–Dr. Barth, for NAN.

Perhaps you can see why we see "private" patients quickly, as we reserve time for them each week. Without cash pay patients we would be unable to see any Medicare patients, as this subsidizes our Medicare work. The crisis in mental health geriatric service delivery is a combination of two facts:

1. Most elders are covered by Medicare and need to use it, and;
2. Medicare has always devalued mental health services, actually calling the reduced fees to social workers, psychologists and psychiatrists the "psychiatric reduction" as compared to any other speciality from nutrition to podiatry to dermatology to whatever.

The result is very few mental health providers willing or able to accept Medicare. An internet search of the Boston area found 1 neuropsychologist in the Brookline area interested in dementia, and looking him up revealed he specialized in motivational psychology! We encounter much desperation, and sometimes out-right anger, about our waiting list.

We thought you might like to know why the problem exists. Patients have screamed at us on the phone and even threatened to sue Dr. Elovitz for malpractice over the waiting period for a loved one to be seen. That anger is understandable, but we believe it should be directed at Congress which refuses to fund Medicare adequately or insist on full parity for mental health services. Remember, at least we take Medicare. The question is why so few others do in mental health. Of course the reason is self-evident; i.e., providers can afford to when Medicaid (usually the poorest payor) pays more then Medicare does for mental health services.

Families and Doctors

We are often asked for advice on services needed to keep a patient living at home. This starts with assessing what activities of daily living or ADL domains need assistance. We can estimate the time and costs for in-home services, and what types (companionship, home health aide, assisted living) of service is needed. We can refer you to Geriatric Care Managers (GCMs) with whom we very often work in SE Massachusetts and on the Islands. We will provide you with referral information for at least a dozen Elder Law attorneys, all of whom we have known and worked with typically for decades.

We advise on options like independent, standard, or memory impaired Assisted Living Facilities (ALFs), and skilled nursing facility (SNF) care. Of course, the goal is the least restrictive type of service possible ideally in one's own home. However, home care can add up to three 8-hour shifts per day, which at $24/hour is $575/day = $17,000 per month. We can often mix services like an Adult Day Care program for one shift, a companion for 2 hours in the morning and 2 hours in the evening, and then use a soporific medication to ensure the patient sleeps through the night with an alarm system for problems that occur during the night. This can save hundreds of dollars per day and be less chaotic than having 5 or 6 different aides coming into the house every week, which can worsen a patient's confusion. We can refer you to help from the VA and Elder Services regarding financial assistance for home and ALF care.

We travel to all independent and assisted living facilities on the Cape routinely and we know the resources. If you are feeling overwhelmed and need help negotiating among the ALF options vs. home care we can refer you to consultants who will work with you.

Due to the extremely low Medicare allowed rates for all mental health services, we know of no private psychiatrists taking new patients with Medicare in Massachusetts. Yep, you read that right! Nor, do we know of any other specialized dementia assessment experts we can refer you to, outside of the Boston area–which often means students performing services. Consider that psychotherapists make significantly less money from Medicare seeing seniors than they do seeing from Medicaid/MassHealth indigent people and you'll start to understand the situation. Mental Health has always been devalued in the Medicare system, as described elsewhere on this website. We can assist in arranging Medicare reimbursed mental health services, (counseling, neuropsychology and psychiatry) but there may be a wait...