Discendo Vox posted:

I'm curious if CPAP devices might have been identified as another potential locus of Medicare fraud. That would explain a lot about the circumstances.

Zauper posted:

Just a quick correction;

Insurers are not paid as TPAs (third party administrators) for Medicare. The PDP and MA plans are just that - health insurance plans that people opt into in lieu of traditional Medicare (or in addition in the case of the PDP). While there is a standard benefits package that must be covered, premiums, copays, and additional benefits can differ significantly. It is very different. I can't recall whether the MA plans pay Medicare rates. I want to say they do not. Reimbursement rates do tend to be fairly close though. The insurers are underwriting costs for Medicare. I believe many are for Medicaid as well - they essentially bid a PMPM to cover all services and then are responsible for the costs.

So unlike Medicare, with MA you could have out of network hospitals or providers and actually be denied service. I had an aunt on a MA plan who was referred to an oncologist that was the specialist for her kind of cancer. He refused to treat her because he was out of network for her MA plan but took traditional Medicare so he could not allow her to pay him out of pocket.

Discendo Vox posted:

I'm curious if CPAP devices might have been identified as another potential locus of Medicare fraud. That would explain a lot about the circumstances.

Spacewolf posted:

Similar to what everybody else says - remember how hearing aids aren't covered under Medicare (or, IIRC, any *other* federally-funded insurance plan).

Why is that? My mind says "because tests are manually scored" but.

Willa Rogers posted:

I was under the impression that MA plans are paid flat fees per enrollee by the government, and are allowed to keep any money not spent on care--but if costs exceed the payment, then the government pays those plans extra money. How is that, then, "the insurers underwriting costs for Medicare"?

quote:

And while enrollees in MA plans are limited to the MCO's managed-care networks, and thus not able to seek treatment from any provider, enrollees don't face the surprise billing/balance billing issues that people in individual non-Medicare plans face.

So whereas your aunt was justifiably turned down because the oncologist wasn't in the plan's network--and bc he takes trad Medicare he wasn't allowed to have her pay out-of-pocket--if it'd been an individual plan he could have said "Sure, hop on board" and then the person would have to pay the entire cost of treatment, because unlike Medicare, most individual plans under the ACA have no limit on costs to patients from out-of-network providers. And even worse, most people have little say on whether every person who treats them during a hospitalization is in-network as defined by their insurance plans.

quote:

While a M4A plan like Bernie's, which gets rid of insurers altogether and has the government directly pay providers, is the ideal, the MA plans are considerably less expensive to consumers than other types of Medicare gap coverage (which require both higher premiums + separate policies for prescription-drug coverage), and thus the only option for lower-income people who don't qualify for Medicaid/Medicare dual enrollment.

As an example, one can get an MA plan for zero cost above the standard Part B $135/month, whereas gap insurance can run an additional $200/month and a drug program yet an additional $25 for prescription-drug coverage--on top of the same Part B $135/month.

Zauper posted:

MA plans are less expensive for consumers but significantly more expensive for the government for generally equal/worse care (because the benchmarks are set horribly so you can get a bunch of free services in places with lots of medicare fraud and pay a lot more in the flyover states)? IDK, pitching MA is kind of a losing idea IMO.

Hieronymous Alloy posted:

For kids at least, you can pursue coverage of hearing devices either through Medicaid under the EPSDT mandate or through the public schools under IDEA as assistive technology.

Willa Rogers posted:

I wasn't "pitching" MA plans; merely pointing out that they're often the only affordable option for lower-income seniors vs. $135/month for Part B premiums + $200/month for gap coverage + $30/month for drug coverage.
.
I did, though, come across this study, which contends that MA plans have been successful in better outcomes for post-acute care at less cost than traditional FFS Medicare.

But I'd much rather chuck it all and go all-in on Bernie's plan to get rid of private insurance entirely.

quote:

On Aug., 1, 2017, Brittany Cloyd of Frankfort, Kentucky, said she experienced pain "worse than childbirth." Her mother -- who had been to nursing school -- drove her to the nearest emergency room. Brittany thought her appendix had burst, but tests at the ER found she had ovarian cysts. She was given pain medication and told to follow up with her primary doctor.

