Why, in simple terms, we need MASSIVE HEALTH CARE OVERHAUL

This post is to provide you guys with a nuts and bolts example of how the current system of paying for health care services is really broken. Bad. Here is a personal example from today’s mail. It is painful to read, I admit, but it is a very, very painful subject. This stuff happens 1,000's of times a day, every day. The cost is enormous. So is the waste.

I am not trying to be smarter than any of you. I just had the mis-fortune to work in the bowels of administering health care services (referrals, paying claims, id cards, etc) for 10 years. I ran the quality department of the, at the time, largest privately owned claims payer in the US.

I have seen how physician billing offices MANIPULATE claims submitted to get the physician the highest possible money for the service. I have seen reports from auditors that showed the physician spent x minutes with a patient, then charged for 4x minutes (routinely). I have seen claims mis-paid and requests for refunds die on the vine. My point is that I know about what I am talking to you about.

Today, 11/29 I received a bill for a radiology service from 11/07/08. Yes, 08, that would be 13 months ago.

The bill showed the insurance company paid $45.34 for a claim by the physician of $130. This occurred in December of 2008. That would be “the amount paid.” I paid $11.34, which would be 20% of the total (that would be my co-insurance amount) also in December of 2008. The ALLOWED amount, $56.68, is what the insurance company was willing to say the service was worth…Less than ½ of what was billed.

Now, a year later less one day (uhmm), on 11/06/2009. The billing service refunded the insurance company the $45.34 paid a year earlier. Why??? Because a claims audit at the insurance company, just before the 1st anniversary of the claim, showed the billing office had combined a number of “codes” to get to the initial $130 when they should have billed a less expensive, consolidated code. As a result, the insurance company's allowed amount will be less, their paid amount will be less, and my 20% of the allowed amount will be less.

These codes are what are checked when you go to the doctor and take the pink or yellow or whatever sheet to the check out person. They are called CPT codes, if you care.

The billing company, in the meantime, sent me the bill (called balance billing and NOT PERMITTED for in network services) for $118.66, the difference between the ORIGINAL and IMPROPER bill of $130 and the 20% co-insurance payment I paid last year of $11.34.

I basically am a PhD in medical claims billing and called the insurer and then the billing company and explained, rather gently, that this dog would not hunt. At the billing office I got the “I am sorry sir, there has been an error.” NO SHEET.

The point of this tiresome tome, is that my wife was ready to pay the $118. Would I have received a refund when the insurance company pays the adjusted amount. NO. Will I receive a refund on the difference between the original 20% and the adjusted 20%. NO.

This system is sick and rife with fraud and probably in this case, just plan errors. We have got to change it. Yeah, you may not like where we are going, but please understand we have got to go somewhere. We have got to go somewhere different.

How many widows and orphans would have paid the $118.00 without asking further? How many of you guys would have?

Oh, by the way, the real tragedy is that when the UN-insured gets the same service, he or she is charged $130, there is no insurance company to extract a discount, so the doc gets paid the $130. If the person without insurance is indigent (what are the odds?) guess who eventually gets to pay??? That is the rest of the story. Yeah, some of these bills get written off. But not all.

hwr

 

So in short are you saying you think doctors shuld be paid a capitation?

Also I have never in my professional experience encountered a healthcare provider of any size that did not discount charges for cash paying patients.

 

Corruption and dishonesty is going to end with Obamacare? I didn't know it was an ethics bill.:huh:

 

When are people going to understand the politicians have bankrupt the country.
We have no money for these massive programs.
Don't people see we are becoming a third world country?
Don't people understand when you keep going into debt you become a slave to those you owe money?
China has us by the nuts, the way its going they won't have to fire a shot or invade!

 

So let's spend a few hundred billion dollars that we don't have and fraudulently bill an additional 30 million people. Yeah. That'll work. :dis:

 

Guys, I am not saying that "Obamacare" as you like to put it is the answer, just that there's big trouble in River City and the answer is not more of the same. You may be comfortable with the way it works, today, but it is truly broke.

 

I get that you got burned by CPT code idoicy. It does happen, and it is a complex system, but do you think desrting the procedure model will fix that?

The bills that went through Congress don't come close to addressing that.

I will ask again do you think a capitation re-imbursement system would really be any better for anyone? How? What are some other alternatives?

 

NO capitation is not the answer, single payer, single form, single data base, single everything. Level playing field. Just like Wally, Discount by TIN to your heart's content. Docs make money based on pure value: Quality/Price. Market forces stay in the game, but all the admin is the same. That in itself won't cure upcoding, but reducing the variables certainly will.

Try that awhile, see what needs tweaking, go from there.

 

I had a prescription filled yesterday and paid $1.00. I wonder what it will be next year after this bill passes. I guess all the taxes I pay to support those who don't want to work is not enough.

Some would say it's not fair that I only paid a dollar without considering how many years of "work" it has taken to "earn" my salary or the amount I pay in premiums to have a quality policy.

They'll just complain that it's not fair and want to raise my taxes to pay for people who haven't "worked" or "earned" anything.

It's not about duty or compassion...it's about buying votes and making people dependent on the government.