Ah...The 'Crisis' Continues.......

[Excaliber]

...delima in the coconut

That pretty well sums up Hawaii's business plan.

[Anthony]

There is some good info here, and also some misinformation.

Medicare is a government run HMO plan. Unless a medical provider (hospital-doctor) has signed a contract with Medicare, the medical provider will not get a penny from Medicare for any services, as Medicare has no out of network benefits. Hospitals and doctors know that patients in general will not go to them unless the services are covered, which is why practically all hospitals and doctors are signed up with Medicare, and have agreed to accept medicare reimbursement rates for services rendered, at whatever rate Medicare has deemed to be appropriate and reasonable, with the balance of the charges to be written off by the medical provider. Medicare designed their plan in such a way so the enrollees would not overuse their benefits. They did this by setting the system up as a 80/20 plan, where the patient is still responsible for the 20% of the allowed amount. So, for an example, for an intial patient visit of $ 120, medicare would pay $96, and the patient would be responsible for $ 24. For a typical established office visit of $45, medicare would pay $36, and the patient would owe $9.

Medicare until recently did not cover any prescriptions, so in the past, the significance of any supplemental plan was to also cover a good portion of the prescription costs, and for a bonus, the extra 20% that the patient would normally be responsible for.

There are Insurance based Medicare plans, where as an enrollee, you decide to sign up with an insurance company, say BC/BS (Blue Cross and Blue Shield), their Medicare plan. What happens now is that you have agreed to sign up for, and are enrolled in the BC/BS Medicare HMO plan, and will now only be covered by medical providers who have signed up with BC/BS's Medicare plan, and not just any doctor who is signed up with Medicare. What is happening is that Medicare is paying BC/BS a set feee per month, for every individual on the BC/BS medicare plan, and Medicare stipulates that BC/BS must now be responsible for all medical services. BC/BS has bet that they will spend less on medical care for that particular enrollee than what Medicare is paying them, and therefore will make a profit. Often, they will have more benefit limitations in place than general Medicare, as well as the limitation on which physicians the enrollee can go to, whre as with standard Medicare, the enrollee has his choice of every doctor who has an agreement with Medicare.

Medicaid is also a government run HMO plan for the poor, but run and funded jointly by the Federal and State governments. The difference is that Medicaid covers basically 100% of the cost of any medical services, and the enrollees generally owe nothing, either for medical care or prescriptions. Again, like Medicare, the medical providers have to sign an agreement with Medicaid to be paid for any services, at a rate as set by Medicaid, which is usually about 70% of the medicare rate, which is why there are a significant number of doctors who opt out of providing care under this plan. Enrollees can have Medicaid benefits without Wellfare benefits (general living supplementation).

The bottom line is that if you are on Medicare, and healthy, basically on little or no medications, you may be better just to have basic medicare coverage with no supplemental insurance. If you have some illnesses and take considerable medications, you may be best to buy a supplemental plan, to cover the additional costs, the extra 20% and prescription costs. If you don't have the money to buy supplemental insurance, then you are better off to sign up with one of these insurance medicare plans, where in general, the vast majority of the medical costs and prescription costs will be covered, although you will be limiting your care as to which doctors, hospitals, and treatments you may be able to receive.

[Dan40]

Originally Posted by Anthony

There is some good info here, and also some misinformation.

Medicare is a government run HMO plan. [WRONG] ANY Medicare beneficiary may see ANY Doctor and/ or any hospital in the US. No change in coverage.

Unless a medical provider (hospital-doctor) has signed a contract with Medicare, the medical provider will not get a penny from Medicare for any services, as Medicare has no out of network benefits. [WRONG] False from beginning to end, SEE BLUE below

Hospitals and doctors know that patients in general will not go to them unless the services are covered, which is why practically all hospitals and doctors are signed up with Medicare, and have agreed to accept medicare reimbursement rates for services rendered, at whatever rate Medicare has deemed to be appropriate and reasonable, with the balance of the charges to be written off by the medical provider. Medicare designed their plan in such a way so the enrollees would not overuse their benefits.
[INCOMPLETE AND MISLEADING]
If ANY US Doctor treats ANY Medicare beneficiary, for any reason, the doctor is BOUND by Medicare rules. If the Doctor has NO contract with Medicare and does NOT accept Medicare assignment then he may charge 15% over the Medicare approved amount, and he may not bill the patient for any more than that OR make a separate agreement. AND, in an emergency, he MUST treat the patient and be bound by the rules.