Cloyd had an Anthem Blue Cross PPO health insurance plan and thought she would get charged just a co-pay for her ER visit. Instead, 15 days later she received a letter from health insurer Anthem. "Your condition does not meet the definition of emergency," read the letter. She was responsible for the total ER bill -- $12,596.

What Brittany endured is becoming more common in the health insurance industry, according to a Doctor Patient Rights Project (DPRP) study. It highlighted Anthem, which through its affiliated networks is the nation's largest private health insurer. The DPRP contends that Anthem has instituted an organized policy of denial designed to make its subscribers -- particularly those who are poor and reside in rural areas -- too afraid to go to an ER for fear of receiving a bill like Cloyd's, or more, for the visit.

Reik posted:

Lol, Anthem is going to get so sued.

https://www.cbsnews.com/news/anthem-among-health-insurers-refusing-to-pay-er-bills-doctors-say/


Intense pain is specifically mentioned in the prudent layperson definition of an appropriate reason to go to an emergency room. Can't believe anyone over at Anthem thought this was a good idea.

quote:

As of January 1, Anthem said it would always pay for ER visits based on certain conditions. These exceptions include provider and ambulance referrals, services delivered to patients under the age of 15, visits associated with an outpatient or inpatient admission, emergency room visits that occur because a patient is either out of state or the appropriate urgent care clinic is more than 15 miles away, visits [between] 8 a.m. Saturday and 8 a.m. Monday, and any visit where the patient receives surgery, IV fluids, IV medications or an MRI or CT scan.

quote:

Two groups, the American College of Emergency Physicians (ACEP) and the Medical Association of Georgia (MAG), sued Anthem's Blue Cross Blue Shield of Georgia, alleging that the ER policy violates the "prudent layperson" standard in the Affordable Care Act—which, the plaintiffs say, requires Anthem and other insurers to cover emergency care based on a patient's symptoms rather than their final diagnosis.

"We can't possibly expect people with no medical expertise to know the difference between something minor or something life-threatening, such as an ovarian cyst versus a burst appendix," ACEP President Paul Kivela, MD, FACEP, said in a statement calling the policy "dangerous."

quote:

According to a report issued this past July by Sen. Claire McCaskill, D-Mo., Anthem denied roughly 12,200, or 5.8%, of all emergency room claims in Missouri, Kentucky and Georgia from July 2017 to Dec. 2017 through this policy. Missouri's hospital association was one of many health organizations to publicly oppose the policy.

In a statement to Healthcare Dive, Anthem defended its ER policy as a way to "ensure access to high quality, affordable healthcare" by encouraging consumers to receive care in "the most appropriate setting."

"If a consumer reasonably believes that he or she is experiencing an emergency medical condition, then they should always call 911 or go to the ED," the statement reads. "But for non-emergency health care needs, EDs are often a time-consuming place to receive care and in many instances 10 times higher in cost than urgent care."

Spacewolf posted:

Waaaait, there's a definition in statute or case law of "what a prudent layperson would consider an appropriate reason for an ER trip"?

That's a serious question...because tbh I had always thought there was no standard whatsoever, legally.

Willa Rogers posted:

Even though Anthem has reversed a lot of ED denials on appeal, just having the policy in place discourages people from seeking medical care. "Bending the cost curve" through massive deductibles hasn't been profitable enough on its own, so let's throw a few more wrenches into the process of people seeking and receiving medical care.

Malcolm XML posted:

Medicare fraud is real lol but it's usually collusion between patients and doctors or possibly providers creatively billing or lying

Spacewolf posted:

Don't people usually mean doctors when they say providers...?

Spacewolf posted:

Don't people usually mean doctors when they say providers...?

Yeowch!!! My Balls!!! posted:

most people, yes, but in the healthcare business arena doctors are an inconveniently expensive set of Provider employees and contractors.

when you read "provider" replace it with the word "hospital" and you will only occasionally be wrong.

