ACA (Obamacare) meets the goal of 7 million sign-ups

[modhatter]

The only thing that I am aware of as far as Medicare digging into billing issues further has to do with fraud, and trying to catch it, in which the patient is usually innocent. That would contribute to a cost savings. In the past, Medicare paid all bills right away, and asked questions much later. By that time - the crook was long gone. They have changed that now, but I am too tired at this late hour to Google the actual changes made in recent years.

Not saying that what you are espousing to is not true, only that I have never heard of it happening, either to myself or any of my friends or family members on Medicare. As I pointed out in my case, when there was any question of coverage, both my doctor and the hospital checked and confirmed authorization, which they got right away.

My experience with private insurance runs along the lines you mention. Perform the service, then later down the road after the fact, OH OH, seems that wasn't covered as you were led to believe. Only in this case the patient is on the hook. What you are saying, if I am understanding you, is that if the provider (Medicare) pays for a service, and that service is not covered, then they will basically do a charge back to the physician or hospital? To me, if this were to occur, I would expect to see a bill forwarded to me real pronto from that doctor or hospital. Wouldn't you concur? Are you on Medicare yet?

[NSHL10]

That is what the ABN is for now. It allows the provider to re coup the lost payment from the patient if Medicare denies payment for the service. The provider has to provide the cost of such service you are providing and have the patient sign it. Every Medicare patient I service is required to sign the ABN form before we start treatment. Check my link for an explanation.

I still have 20 years before I can receive Medicare. I service Medicare, Medicare Advantage, Medicaid, and private insurance patients via home care agencies.

[modhatter]

Originally Posted by NSHL10

That is what the ABN is for now. It allows the provider to re coup the lost payment from the patient if Medicare denies payment for the service. The provider has to provide the cost of such service you are providing and have the patient sign it. Every Medicare patient I service is required to sign the ABN form before we start treatment. Check my link for an explanation.

I still have 20 years before I can receive Medicare. I service Medicare, Medicare Advantage, Medicaid, and private insurance patients via home care agencies.

I am familiar with the ABN form. However, prior to receiving medicare and under private insurance, I always had to sign a form stating that I am ultimately responsible for payment (in so many words). I did have billing issues with BCBS from time to time, though I never required very much in the way of treatment prior to reaching 65, so any claims were small. However, when I was found to have cancer (age 66) then I had some very large claims as along with my cancer I developed some other serious complications and my total tab was reaching the $170,000 mark. And as I mentioned, nothing was ever denied.

My familiarity for home care is that a great deal of it is picked up by your supplement policy that you purchase, as I do believe Medicare is somewhat lacking in that area of coverage. I do not profess to know what coverage Medicare affords and what it doesn't in home care, so I can not argue that point. It could be a totally different can of worms than non-home care Medicare coverage.

During my treatment period, I did have a visiting nurse, as well as physical therapy at home, and to the best of my recollection, it was my supplemental policy that covered it. I have J, which is no longer available, and I believe it covered more in home care than most.

I do not doubt that there are some Medicare charge backs that occur. But what we are arguing here is who is more likely to deny a claim and issue a charge back. (government vs private insurance) My contention is that based on my own experience and those of Medicare age individuals who I know, I have not heard any complaints. I can't tell you how many times I thought how lucky I was to have incurred my illness under medicare as opposed to private insurance. Now in fairness, I am sure there are some Cadillac plans that cover everything under the sun, and even the universe, and they would probably put Medicare to shame. However, we are talking broad spectrum here, so that is how I am basing my opinion.

And I agree you can not base an argument on one individuals experience or a dozen, but there have been many surveys done with seniors on medicare, and by far the percentage of satisfaction is way up there.
Here are just a couple of articles illustrating my point.

Medicare Beats Private Plans for Patient Satisfaction: Survey - US News

Medicare Works: Public Program Continues to Outperform Private Insurance in Ensuring Access to Care and Providing Financial Protection - The Commonwealth Fund

[NSHL10]

I'm not here to beat up Medicare for those who are on it. For the premium paid, it is a bargain.
My contention was just that for providers it can be wishy washy with what is covered compared to a HMO model which requires preauthorization.

Of course HMOs and their narrow networks have their own problems.

Nothing is perfect.

[Ariadne22]

Ha - here is my favorite post on HMO's - in this case a Medicare Advantage:

Originally Posted by ocnjgirl

The vast majority of Medicare Advantage plans are state-specific, you can't even use them outside your state let alone the country.

[I would add to this for the UHC Medicare Advantage - in WI - you can't even use a Milwaukee County UHC MA Plan if you're on vacation in Northern WI - except for ER. There is no "Passport" in-network] HMO/MA's suck, imo.

My Mom had Blue Cross of Pa plan, and when I brought her here to NJ (she was being D/C'd from rehab and couldn't return home alone) her plan paid for nothing here. We had to pay out of pocket for her to get a physical for ALF placement, no reimbursement. From the minute she set foot in NJ, she basically was uninsured until I could get her disenrolled from Pa to NJ Blue Cross (they are run completely separately, you can't switch just from one to the other) and it took weeks to complete the change. She would have been covered for ER only in NJ under the Pa Blue Cross Plan.

As a rehab therapist who's worked in geriatric health care for 18 years, I would scrimp so I could get traditional Medicare and a supplemental.

If you ever get sick or need rehab, your co-pays are going to be astronomical with any HMO Medicare plan, and your choices of places to go for rehab may be limited as well.

You will also have to get re-approved for rehab every few days to a week, while under traditional with a supplemental, you can get up to 100 days of rehab after a 3-day hospitalization (as long as you're still making progress and have goals you haven't met yet).

My Mom had about $7000 total co-pays for that illness, including ambulance, hospital and rehab (about 2-3 weeks).

I switched her to traditional as soon as open enrollment came, and now if she had the same illness and went to the same rehab, she'd have zero in co-pays. She thought her plan was great, no premiums, what could be better??

Better is a plan that covers everything, and without begging (her plan wanted to cut her after the first week, even though she couldn't walk by herself yet but had been living alone independently prior to getting sick).

And, it gets worse:

Originally Posted by ocnjgirl

I thought it was crazy the hoops we had to jump through to get my Mom from PA Blue Cross to NJ Blue Cross...you'd think, oh, it's the same company, right?

I was on the phone and fax for hours, disenrolling her from PA, then I had to wait until PA Blue Cross sent us proof that she disenrolled, then send that to NJ Blue Cross and spend hours on phone and fax to enroll her there.

Then it took NJ Blue Cross 2-3 weeks to issue her a policy number, so I couldn't prove to any care provider she was insured before then.

2-3 weeks during which I couldn't get her in any ALF because technically she had no proof of insurance.

2-3 weeks that I had to have her here in my one bedroom, second floor apartment (she was in a wheelchair, that was fun, getting her up the stairs!),

2 weeks in which we had to pay out of pocket for aides to come in and care for her, again because technically she didn't have proof of insurance.

If she had traditional Medicare, she would have qualified for home health under Medicare for nurses, aides and therapists to come, since she was just out of rehab.

Instead we paid several hundred a day for aides to come while I was at work and overnight (she needed the bathroom every 2 hours, and I needed to sleep to get up for work), and she almost ended up in the hospital again because we had no nursing care to deal with the ulcers on her legs properly.

The foregoing speaks for itself. Generally speaking, HMOs - especially MA's - are a very poor third choice.

So far, we haven't - in the couple of years I've been reading this forum - had even one Medicare patient state they were subject to clawback on payment for services previously paid by Medicare. Not one.

Everyone here - on Original Medicare - is very happy with it, far as I can tell.