They did this by setting the system up as a 80/20 plan, where the patient is still responsible for the 20% of the allowed amount. So, for an example, for an intial patient visit of $ 120, medicare would pay $96, and the patient would be responsible for $ 24. For a typical established office visit of $45, medicare would pay $36, and the patient would owe $9.

Medicare until recently did not cover any prescriptions, so in the past, the significance of any supplemental plan was to also cover a good portion of the prescription costs, and for a bonus, the extra 20% that the patient would normally be responsible for. [WRONG]
Prior to PART D only a couple of the 10 Medigap policies covered Rx and those plans were outrageously expensive and offered very poor coverage. I do not remember the exact wording but they had a $250 deductible, then only paid 50% of the drug cost [WITH NO PRICE PROTECTION] and only covered up to $2000, or $4000. For that coverage, the premiums were $1800 to $3600 higher than any other plan. So ONLY if the insured absolutely MAXED out the Rx limit, would they break even with the premium.

There are Insurance based Medicare plans, [ Point of order, Insurance based Medicare plans are the 10 standard Medigap plans] where as an enrollee, you decide to sign up with an insurance company, say BC/BS (Blue Cross and Blue Shield), their Medicare plan. What happens now is that you have agreed to sign up for, and are enrolled in the BC/BS Medicare HMO plan, and will now only be covered by medical providers who have signed up with BC/BS's Medicare plan, and not just any doctor who is signed up with Medicare. What is happening is that Medicare is paying BC/BS a set feee per month, for every individual on the BC/BS medicare plan, and Medicare stipulates that BC/BS must now be responsible for all medical services. BC/BS has bet that they will spend less on medical care for that particular enrollee than what Medicare is paying them, and therefore will make a profit. Often, they will have more benefit limitations in place than general Medicare, as well as the limitation on which physicians the enrollee can go to, whre as with standard Medicare, the enrollee has his choice of every doctor who has an agreement with Medicare.
The reason Medicare pays a monthly fee to an insurance HMO is that in joining a HMO the person RESIGNS from Medicare. So Medicare has no more risk from that person. Then Medicare sends that person's Medicare premium deducted from their Soc. Sec. check to the HMO. There WERE a few advantages to the VERY poor as they did cover Rx in the beginning, with only a small co-pay. Now the HMO's charge a monthly premium over and above the Medicare payment they receive and they have much higher co-pays on Rx and much lower limits on yearly Rx totals.

Medicaid is also a government run HMO plan. The difference is that Medicaid covers basically 100% of the cost of any medical services, and the enrollees generally owe nothing, either for medical care or prescriptions. Again, like Medicare, the medical providers have to sign an agreement with Medicaid to be paid for any services, at a rate as set by Medicaid, which is usually about 70% of the medicare rate, which is why there are a significant number of doctors who opt out of providing care under this plan. Unlike Medicare which is a 100% federal funded program, Medicad costs are shared by both the Federal and State governments (tax payers). I'm not a Medicaid expert, but the Feds fund the money to the State and the State administers the payout.

The bottom line is that if you are on Medicare, and healthy, basically on little or no medications, you may be better just to have basic medicare coverage with no supplemental insurance. If you have some illnesses and take considerable medications, you may be best to buy a supplemental plan, to cover the additional costs, the extra 20% and prescription costs. If you don't have the money to buy supplemental insurance, then you are better off to sign up with one of these insurance medicare plans, where in general, the vast majority of the medical costs and prescription costs will be covered, although you will be limiting your care as to which doctors, hospitals, and treatments you may be able to receive.

[not quite right] A person can have a PART D Rx plan without having a supplement plan, I do. And a person has to be really ill to make a supplement worthwhile. The wife and I together have 11 years on Medicare without a supplement. All of our 20%'s and PART A deductibles together DO NOT add up to a single years supplement premiums for either ONE of us.

[Anthony]

Dan, Medicare is really a HMO. To get what they call "out of network" medicare benefits, you still, as a provider still have to register with medicare as a "non-participating" provider, at which time you agree to accept the "non-participating" fee schedule, 15% more than the standard rate. If you never register with medicare, then you charge the patient anything you want, and are not bound by any limits, and can accept anything you want as a "true" out of network provider. If it walks like a duck, quacks like a duck, then it is a duck (HMO). What medicare calls "out of network" is really not "out of network". Any medicare beneficiary can see any doctor they want, but, if that doctor is not registered with medicare at all, then medicare pays that doctor nothing. There is nothing that states any doctor has to treat anybody in an emergency, only the ER is mandated to treat any patient that enters the ER. If I were not signed up with medicare, I could easily refuse to treat any medicare patient that I did not want to treat, for whatever reason.