Lightning Knight posted:

So the hospitals and the insurance companies are colluding to commit fraud or unethical practices, in billing and not generally the doctors, is what you're positing?

Yeowch!!! My Balls!!! posted:

those two are rarely colluding, actually, and it's one of the biggest sources of friction in the system!

unethical doctor practices are, despite the amount doctors make, generally of the good old-fashioned employee unethicality type. half-assing it, loving patients/staff on the job, stealing poo poo, getting high and/or drunk, lying about billable hours, and general incompetence. but doctors are not paid by how expensive the problems they take care of are (well, directly, at least) and doctors are not the ones who write up the bill to insurance companies.

providers, however, are paid in direct proportion to how expensive the problems they take care of are. and they are the ones who own the billing department. so, with the billing department given the choice of describing checking up on your sniffles as a Standard Checkup or as a Pneumonia Screen? spoiler warning, there is someone looking over their shoulder politely reminding them that this is a business, and it would be ever so helpful to categorize it as the one that lets them charge insurance more.

and that's only if you're worried about being caught! flat-out inventing patients you say you've treated and procedures you say you've subjected them to is FAR from unheard of. the all-time champion at this is currently the junior Senator from the State of Florida.

and then on the other side of the equation, fighting this, are the insurance companies. who make their money by strategically refusing to pay for the service their customers paid for. on the grounds that "nah, that doesn't look right" or "nope, looks expensive."

Lightning Knight posted:

Well this is lovely. What should be done about this on a policy level? I imagine the answer is "nationalize healthcare" but I assume there are intermediate steps we could take?

Discendo Vox posted:

I'd disagree with that a bit. Fee for service also creates perverse incentives for physicians.

Yeowch!!! My Balls!!! posted:

this model has the -minor- issue, however, of being reliant on insurance and providers playing nice with each other. the insurer is fundamentally going to want the money bag to be as small as possible and the patient bag to be as expensive as possible. the provider is going to want the reverse. and both are going to fight like hell over how best to structure that such that people at risk for heart attacks don't piss in their nice clean risk pools. as opposed to now, when only insurers are trying to ice them out.

quote:

The Affordable Care Act kept profit margins in check by requiring companies to use at least 80 percent of the premiums for medical care. That’s good in theory but it actually contributes to rising health care costs. If the insurance company has accurately built high costs into the premium, it can make more money. Here’s how: Let’s say administrative expenses eat up about 17 percent of each premium dollar and around 3 percent is profit. Making a 3 percent profit is better if the company spends more.

It’s like if a mom told her son he could have 3 percent of a bowl of ice cream. A clever child would say, “Make it a bigger bowl.”

Wonks call this a “perverse incentive.”

“These insurers and providers have a symbiotic relationship,” said Wendell Potter, who left a career as a public relations executive in the insurance industry to become an author and patient advocate. “There’s not a great deal of incentive on the part of any players to bring the costs down.”

Yeowch!!! My Balls!!! posted:

Yeowch!!! My Balls!!! posted:

definitely, but they're a lot less dramatic than a provider group cutting all funding for preventative care on grounds its existence is cutting their own throats financially.

Willa Rogers posted:

Not necessarily:

Discendo Vox posted:

I'm sensitive to it because private practitioners and networks are a locus of abuse for things like prescription drugs and alt med abuses.

Yeowch!!! My Balls!!! posted:

in conclusion, the profit motive in health care, uniquely, is not a land of contrasts, and the insurance industry as it exists in america today needs to be burned down and the ashes salted.

in deference to their decision to pay ten dollars for a dying comedy forum, Reik and Zauper will be given fifteen minutes warning before their workplace's unscheduled demolition.

