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Old 02-23-2016, 05:44 AM
 
Location: Ponte Vedra Beach FL
14,628 posts, read 17,938,980 times
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Quote:
Originally Posted by Weichert View Post
There are a few, especially if you live in an area with 40%-50% (or more) of all Medicare eligible are enrolled in Advantage plans AND a major hospital (like Mayo) or medical school (and their associated facilities) are in the plan networks. And they are highly rated.

But I think generally the high deduct plan F is the best deal going.
Mayo in Rochester takes local Medicare Advantage patients. Mayos in Florida and (I think) Arizona don't. Makes sense since Mayo in Rochester is pretty much the only game in (a pretty isolated) town. Here in JAX we have more medical systems/homes. At least five majors I can think of. Mayo - the Baptist system (multiple locations) - the St. Vincent's system (multiple locations) - Shands (University of Florida) and Memorial. There are also various military/veteran's facilities. Not only does Mayo offer just about all the medical services we need - in a "1 stop shopping" campus - it's also the place that's closest. 15 minutes door to door. So it's a no-brainer for us.

I think people really have to shop around locally before they decide what's best for them. For example - although Shands here is a teaching hospital (good on paper) - it has a lot of uninsured/underinsured patients and is in a part of town that isn't particularly safe (40+ minutes from where we live). It also has chronic funding issues. Which can lead to quality issues. So - even though it might take MA patients - it wouldn't be anywhere near my first choice in terms of a "medical home".

High deductible plan F isn't offered where we live. So my father and I have regular plan F (my husband has a similar plan - J - now discontinued). Even if high deductible plan F was available - I'm not sure it would sense for us (we usually go through the deductible every year). But it apparently makes sense for a lot of people. Robyn
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Old 02-23-2016, 06:02 AM
 
Location: Ponte Vedra Beach FL
14,628 posts, read 17,938,980 times
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Quote:
Originally Posted by Stymie13 View Post
The worst part of what gets reimbursed? The AMA has the contract and they assign a payment indicator or status indicator to each cpt code. All of that is public on cmms.gov but it does take some familiarity to 'get it'.

Hearing devices is another. Dme services... The lists of what is vs what isn't does always pass the common sense.
Don't even get me started on DME (durable medical equipment). My husband wears a leg brace. Medicare will pay for 1 new non-custom brace every 5 years. And it pays wildly inflated prices for them (over $1000). Not only does my husband need more than 1 new brace every 5 years - the non-custom ones don't fit him/work very well. So - when we need a new one - we just buy a custom one direct from the manufacturer (didn't know we could do this until I found out we could on a chat board quite a few years ago). And we pay about $300 for the fitting/brace (from the same manufacturer). Which is what all normal consumers - including professional football players (who aren't exactly poor) - pay for them. I can't imagine how much Medicare overpays annually for durable medical equipment. How much money it would save/be able to spend elsewhere if it didn't overpay for DME. Robyn
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Old 02-23-2016, 06:09 AM
 
Location: louisville
4,754 posts, read 2,014,098 times
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Quote:
Originally Posted by Robyn55 View Post
Don't even get me started on DME (durable medical equipment). My husband wears a leg brace. Medicare will pay for 1 new non-custom brace every 5 years. And it pays wildly inflated prices for them (over $1000). Not only does my husband need more than 1 new brace every 5 years - the non-custom ones don't fit him/work very well. So - when we need a new one - we just buy a custom one direct from the manufacturer (didn't know we could do this until I found out we could on a chat board quite a few years ago). And we pay about $300 for the fitting/brace (from the same manufacturer). Which is what all normal consumers - including professional football players (who aren't exactly poor) - pay for them. I can't imagine how much Medicare overpays annually for durable medical equipment. How much money it would save/be able to spend elsewhere if it didn't overpay for DME. Robyn
More than you want to know (in overpaying). And, since most private payors now use Medicare rates for reimbursement, then go up or down percentage points....