As far as supplemental insurances ( I'm talking the 1980's-1990's, way before part D), I believe AARP, and various BC/BS plans, and other insurance companies have had prescription coverage, whether 50% , more or less, brand name vs. generic, I'm sure there were differences, but way before part D, there were numerous supplemental plans, called a secondary. Medicare primary, another insurance secondary. That's what I was talking about, not medigap.

With Medicaid, I believe there's an arrangement with each state, such that the Fed matches a percentage of what each state puts into their Medicaid program, and there may be some other specific requirements as well. Medicaid is like Medicare as well, a HMO. If you are not registered with your states Medicaid program, you can charge and bill medicaid patients anything you want. I know this, because I opted out of my state's medicaid program for several reasons, about 10 years ago, and have been charging those patients cash, what I deemed to be a fair and reasonable amount.


As far as a patient resigning from medicare, I wouldn't call it resigning, as all of these patients still are under many medicare guidelines. I would call it choosing an insurance based medicare plan instead of standard medicare, which they have to agree to for a period of 1 year. And, I don;t believe Medicare sends this persons premium to the chosen insurance-medicare plan. I believe medicare still collects that premium from the patient, but in a separate arrangement, pays that insurance company on a negotiated amount per enrollee, a number that I believe is not the same as the patient's premiums, but actually a higher value.

If you are unfortunate enough to be ill, and require a great deal of multiple procedures, tests, then a supplemental plan would likely benefit you. If you are seeing 4 different doctor's every month, constantly getting multiple tests done, that 20% that you owe will add up fast

[DAVID GAGNARD]

On the other hand, since they do exist, I’m thinking that it would be fun to start a White Caucus, along with a National Association for the Advancement of White People (NAAWP). That would at least be entertaining for a short time and may point out how silly it is the have Black and Latina organizations at this time in American. The ironic scenario in the future may be that once Latinas take over America a white organization just may be necessary to do whatever it is that the NAACP does for blacks at this time - I'm really not sure what that is other than collect dues.

We had a "good ole boy" from down here in Louisiana do just that, the NAAWP, remember David Duke????????? he was a Louisiana state representative at the time and ran for governor and gave Edwin Edwards a reallllllllll run for his money. His main problem was he was at one time a big wheel in the KKK and a white supremacist, he couldn't shake that part of his younger days no matter how hard he tried.......He was called everything in the book and then some by all the black organizations/leaders for forming the NAAWP!!!!!!!!!!!!!

BTW: I didn't agree with him and his general ideas, but he did have one good idea/ideal, do away with race and race quotas, hire the best person for the job, regardless of race/religion/gender or anything else, very simple plan.........

As for the NAACP, there are a real piece of work........Last year the New Orleans district elected a Vietnamese refugge from the war to replace the "great" William Jefferson (aka; money in the freezer Jefferson), so, being his district is majority black, when he got to Washington DC, he decided to join the black cacus, since he is representing a majority black district.....when he tried, they threw him out on his ear telling him it was for blacks only for the advancement of blacks only and he was neither....now just exactly whom is PREJUDICE here ??????????????????

David

[Dan40]

Originally Posted by Anthony

Dan, Medicare is really a HMO. To get what they call "out of network" medicare benefits, you still, as a provider still have to register with medicare as a "non-participating" provider, at which time you agree to accept the "non-participating" fee schedule, 15% more than the standard rate. If you never register with medicare, then you charge the patient anything you want, and are not bound by any limits, and can accept anything you want as a "true" out of network provider. If it walks like a duck, quacks like a duck, then it is a duck (HMO). What medicare calls "out of network" is really not "out of network". Any medicare beneficiary can see any doctor they want, but, if that doctor is not registered with medicare at all, then medicare pays that doctor nothing. There is nothing that states any doctor has to treat anybody in an emergency, only the ER is mandated to treat any patient that enters the ER. If I were not signed up with medicare, I could easily refuse to treat any medicare patient that I did not want to treat, for whatever reason.

