The only reason Medicare is not well enough funded is because of the COST of

[rainy]

Healthcare, including the cost of medicines, doctor pay, medical supplies etc... This has to be brought up when some say that Medicare is bankrupt. It is because of the cost charged to them by the pharmaceuticals and other healthcare providers. My mom is on medicare and her new doctor actually billed $435.00 to medicare for a single office visit that consisted of just talking. No blood work was done and no other tests. I go to the doctors' with my mom because she has dementia.

Medicare decides how much they will pay but what is that based on? the high overpriced cost already in existence.

[rucky]

1. If we don't control costs first, any program we promote will fail.

[fascisthunter]

2. the Current System is a Bigger Burden on Us all

than if we had Single Payer... and Republicans who are invested in the current system know it. They are liars...

[HowHasItComeToThis]

15. COMPETITION SETS THE MAXIMUM PRICE, NOT THE MINIMUM

[TahitiNut]

3. Medicare (dis)Advantage and Part D both cause a hemorrhage of funds - it's GOP privatization.

Virtually every fiscal failure of federal programs can be attributed to piracy ... privateers pillaging the treasury.

[truedelphi]

18. So true and so sad. n/t

[cascadiance]

21. And since payroll tax funds both social security and medicare, it's a backdoor to privatizing BOTH!

GOP probably figures by finding ways to scam more money out of medicare, that they can find ways of declaring both Medicare and Social Security fiscal failures and that way clear the way to privatize both. That's been their ultimate objective all along.

[havocmom]

26. you da man!

Spot on, 'nut

[yellowdogintexas]

4. the doctor did NOT repeat NOT get that much back from Medicare.

reimbursements to Medicare are based on area averaging for comparable services.

[rainy]

5. I know that but the fact that he billed that amount so that he could get the most

that medicare would pay seems a bit shady .

[yellowdogintexas]

9. he is most likely trying to boost the average for the next run of the UNC

(Usual and Customary)data ... remember his charge for that procedure code is being averaged in with everyone else in his specialty group in a pretty large area. The end result most likely would be a small percentage up grade for every one in that area IF they all up charge equally. Doctors have been doing this since the inception of Area Prevailing Rates and Usual & Customary data.

Is it outrageoous? yes, do I like it no but it is an outcome of all the repricers, discounters, PPO networks, greed, etc.

We used to find it funny that there were always a few providers who just knew if they jumped their rates a whole lot every year, they would get more money. Immediately. Another thing is there are not supposed to be separate $$ amts for Medicare/Medicaid patients vs private pay. So he charges the same across the board, and makes it up on the private pay patients. Also they jack up their fees because every contract they have with the various PPO and HMO and other discounters is reimbursing them differently so they are trying to average it out.

Did the doctor accept Medicare's payment as the full payment? That is called taking assignment. If so, your mom can only be billed for the 20% difference between the ALLOWABLE $$ and the amount Medicare paid. so on a $100 fee if Medicare says $75 is allowable then Medicare pays 80% of $75 and the patient pays 20% of $75. The other $25 is written off. The writeoffs have some sort of tax advantage, if I recall correctly for the provider.

If the doc didn't take assignment, using the same dollar amounts, he could bill the patient the entire difference between the 80% of $75 and the original $100 fee. I think all participating physicians are required to take assignment these days but am not 100% certain of that.

[yellowdogintexas]

14. fraud would be more like charging for a 1 hour visit when it was a 15 min

visit. over and over. Then you have to prove he was doing it with intent to deceive.

[madokie]

6. The money is the problem with our healthcare

get rid of that one thing and we could all enjoy sane and sensible healthcare. It's the money thats the problem and always has been.

[rainy]

8. The profit ratio is out of control. The thought that going to the hospital for one night

can cost so many thousands of dollars is and a huge percentage of it is all profit is killing us.

[madokie]

12. literally killing us, or some of us anyway

[madrchsod]

7. medicare fraud exists because people fail to report doctors and others who defraud the system.

the doctor may bill 435 but what he gets paid is what medicare thinks he`s entitled to. a little known fact is that the majority of health care charges are based on what medicare pays in a given region.

[yellowdogintexas]

13. oh they do catch them. Those that upcharge and those that undercharge

get absorbed into the averageing anyway.

each service has its own procedure code, and the provider must consistently bill the same amt for the same code and match the code to the level of care.

If a provider kicks out as too high on too many services, he will get counseling on billing. I have done a little of that.

Fraud investigations have to prove intent to actually get them for fraud. Intent is hard to prove.

We actually had a case of beneficiary fraud in Tennessee...ER overutilizer seeking pain meds. We caught it because too many ER physician charges were submitted on her member ID within a particular amount of time. She had visited like 10 ER facilities in about 6 weeks for pain. The parameters of a routine program caught it, the claims were pulled and it was investigated. None of the providers knew about the others because she was hopping from one hospital to another.

[madrchsod]

23. i wonder how the insurance companies deal with fraud...?

i never read anything about big insurance companies going after fraud.

[yellowdogintexas]

25. good question. I am sure the really large carriers have fraud and abuse

departments and run programs to trap oddities.

However I expect they let Medicare and Medicaid find them because they really do a pretty good job of it.