You mentioned Shands. A simplistic explanation is they get 105 to 107% of Medicare rates for ma plans, 110% for group plans. Been a couple of years since I looked at theirs for one of my clients but those numbers are pretty typical.
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Old 02-23-2016, 06:17 AM
 
Location: Ponte Vedra Beach FL
14,628 posts, read 17,938,980 times
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Originally Posted by 2sleepy View Post
I guess I'm lucky, both my Vitamin D test and two visits to a dermatologist to remove skin growths were covered without question. In fact I never had any service denied, that was with my Anthem PPO medicare supplement. I'm healthy but have a somewhat unusual condition, Raynaud's disease and I had multiple referrals to specialists, and I never heard a peep from Anthem, they just paid the bills that were left after Medicare paid. I would have probably stayed with them but their rate went up to $380 a month and my employer supplement is $300 so I jumped ship and went to Kaiser, but in retrospect I'm glad I did, I really like Kaiser.
Medicare may well pay for my Vitamin D test (it did last year). But it apparently doesn't pay for all of them for everyone (which is why I had to sign an ABN form). There sometimes seems to be little rhyme or reason in terms of what Medicare covers and under what circumstances. Also - it seems that Medicare coverage can vary by region. We ran into this when my late FIL needed an ICD (implantable cardioverter defibrillator). Which may - or may not - be covered. When we were reading - we found that region X covered the procedure if you had A/B/C and region Y covered it if you had D/E/F.

Overall - I am glad we have ABN forms. To give us a "heads up" about things that Medicare might not cover - and how much we might (but won't necessarily) have to pay out of pocket (in my case usually small amounts - like $4.64 - for various lab tests). Robyn
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Old 02-23-2016, 07:50 AM
 
Location: louisville
4,754 posts, read 2,014,098 times
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Quote:
Originally Posted by Robyn55 View Post
Medicare may well pay for my Vitamin D test (it did last year). But it apparently doesn't pay for all of them for everyone (which is why I had to sign an ABN form). There sometimes seems to be little rhyme or reason in terms of what Medicare covers and under what circumstances. Also - it seems that Medicare coverage can vary by region. We ran into this when my late FIL needed an ICD (implantable cardioverter defibrillator). Which may - or may not - be covered. When we were reading - we found that region X covered the procedure if you had A/B/C and region Y covered it if you had D/E/F.

Overall - I am glad we have ABN forms. To give us a "heads up" about things that Medicare might not cover - and how much we might (but won't necessarily) have to pay out of pocket (in my case usually small amounts - like $4.64 - for various lab tests). Robyn
ABN's = advance beneficiary notice for those who aren't familiar. It is HIGHLY ADVISABLE to review this before undergoing anything considered experimental or investigative.

https://www.cms.gov/Outreach-and-Edu..._ICN006266.pdf

DISCLAIMER: For those on Medicare Advantage plans, the corollary question to ask your provider is 'are you contracted off medicare coding guidelines'. That means their billing system is set for the MA Plan the same as traditional Medicare, and the MA plan sets their system to follow the same coding aspects CMS does. At that point, if an ABN would be needed for traditional Medicare, ask your MA for the documentation requirements for medical necessity. It will help prevent the administrative issues that can arise (and I only say help as there is no 100% fool proof way to prevent breakdowns).
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Old 02-23-2016, 05:01 PM
 
Location: Ponte Vedra Beach FL
14,628 posts, read 17,938,980 times
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Quote:
Originally Posted by Stymie13 View Post
More than you want to know (in overpaying). And, since most private payors now use Medicare rates for reimbursement, then go up or down percentage points....

You mentioned Shands. A simplistic explanation is they get 105 to 107% of Medicare rates for ma plans, 110% for group plans. Been a couple of years since I looked at theirs for one of my clients but those numbers are pretty typical.
Shands - don't get me started. A ton of cost shifting going on there. When we first moved to this area 20 years ago - my husband needed an EMG (he has MS). His neurologist in Miami referred us to a doctor at Shands. And - pre-Medicare - Shands billed us $4k (out of pocket because we had a high deductible) for that one lousy EMG. We eventually negotiated the price down to about $2000 - for a procedure that we found in later years (at Mayo after we went on Medicare) that Medicare reimburses at about $450. Now $450 is probably too low - but - OTOH - $4k is much much too high.