As I stated above, Medicare will pay the 80% to ANY Doctor in the US. There is no in or out of network. YES a Doctor can refuse to make an appointment and treat a Medicare patient. But if he does treat the Medicare patient then he is bound by the Medicare rules with or without an agreement with Medicare. And he/she WILL be paid by the Medicare administrating agency, IF the Doc files a claim with Medicare. I specialized in Senior health care insurance, and taught the rules to agents, Chambers, and Senior groups.

As far as supplemental insurances ( I'm talking the 1980's-1990's, way before part D), I believe AARP, and various BC/BS plans, and other insurance companies have had prescription coverage, whether 50% , more or less, brand name vs. generic, I'm sure there were differences, but way before part D, there were numerous supplemental plans, called a secondary. Medicare primary, another insurance secondary. That's what I was talking about, not medigap. I was licensed with 50 or 60 insurance companies that offered Medicare Supplement policies. For many many years now there have been 10 Supplement plans STANDARD to ALL insurance companies. Not a single word of difference in all the plans of all the companies.


Again as I said above some plans [J & K] had Rx coverage prior to PART D. And as I said above the coverage vs the extra premiums was pitiful

Medicare Supplement Policy is the official name of any the 10 supplemental plans.
Medigap policy means the exact same thing. As does Med Sup, or just plain, supplement. All short, or slang, or nick names, for the same thing.
Our agency had tens of thousands of these policies in force and never had an errors and omissions claim against us. I'd say that meant we KNEW of what we spoke.

With Medicaid, I believe there's an arrangement with each state, such that the Fed matches a percentage of what each state puts into their Medicaid program, and there may be some other specific requirements as well. Medicaid is like Medicare as well, a HMO. If you are not registered with your states Medicaid program, you can charge and bill medicaid patients anything you want. I know this, because I opted out of my state's medicaid program for several reasons, about 10 years ago, and have been charging those patients cash, what I deemed to be a fair and reasonable amount.
I did not sell Medicaid, or teach it, or care about it, so I cannot and do not wish to argue with you about it. And yes, I know there is nothing to be sold with Medicaid.

As far as a patient resigning from medicare, I wouldn't call it resigning, as all of these patients still are under many medicare guidelines. I would call it choosing an insurance based medicare plan instead of standard medicare, which they have to agree to for a period of 1 year. And, I don;t believe Medicare sends this persons premium to the chosen insurance-medicare plan. I believe medicare still collects that premium from the patient, but in a separate arrangement, pays that insurance company on a negotiated amount per enrollee, a number that I believe is not the same as the patient's premiums, but actually a higher value.

I did not say the person was out of Medicare forever, but they do technically resign from it while in an HMO. Yes the Medicare premium is still deducted from the Social Security check, I never said it was not. But then it and possibly MORE, not less is sent to the HMO company.

If you are unfortunate enough to be ill, and require a great deal of multiple procedures, tests, then a supplemental plan would likely benefit you. If you are seeing 4 different doctor's every month, constantly getting multiple tests done, that 20% that you owe will add up fast

I personally have/had [many have passed] thousands of Medicare Supplement clients and the agency has/had multiple thousands more. In the 10 to 15 years a client normally lives with a Med Sup policy, I doubt 100 received payouts equal to the premiums paid in.
I sold the policies because people were GOING to buy them in any case, but when I told them they didn't need it, it was the TRUTH. As was EVERY word that came out of my mouth. I have a very serious problem with lying from anyone about anything.

Since you are stating you are a Doctor, would you tell me if you have your own billing and collections dept. or do you contract that out? And do you accept Medicare assignment or not?

[Anthony]

Dan, I am a doctor and do my own billing.

But first I want to talk about your medicare premiums. Although I'm not on medicare, my parents are, and obviously pay premiums. Obviously yours and my parents premiums go to help pay for medicare benefits. But, at the same time, medicare is also heavily subsidized by the working class. Ever note that Medicare tax on your W2's. Although I haven't seen the breakdown, I bet the majority of Medicare funds come from the working class, not the premiums from medicare enrollees. I can't remember the exact figure, but I think medicare pays these insurance companies about 3X your monthly medicare premium to take "acceptable" care of you; what they believe is acceptable and what medicare believes is acceptabel may be two different things. These insurance companies entice you with prescription benefits, lower deductables, whatever, to join their program and give up basic medicare, as they think they can make a profit by having doctors like myself accept lower rates than medicare. For a while, they were picking and chosing which medicare enrollees were the healthiest, since they knew those healthier enrollee's wouldn't cost them alot of money. Believe me, it's a money maker for Aetna, Kaiser, BC/BS, etc.