Malcolm XML posted:

Medicare fraud is real lol but it's usually collusion between patients and doctors or possibly providers creatively billing or lying

Yeowch!!! My Balls!!! posted:

the answer that some people have tried to make work is consolidating insurers and providers under one roof. Kaiser out on the West Coast is the biggest example, an insurance company that also owns a shitton of hospitals. they still run into the perennial problem with this model: provider-owned insurers lose money on insurance, and insurer-owned providers lose money on providing.

one of the biggest underlying issues, that helps but will absolutely not be a silver bullet, is a switch from a fee-for-service to capitation model. remember how providers get paid by how expensive the problems they treat are?

this means that, from a raw economic perspective, any amount of preventative health care, trying to stop you from having a heart attack, is providers picking their own pockets. if I can make five hundred dollars from putting you on statins now, or five hundred thousand from putting your heart back together after it tries to rip itself in half? sure, option B is hopelessly inhuman and monstrous. but this hot tub is really nice.

this problem in particular is solved under a capitation model. in a capitation model, a hospital is given a big sack of money, and a big sack of patients. it is told "this is for those. if you do a good job, you make more. if you do a bad job, you make less. good luck!"

this model has the -minor- issue, however, of being reliant on insurance and providers playing nice with each other. the insurer is fundamentally going to want the money bag to be as small as possible and the patient bag to be as expensive as possible. the provider is going to want the reverse. and both are going to fight like hell over how best to structure that such that people at risk for heart attacks don't piss in their nice clean risk pools. as opposed to now, when only insurers are trying to ice them out.

Hieronymous Alloy posted:

There really isn't an answer that isn't some form of socialized medicine. Fundamentally, insurers are middlemen who profit by promising to provide coverage and then not doing so. Fee-for-service Medicaid has the lowest cost-per-patient of any American system, and the reason is because it's single-payer and that is just an inherently more efficient model.

Willa Rogers posted:

Not necessarily:

Willa Rogers posted:

I agree with the rest of your post but wanted to point out that the vast majority of state Medicaid programs are now bucketing people into managed-care plans. And as someone upthread mentioned, the state-based Medicaid MCOs are usually way better than the ultra-narrow-network MCOs that come with bronze plans in the individual market.

It's easier to get providers on board when they're given a flat fee whether a person uses them or not. When the Medicaid expansion under the ACA rolled out, everyone figured that people who had deferred medical care bc of lacking insurance would rush in and explode costs under capitation, but that didn't happen--because in spite of what economists and policy wonks said, people aren't inclined to seek medical care until they actually need it.

Willa Rogers posted:

(That's what makes all the bullshit "skin in the game" rationales so infuriating. High out-of-pocket costs do nothing toward public health as a policy, and now we know that even when people are very sick, they avoid treatment because of those costs.)

Willa Rogers posted:

It's easier to get providers on board when they're given a flat fee whether a person uses them or not. When the Medicaid expansion under the ACA rolled out, everyone figured that people who had deferred medical care bc of lacking insurance would rush in and explode costs under capitation, but that didn't happen--because in spite of what economists and policy wonks said, people aren't inclined to seek medical care until they actually need it.

Hieronymous Alloy posted:

Absolutely, it's the worst kind of Lucky Ducky bullshit. Nobody seeks out medical care they don't genuinely believe they need. It doesn't happen, ever. It's too much goddam hassle. On the rare occasions when it does occur, there's some other medical reason causing it (addiction, Munchausen's).

Rhesus Pieces posted:

Yeah I’ve never understood this logic. Do they really think that if medical care were free people would treat hospitals like amusement parks and wait for hours in waiting rooms with sick people to get unnecessary MRIs and blood draws for the fun of it?

Aside from opiates, most medical care is unpleasant unless you have a real problem that needs fixing.

Rhesus Pieces posted:

https://twitter.com/drewtoothpaste/status/1070701774095425541?s=21



What’s the loving point of “insurance” like this?

JustJeff88 posted:

I just spent a full week in hospital due to not one but two pulmonary embolisms. I only have any insurance due to the Medicaid expansion, but I'm alive because of it. Cost to me: $0 with no hidden costs, including that of my own life which would have been lost without it.

Tell me how only the free market can provide effective health care.