Can you with your industry experience see any way that providers will charge the same (perhaps reasonable) costs to everyone for the health care they're getting? Eliminate the cost shifting? Or will cost shifting always be in our health care billing - in some way/shape/form? Robyn
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Old 02-23-2016, 06:07 PM
 
Location: louisville
4,754 posts, read 2,014,098 times
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Quote:
Originally Posted by Robyn55 View Post
Shands - don't get me started. A ton of cost shifting going on there. When we first moved to this area 20 years ago - my husband needed an EMG (he has MS). His neurologist in Miami referred us to a doctor at Shands. And - pre-Medicare - Shands billed us $4k (out of pocket because we had a high deductible) for that one lousy EMG. We eventually negotiated the price down to about $2000 - for a procedure that we found in later years (at Mayo after we went on Medicare) that Medicare reimburses at about $450. Now $450 is probably too low - but - OTOH - $4k is much much too high.

Can you with your industry experience see any way that providers will charge the same (perhaps reasonable) costs to everyone for the health care they're getting? Eliminate the cost shifting? Or will cost shifting always be in our health care billing - in some way/shape/form? Robyn
On the cost shift, not as long as Medicare continues to raid the Medicare and ss trust funds, politicians continue to use healthcare to get themselves re-elected, not allow the industry to correct itself, and not without fiscal responsibility by the government itself. I'm not referring to the simple fraud and waste we hear about. Even the billions that it accounts for is a mere drop in the promises made in 1965 that the government has only upheld by raiding other trusts and falsifying numbers, from both political parties.

If I may ask, pre-Medicare, were you on an individual plan where the emg was not covered?
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Old 02-24-2016, 09:58 AM
 
Location: Ponte Vedra Beach FL
14,628 posts, read 17,938,980 times
Reputation: 6716
Quote:
Originally Posted by Stymie13 View Post
On the cost shift, not as long as Medicare continues to raid the Medicare and ss trust funds, politicians continue to use healthcare to get themselves re-elected, not allow the industry to correct itself, and not without fiscal responsibility by the government itself. I'm not referring to the simple fraud and waste we hear about. Even the billions that it accounts for is a mere drop in the promises made in 1965 that the government has only upheld by raiding other trusts and falsifying numbers, from both political parties.

If I may ask, pre-Medicare, were you on an individual plan where the emg was not covered?
Before we went on Medicare - my husband and I were enrolled in the Florida Comprehensive Health Association (state high risk pool - which was closed to new enrollment in 1991). The plan pretty much covered everything/everywhere - but we chose to have a high deductible ($10,000). Just made the most sense for us (we rarely if ever paid more for health care than we would have paid for policies with the lowest deductible - $2500 - and we could afford to self-insure for the deductible). We also had an excess group policy through the Florida Bar - which kicked in if we had more than $25k in out-of-pocket medical/drug costs over a rolling 3 year period. I think the FCHA went totally out of business after the ACA went into effect (not sure).

People were generally horrified by our deductible during the years when we were in the plan. It is ironic that now - many people who were horrified by our FCHA deductible are facing similar large co-pays/deductibles with ACA policies (even though many people can't afford them). They're paying large premiums too. It is also ironic that with our Medicare/Medigap policies and even being part of a concierge practice at Mayo (Mayo here isn't accepting new Medicare primary care patients) - we are generally paying the same (or less) than we used to pay pre-Medicare. And - with Plan F - once we pay our premiums - that's it. No co-pays/deductibles. IOW - we are kind of going in the opposite direction compared to a lot of people here in the US - even as we get older/sicker.

We were fairly new to the FCHA - and fairly new to JAX - when we had our Shands billing dispute. And became very conscientious about comparison shopping after that incident.

Drug coverage is another issue. Medicare Part D isn't fabulous. But the FCHA didn't offer drug coverage at all. And we still have the old excess Florida Bar policy if we ever need a drug that's hideously expensive. Robyn
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Old 02-24-2016, 10:17 AM
 
Location: louisville
4,754 posts, read 2,014,098 times
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Quote:
Originally Posted by Robyn55 View Post
Before we went on Medicare - my husband and I were enrolled in the Florida Comprehensive Health Association (state high risk pool - which was closed to new enrollment in 1991). The plan pretty much covered everything/everywhere - but we chose to have a high deductible ($10,000). Just made the most sense for us (we rarely if ever paid more for health care than we would have paid for policies with the lowest deductible - $2500 - and we could afford to self-insure for the deductible). We also had an excess group policy through the Florida Bar - which kicked in if we had more than $25k in out-of-pocket medical/drug costs over a rolling 3 year period. I think the FCHA went totally out of business after the ACA went into effect (not sure).