I do accept medicare assignment, and I am a participating provider. But, I can tell you, when you first sign up for medicare, as a provider, you have an option of whether you want to sign up as a "participating" provider, or a non-participating" provider. If you sign up as a participating provider, you agree to accept the standard Medicare rates, and the money is sent to me, the provider. As a non-participating provider, I still participate with medicare, and I agree to the medicare 15% higher rate limits, but the patient will be responsible for more of the percentage, and medicare instead sends the payment to the enrollee, meaning I, as the doctor, would need to have the medicare enrollee pay me up front for the 15% higher allowed amount, bill medicare, and then medicare will then reimburse the patient for their portion. So even if a provider is a" non-participating", he still is participating to a different degree. Dan, I have realized from your posts that you have a wealth of information. Believe me, I run my practice like a business now, and at one point had thought about changing my status to non-participating, but that's going to turn off patients badly, overall hurting my business as well as collecting money. That's why very few doctor's are non-participating. Believe me, I didn;t learn anything about this in med school or residency.

here's a good explanation. Although it talks about audiologists, the same is true for doctors.

http://www.audiologyonline.com/askex...uestion_id=523


What is the difference between participating and non-participating providers for Medicare? What are the options for audiologists in being able to participate in either manner?




Every audiologist must decide if they should participate or not with Medicare, as well as, other third party payors. Most seniors and people in general do look for providers who accept their insurance, so choosing not to participate can have devastating negative affects on a healthcare business. That said, randomly participating with all third party payors without understanding the terms of that participation including reimbursement levels and potential risks can also be devastating to an audiology business.

With Medicare, audiologists basically have three choices; participate as a “participating provider”, participate as a “non-participating provider”, or “opt-out”. One’s chosen status with Medicare will dictate who you bill, how much you collect for a given procedure, the responsible party, whether or not you must have a “private contract” with beneficiaries, and what that private contract must include to name a few things.

Although Medicare is a federally funded program, it is also administered by state or regional intermediaries who have been know to interpret Medicare (federal) policy differently. It is always wise to identify, contact, and document in writing any information that is provided to you by your intermediary.

As a general rule:

“Participating Providers” accept assignment from Medicare. The provider bills Medicare at their usual and customary fee; however, Medicare pays the provider 80% of the “allowed amount” for each CPT code. Patients are responsible for 20% of the allowed amount and this 20% should not be waived. The provider cannot bill patients for amounts in excess of the allowed amount and must write off the difference between the allowed amount and usual and customary fees.

“Non-participating Providers” do in fact participate with Medicare. Non-par providers generally do not accept assignment on a regular basis; however, can choose to accept assignment on a case-by-case basis and be reimbursed at the non-par level. Non-par providers must bill Medicare, but Medicare reimburses the patient versus the provider. The amount patients receive from Medicare will be 5% less than the par-allowed amount and the patient pays the provider for services rendered.

A non-par provider can legitimately increase reimbursement by charging the “limiting fees”, which represent the maximum allowable reimbursement. Limiting fees, as well as, par and non-par allowed fees can vary by region, state, and even city and can be found at www.cms.gov.

“Opting-Out” If an audiologist sees Medicare beneficiaries and chooses not to participate with Medicare, they must opt-out and in many states sign an opt-out affidavit. That opt-out affidavit also includes private contract requirements. If you choose to opt-out, you cannot re-apply for Medicare participation status for two years. It is very important to understand the impact third party payor participation can have on one’s practice before committing to any level of provider status or choosing to opt-out.

Note: “Audiologists” are not specifically listed under physicians or practitioners who are eligible to contract privately; however, audiologists do meet the criteria of being “legally authorized to practice by the state and otherwise meet Medicare requirements”. Various Medicare intermediaries can interpret this differently.

Kathy Foltner, AuD, is CEO of AuDNet, Inc. She also teaches courses in Practice Management and Basic Business at Rush University Medical Center and PCO. Dr. Foltner can be reached at kfoltner@aud-net.com or 312-593-1787.