[havocmom]

27. Yes; former Senator Bill Frist's(R- pirate) family got hit with a hefty fine for fraud

http://www.democraticunderground.com/discuss/duboard.php?az=view_all&address=389x6190103

http://www.usdoj.gov/opa/pr/2003/June/03_civ_386.htm

http://www.truthdig.com/uncovered/item/ucvd_frist/

[WeCanWorkItOut]

10. LBJ was in too much of a hurry to get Medicare passed

The power of the AMA was preventing the Medicare bill from getting out of committee
and up for a vote. Johnson was anxious not to fail like Truman, so he gave in.
He gave up pushing for proper price controls, gave too much power to the hospitals
and doctors to charge what they liked (what they considered "usual and customary").
The result was serious inflation, double-digit inflation of health care prices.
"Medicare is why doctors are rich," as Jonathon Oberlander once told Terri Gross.

Of course Johnson tried to correct the damage, but couldn't.
Some changes were made later, but no good thoughtful overhaul.

Of course that doesn't explain why the labor unions just let things happen.
(My theory about that is that they pay for advice from some rather narrow
high-income academics who identify not with people in general, certainly not
with labor, but instead with other high-income academics and professionals.)

I'm worried that we're in too much of a hurry now too. And I'm worried that
the Democrats are uncritical of the advice they get from those narrow academics.

[Aspca4ever]

11. I worked in the LTC {long term care} industry for over 7 years!

Medicare has provided ancillary charges such as {OT, PT, RT} to to be marked up 125%:

So my aunt Susy has a hospital stay {we'll say a stroke} she is released to her home for convalescent care {she's lucky that she won't need to go to the LTC facility near her home, she'll be receiving all of the therapy care at her house}, but regardless if it is provided at her house or at the LTC facility the daily invoice for actual therapy is going to be marked up 125% per invoice, per each specific therapy because that is what MEDICARE allows the medical billing to do {it's mandated to allow that amount of mark up}!!!:wtf:

HOLY BAT CRAP BAT MAN, who in the world decided that it would be necessary to allow that type of gouging for therapies...Oh, yes the therapies have over head cost involved in the billing, yes, my time doing the billing was so huge, the facility that housed the therapy room was so plush that the 125% mark up was needed, the mileage to & from my Aunts house was such a great distance that the 125% mark up was needed, the total man hours for the therapy session were so extensive/complex/mind boggling that the training to provide that service took years & years to study before a person was sufficient trained to provide the service... :sarcasm: This was over 10 years ago but the 125% mark up lives in infamy!

[patrice]

22. Some nurses I know say the Elderly are, on the average, definitely over medicated.

I wonder if that includes scooters for people who, at least at one time, would have been able to avoid those scooters if their care had been conducted under a different set of basic assumptions.

[GodlyDemocrat]

16. Yet we have no roblem spending $1 trillion for a preemptive war

This is not about costs, it's about priorities.

[truedelphi]

17. You got it! K & R. n/t

[nightrain]

19. and the privatization that has occurred, sucking the public money out of Medicare....

[patrice]

20. Only? How about the fact that "we" put War off budget and then "we" question nary a dime for it? 50%

of US revenues have gone into weapons and the military for decades and NO ONE questions it one bit.

[Gregorian]

24. When I was 15 I was teaching doctors how to interpret electrocardiograms.

I had volunteered to work at the Palo Alto VA hospital. The chief of carddiology took me under his wing and kind of dragged me around with him to all kinds of amazing places. Soon I was actually interpreting ekg's for the department. I could fly through a stack of them in a short period of time. And these were all difficult patients. Almost none were normal.

Some years later I was working at Stanford university hospital, and I recall a doctor who came in all dressed up in his best suit, after going out to dinner with his wife. He had come in to make a few bucks interpreting ekg's. I asked what he made, and it was $25 per ekg. Wow. It's all computerized now, as they were busy perfecting that back when I was working there. But I would bet that it's a lot more now. And there is absolutely no reason for it to be so. An ekg should be essentially free. And I'll bet anything it's well over a hundred bucks for one now days.

There are things that cost, such as special instruments. But the whole cost schedule could, and should, come down.

The way I look at it, after spending time in operating rooms listening keenly to the banter, is that none of us are better or worse than anyone else. After all, the chief of cardiology can't reroof a house worth a damn. And a roofer can't do a mitral valve replacement. One affects someone's life, and the other affects everything under a roof that someone has spent their life working for. I guess I have a unique perspective since I did both of those things. And I never felt like any of them deserved more than the other. I know this is flawed logic. If you had a bad roof and an aortic aneurism, I think I know which one you'd want to fix first. But things are way way out of perspective.

Furthermore, our government subsidizes the cheap cost of fuel through wars. And subsidizes defense. Let's shift priorities. It's a no brainer. Dropping bombs is the stupidest thing on earth. Being sick is also counterproductive. Therefore... Duh!

[Cleita]

28. The Medicare prescription drug benefit is draining the system because

the drug companies can charge anything they want. Get them in line with what the VA spends and the drain will stop. Also, the Medicare Advantage programs aren't helping. It isn't that the doctors are getting too much. No matter what they bill, Medicare only pays the accepted amount on their fee schedule so that is not where the problem is. You can be sure that Medicare will not pay $435 for an office visit.