People were generally horrified by our deductible during the years when we were in the plan. It is ironic that now - many people who were horrified by our FCHA deductible are facing similar large co-pays/deductibles with ACA policies (even though many people can't afford them). They're paying large premiums too. It is also ironic that with our Medicare/Medigap policies and even being part of a concierge practice at Mayo (Mayo here isn't accepting new Medicare primary care patients) - we are generally paying the same (or less) than we used to pay pre-Medicare. And - with Plan F - once we pay our premiums - that's it. No co-pays/deductibles. IOW - we are kind of going in the opposite direction compared to a lot of people here in the US - even as we get older/sicker.

We were fairly new to the FCHA - and fairly new to JAX - when we had our Shands billing dispute. And became very conscientious about comparison shopping after that incident.

Drug coverage is another issue. Medicare Part D isn't fabulous. But the FCHA didn't offer drug coverage at all. And we still have the old excess Florida Bar policy if we ever need a drug that's hideously expensive. Robyn
Those who work for payors are 'guinea pigs'.... meaning we usually have plans 6 to 10 years in advance of what is going to be offered to the public.

I had a 6000 ded in 05! And that was before I got married.

I was just curious on the EMG why you were having to negotiate. Now it makes sense.

If you ever want to see, I can show you where you can find Medicare Rates... it's public knowledge. From there, any time you, family, or friends are going to have a procedure, you will see what the Medicare rate is (they are adjusted quarterly although usually static). There are 'adjustments' to reimbursement, such as PQRI, HPSA for professionals and DSH, Wage Indices, etc... for institutions.

That way, you can know if you are ever getting fleeced. Ask the provider the CPT they are billing... although not the doc. They don't know the billing language. They shouldn't have too (some do, that was a broad overstatement and not really fair) as they are the practitioner.

Just have to keep in mind that every type of 'coverage' Medicare offers has a different reimbursement formula: IPPS, OPPS, ASC, SNF, CMG, HIPPS, HH, etc.. ,etc...

My payor had issues with Shands. The payor I worked longest with also was the co-developer of Availity which is the largest clearinghouse in Florida. So, all the systems in Tampa, Miami, Jax I have familiarity with.
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Old 02-24-2016, 10:32 AM
 
Location: Chesapeake Bay
6,048 posts, read 3,874,457 times
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Quote:
Originally Posted by Robyn55 View Post
Mayo in Rochester takes local Medicare Advantage patients. Mayos in Florida and (I think) Arizona don't. Makes sense since Mayo in Rochester is pretty much the only game in (a pretty isolated) town. Here in JAX we have more medical systems/homes. At least five majors I can think of. Mayo - the Baptist system (multiple locations) - the St. Vincent's system (multiple locations) - Shands (University of Florida) and Memorial. There are also various military/veteran's facilities. Not only does Mayo offer just about all the medical services we need - in a "1 stop shopping" campus - it's also the place that's closest. 15 minutes door to door. So it's a no-brainer for us.

I think people really have to shop around locally before they decide what's best for them. For example - although Shands here is a teaching hospital (good on paper) - it has a lot of uninsured/underinsured patients and is in a part of town that isn't particularly safe (40+ minutes from where we live). It also has chronic funding issues. Which can lead to quality issues. So - even though it might take MA patients - it wouldn't be anywhere near my first choice in terms of a "medical home".

High deductible plan F isn't offered where we live. So my father and I have regular plan F (my husband has a similar plan - J - now discontinued). Even if high deductible plan F was available - I'm not sure it would sense for us (we usually go through the deductible every year). But it apparently makes sense for a lot of people. Robyn
I think the key as to whether to go with Advantage plans depends on the popularity of them in a particular location. Why they have wide acceptance in some areas and not others is a mystery to me. These plans don't seem to be very popular in Jacksonville yet in other parts of Florida everyone (including providers) seems to be happy with them. Why is that?

I recently read an article about their acceptance in Portland. There the Advantage plans have generally become the plans of choice. They pay more than Medicare (for both doctors and hospitals) with fewer hassles and the associated problems of Medicare (so they say). Maybe its the variability of Medicare in Oregon. Who knows?

But there are other large metro areas than Portland where close to half of those eligible for Medicare are in Advantage plans and like them. Just so strange.

And it could be that Medicare is finally dealing with the bad/poor practices of companies like UHC. They have also banned Cigna-Healthspring from offering Advantage plans to new enrollees until they clean up their act and conform to regulations.
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