For more information about AuDNet, visit www.howtohear.com/ or the AuDNet Web Channel on Audiology Online

[Anthony]

Dan, my understanding of a HMO is a health insurance plan that has no out of network benefits, that is, if I, as a medical provider, have not signed any agreement with that insurance company, then they will generally not pay for any services, either reimburse me or the patient. It is my understanding that an insurance plan that has out of network benefits will pay a provider or reimburse the enrollee for medical services either based upon the "true" charged amount, or the UCR rate even though that provider has never signed any agreement with the insurance comapny. PPO's generally have true out of network benefits, that will reimburse a provider/enrollee, as long as the provider I believe is licensed in that state to provide services.

If a provider is not signed up with either Medicare or Medicaid, no reimbursement will be made to either the provider or the enrollee. It's completely between the enrollee and the provider. I.E. No out of network benefits. HMO like. Medicare and Medicaid are both really like government run HMO's.

[Dan40]

Originally Posted by Anthony

Dan, my understanding of a HMO is a health insurance plan that has no out of network benefits, that is, if I, as a medical provider, have not signed any agreement with that insurance company, then they will generally not pay for any services, either reimburse me or the patient. It is my understanding that an insurance plan that has out of network benefits will pay a provider or reimburse the enrollee for medical services either based upon the "true" charged amount, or the UCR rate even though that provider has never signed any agreement with the insurance comapny. PPO's generally have true out of network benefits, that will reimburse a provider/enrollee, as long as the provider I believe is licensed in that state to provide services.

HMO's, PPO's, "Networks" are very important to health insurance BEFORE one reaches age 65. There was not and is not any mention of them in Medicare other than to allow them in the supplemental insurance coverage.

If a provider is not signed up with either Medicare or Medicaid, no reimbursement will be made to either the provider or the enrollee. It's completely between the enrollee and the provider. I.E. No out of network benefits. HMO like. Medicare and Medicaid are both really like government run HMO's.

Doc, you write your scripts and lance the boils. That is your honorable PROFESSION.
But please stop denigrating my PROFESSIONALISM as an insurance expert.
And I promise not to reduce any fractures or palpitate any livers.
I may check some breasts for lumps however, I'm not too old for that.

[Anthony]

Originally Posted by Dan40

Doc, you write your scripts and lance the boils. That is your honorable PROFESSION.
But please stop denigrating my PROFESSIONALISM as an insurance expert.
And I promise not to reduce any fractures or palpitate any livers.
I may check some breasts for lumps however, I'm not too old for that.

Dan, Dan, Dan.

I actually feel a little insulted if all you think a doctor does is to write scripts and lance boils. That maybe true for some docs, but not for me, and many other docs.

I guess your response is your way of saying you were wrong, and I was right.

[Dan40]

Originally Posted by Anthony

Dan, Dan, Dan.

I actually feel a little insulted if all you think a doctor does is to write scripts and lance boils. That maybe true for some docs, but not for me, and many other docs.

I guess your response is your way of saying you were wrong, and I was right.

No, that was my way of saying that you are so uninformed that I no longer wish to read any more of your ignorant ramblings. And if your medical knowledge equals your Medicare knowledge, writing scripts and lancing boils may be well over your head!

Those that wish to think you were right, are 100% free to follow your advice.
Those that think I am right are 100% free to follow my advice.
The next insult is completely yours as I have no interest in anything you have further to utter.

[Anthony]

Dan, you may be an excellent insurance salesman, but that's all you are. You don't understand the business of medicaine, how a patient's insurance plan translates to the care they ultimately get, how and why providers sign up with whatever insurance plan, or how providers make their money.

Go sell another plan. Leave the medical business and care to me.

[Dan40]

Originally Posted by Anthony

Dan, you may be an excellent insurance salesman, but that's all you are. You don't understand the business of medicaine, how a patient's insurance plan translates to the care they ultimately get, how and why providers sign up with whatever insurance plan, or how providers make their money.

Go sell another plan. Leave the medical business and care to me.

Ahhh Yes, you are SO superior and I only have a Masters Degree in Health Care Finance at my disposal.

But you, the applier of leeches and mumbler of arcane incantations, could further my knowledge by informing me as to what exactly MEDICAINE might be. I think it is unfair for you to use your half vast knowledge to introduce a new word at this juncture.

[Dan40]

And now could we get back on point and discuss what the Stand Up Bullsh!tter had to say in tonights litany of silly lies?


My first question would be, why do we have to wait for a new health care plan to stop all the fraud and waste in Medicare and Medicaid. If there is enough there to nearly fund a Trillion dollar new health care plan, should we stop the fraud and waste even without passing a health bill?

[csx4910]

Both of you have some valid points but just to add another opinion - I am a heath care professional (Respiratory Therapist) who own a durable medical equipment company (paid under part b) My insurance salesman you are quite wrong that the Medicare replacement plans(or whatever cool name you all want to give them) are not HMO's. They are much closer to the HMO family at least on the on the part B side than a PPO plan. The medicare replacement plans are NOT open to any medicare participating provider, since they give exclusive contracts to the lowest bidder to increase their profit. They restrict the Medicare patient from their choice (a Medicare hallmark) The contracts are capitated meaning that the provider is paid by the # of members a certain dollar amount whether they provie nothing, a beside commode, or a $15000 power wheelchair. The incentive is for the providing company to provide the least amount of service possible to maximize profit and to keep the costs fixed for the insrunace compnay. Often, senoirs find out too late that their premiums are higher with less coverage than they had with Medicare.

You sell the plans - we have to deal with what the reality of reimbursement with Medicare and the other plans after the fact. Would you be so hot to trot for these if you didn't receive a commission for them? What if you got a commission for selling Medicare? Would that change your story? And by the way, If I am signed up as a medicare provider I will NOT get paid if I treat and provide equipment for a Medicare patient.( I am not sure where you pulled that one from!)
Ron
Valley Respiratory Services

[Dan40]

Originally Posted by csx4910

Both of you have some valid points but just to add another opinion - I am a heath care professional (Respiratory Therapist) who own a durable medical equipment company (paid under part b) My insurance salesman you are quite wrong that the Medicare replacement plans(or whatever cool name you all want to give them) are not HMO's. They are much closer to the HMO family at least on the on the part B side than a PPO plan. The medicare replacement plans are NOT open to any medicare participating provider, since they give exclusive contracts to the lowest bidder to increase their profit. They restrict the Medicare patient from their choice (a Medicare hallmark) The contracts are capitated meaning that the provider is paid by the # of members a certain dollar amount whether they provie nothing, a beside commode, or a $15000 power wheelchair. The incentive is for the providing company to provide the least amount of service possible to maximize profit and to keep the costs fixed for the insrunace compnay. Often, senoirs find out too late that their premiums are higher with less coverage than they had with Medicare.

You sell the plans - we have to deal with what the reality of reimbursement with Medicare and the other plans after the fact. Would you be so hot to trot for these if you didn't receive a commission for them? What if you got a commission for selling Medicare? Would that change your story? And by the way, If I am signed up as a medicare provider I will NOT get paid if I treat and provide equipment for a Medicare patient.( I am not sure where you pulled that one from!)
Ron
Valley Respiratory Services

Try rereading from the top and add comprehension. IF by Medicare replacement plans [A TERM NEVER USED BY ME] you mean the actual HMO's a person can choose instead of Medicare. Then yes, they certainly are HMO's. If you mean any of the 10 standard Medicare Supplemental Plans, then no they are not HMO's. There is an alternative to the 10 standard Medicare Supplemental plans that is somewhat PPOish. Most of them are the same for part B, but have a participating hospital list under part A. These PPOish plans are called Medicare SELECT plans.

Then there are Medicare ADVANTAGE plans

From Medicare

Medicare Advantage Plans (like an HMO or PPO) See page 6.
• Run by private insurance companies approved by Medicare. • Provide your Part A and Part B coverage, but can charge different amounts for certain services. May offer extra coverage and prescription drug coverage for an extra cost. Costs for items and services vary by plan. • If you want drug coverage, you must get it through your plan (in most cases). • You don’t need a Medigap policy.

Those plans might be your complaint, or maybe your complaint is that Medicare [not Medicare supplemental insurance] pays according to a fee schedule. If so, that is the US Govt's plan not any insurance company plan.

Also from Medicare:

Types of coverage that are NOT Medigap policies
• Medicare Advantage Plans (Part C), like an HMO, PPO, or Private Fee-for-Service Plans • Medicare Prescription Drug Plans (Part D) • Medicaid

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A standard Medigap or Medicare Supplement plan and the Medicare Select plans ALL pay 20% of the Medicare approved amount [fee schedule] for PT and/or durable med. equipment. They are in no way involved in determining Medicare's fee schedule. If Medicare itself approves $200. the supplemental insurance pays $40. They do not care what the retail value could be, they do not determine if Medicare is over or underpaying for the treatment. They have to pay 20% of the Medicare approved amount.

[csx4910]

But you still didn't answer my question of how much of a commission you get for selling them and would your answers change if you were able to "sell " people to sign up with straight Medicare?? Obvioulsy your bias is slanted on how you get paid. Nothing wrong with that but at least be honest with us (and yourself) in admitting it. You dont know the first thing about dealing with Reimbursmeent and payment from Medicare if you actually haven't done it.

[Dan40]

Originally Posted by csx4910

But you still didn't answer my question of how much of a commission you get for selling them and would your answers change if you were able to "sell " people to sign up with straight Medicare?? Obvioulsy your bias is slanted on how you get paid. Nothing wrong with that but at least be honest with us (and yourself) in admitting it. You dont know the first thing about dealing with Reimbursmeent and payment from Medicare if you actually haven't done it.

Of course I got paid, that is a given. Same as you get paid for what you do. I'm happy to help people for money. No money, they're screwed.
Reimbursement from Medicare and non-Medicare Insurance Companies, I probably know more about it than you do. The other half of this household is a semi-retired consultant on just that, Reimbursement! I even know how to spul it. Before retiring my wife ran medical billing companies and has held the position of Chief Financial Officer of a large hospital and the same position in a large hospital chain.
I sympathize with you about The Gov't. run Medicare reimbursement rates. I have held in my hand many times the actual 'schedule of benefits.' and saw that it often times is ridiculously low. But that, not Medicare Supplement Insurance is the source of your complaint. As previously stated, they must pay 20% of the Medicare approved rate and they do not get to determine that Medicare rate. The Gov't. does.
In "normal" insurance, many people complain about long waits to be paid. Homeowners, auto, non-Medicare health insurance, even life insurance. That is because the companies must investigate the claim to verify that it is real and they must pay it. They won't if they can get out of doing so.
But not in a Medicare Supplement. Medicare determines if the claim is payable and notifies the insurance carrier of their responsibility to cover the 20%. Investigation over!
I also sympathize with you about HMO's [And I could have made 2.5 times more commission selling HMO's, BUT NEVER REPRESENTED ONE] The reason? In our area more than a dozen Medicare HMO's came in, signed up VERY few Doctors, none of the 'known Doctors' and eventually closed their doors. When they first started up I told some of my poorest clients to drop their supplement [that I was receiving a commission on] and to join the HMO, reason no premium and Rx coverage. I did not sell them or make money, I lost commission. Then the performance of these HMO's made me regret giving 'free advice'. They instituted premiums for coverage period, and higher premiums for Rx coverage and then they close up and the people are left terrorized with no Supplemental coverage. [I was never a good enough salesman to convince people that they did NOT need what EVERYONE else said they MUST have] So after a year or 2 in a HMO they had to get a new Supplement. Scenario: Senior buys Med Sup at age 65, his "attained age." He will be 65 forever with that company. Keeps his coverage for 3 years, then drops it to join a HMO. 2 years later the HMO folds. Now he buys a Med Sup again. Now his "attained age" is 70 and he with pay the premium for 70 forever with that company. [even if it was with his first Med Sup company.]

And in agreement with BOTH of you, I have often said that the care a senior receives under Medicare is terrific, but ONLY because the low paying Medicare is propped up by the in place, for profit, health care system we all now enjoy. Your non-Medicare patients pay you enough, or nearly enough, to allow you to treat the low reimbursement Medicare patients. A total Gov't system takes over and all reimbursement would be at those low rates which means you would be selling real estate, or UGH, insurance, or building Cobras, or selling shoes. But you would not be able to afford to be in the medical business.

I have never said a word about Medicare being a good financial plan, only that seniors get good care. Which is a compliment to both of you.

[cobra de capell]

the care a senior receives under Medicare is terrific, but ONLY because the low paying Medicare is propped up by the in place, for profit, health care system we all now enjoy. Your non-Medicare patients pay you enough, or nearly enough, to allow you to treat the low reimbursement Medicare patients.

That's the bottomline - a takeover of the entire health care system would be full of this type of unintended consequences – healthcare in America would take a giant step back.

Why not fix those ‘issues’ that can be fixed without government’s direct involvement? Why not secure the $600 Billion fraud and waste (MediCare/MediCaid) savings prior to installing another entitlement program? What’s the rush?