Healthcare question : I hate to ask

[tinkerbell41]

My brother's gf claims to be a Dem, but she parrots RW talking points. She works in billing in a doctor's office. She claims Medicaid pays out 110.00 on a 2000.00 procedure, and if we had a public option "everyone would lose their jobs" and the pay for said jobs would go down. My brother agrees with her, he is against it also. I have alot of shit going on at the moment and under a ton of stress. I didn't have the energy to fight back, I wasn't on top of it so to speak. I haven't watched ANY news program in months, so I have no idea what is being said or where they are getting this info from. I can take a guess, but I don't want to be talking out of my ass, I just felt unprepared. Anyone have an answer?
As a side note, I had to listen to these two tell me over and over, how Obama couldn't and wouldn't win, how they didn't see a Dem ever being in office again. Needless to say, I received about 5 congratulatory phone calls the next day, I was the only one, besides my ex that was on board
since the primaries.

[rucky]

1. "everyone would lose their jobs"

= she's afraid of losing her job

She should get re-skilled in a different industry, instead of trying to defend the indefensible, imho.

[Toucano]

6. She'll still be needed.

In fact, she may be more needed.

She has a job sending out bills.

More people insured under Medicare for All means more bills for her to send in for payment.

She's short sighted.

[tinkerbell41]

17. My thinking also.

She is not very informed. Doesn't bother educating herself. I love her but she is like my GF's I dumped long ago. Only concerned with cell phones, nail polish, beanie babies etc... I feel like an alien except when I am here.

[Old Codger]

2. Misleading info

If she has seen a bill that shows medicare paying 110 out of 2000 she is using a bill that is for a procedure that medicare doesn't cover, I have medicare, I am going in next week for some minor surgery , I made sure ahead what my share would be, the surgical center didn't give me a total but my share of the total bill, Dr and the center including all normal costs, (if there are complications it will be more) is 110.

[abluelady]

3. Let's Look At It Another Way

Perhaps the $2,000 procedure should really ony be $110. Markups are totally for profit How much does something "really" need to be marked up. Believe me when hospitals negotiate prices for services, they make money.

[tinkerbell41]

13. Yes.

I started to answer this way, and I just let it drop. I hate to talk about something when my facts aren't straight. I read so much on so many different subjects, I have a hard time keeping it straight.

[sinkingfeeling]

4. I agree that Medicare/Medicaid/SCHIP all pay providers less than what they would charge someone

without insurance. Now ask her if the $2000 procedure really is a $2000 procedure. I bet that her same doctor will accept around $500 to $800 from any insurance company as 'payment in full' for the procedure. Then ask her if having, let's say 5 patients, pay the full $2000 is more profitable than being paid $500 for 20 of the procedures. If more people have insurance, they will have more 'work', and should be able to price 'procedures' in accordance with supply and demand. Same with drugs and testing.

[ejpoeta]

10. plus, if you think about it.... medicare doesn't make the doctor or hospital fight for payment

like private insurers do. it costs money to have staff whose sole purpose is to fight for payment. since medicare usually wouldn't try to NOT pay the bill, then it would generally cost less anyway for the start to finish of the procedure than dealing with a private insurer would.

[roakes10190]

5. pay scales

On C-span this week the guests are from Virginia Hospital. Three doctors were on last night. When asked how payment was decided, they said that private insurers pay maybe less than 1% over the Medicare scale. In other words, if Medicare pays $100, a private insurer would pay no more than $101 for the same procedure. No insurer, private or Medicare, pays what the hospital charges. In rereading you post, I see you said Medicaid, not Medicare. No one is talking about making the public option like Medicaid. The same payment schedule would apply to doctors.

[Toucano]

7. Has it occurred to them that the procedure shouldn't cost $2,000?

What an amazingly difficult task it is to convince these people that the problem is WE OVERPAY!

What makes it cost $2,000?

It's a made up number.

Let's make up new numbers, okay?

[yost69]

8. I am against the reform as well but I think her numbers are wrong.

I thought medicare and medicaid payed 80% of what the actual bill is. Which is why they overcharge the private insurance companies to make up the difference of what isn't being paid by the government. I could be wrong.

And as for losing jobs, not everyone will lose their jobs, just some people will lose their jobs as the hospitals have to cut costs to come down to the 80% being paid. I don't see why that is that hard to understand. All these people saying no one will lose their job, no equipment is going to be outdated. All I can say is we will see.

All these people saying that doctors get paid to much and they need to come to reality. If a doctor got paid the same as a factory worker who would waste 7 years and more of their life to become a doctor?

[sinkingfeeling]

12. You need to start over. You don't want to see reform, so I assume you're wealthy enough not to be

concerned that the cost of your health care will doubt in the next 8 years. That includes you even if you have employer sponsored health insurance. The cost of said insurance doubled in the last 10 years and will continue. In order for the insurance companies to make their profits, they raise the costs of premiums (sometimes more than once per year), deny coverage, cancel your policy once you need the insurance, raise co-pays, deductibles, and 'out-of-pocket' expenses. The question is who/what determines the amount charged on that bill. Why does the same medical procedure or prescription drug cost 10 times more in the USA than it would in Canada? Why will a doctor or hospital accept 40% of their 'charge' from an insurance company?

I've got 29 pages of EOB from my insurance company right here. It's for the 33 radiation treatments I just completed. On 4/13, the oncology group billed $7010 for my first treatment, including a dosimetry calculation. The insurance company settled it with a total payment of $2774.39. Now tell me was the treatment worth $7010?

Doctors and hospitals that accept Medicare/Medicaid patients have agreed to accept their payment scales.

Now why don't you want health care reform?

[yost69]

25. I am not against a reform. I am against the reform proposed.

Obviously the said treatments were not worth the 7K billed. The hospital probably overcharged because they knew that they would have to settle for less.

HR3200 will give the government power to deny certain coverages as well so I see no difference.

The deductible in HR3200 will start at 5K for a single person and raise every year with inflation, to the nearest $100, I also see no difference.

I have no health insurance. I choose not to have it because of the way they do business. In HR3200 I will be fined 2.5% of my income for choosing not to have it. How is that fair? It's not.

The insurance companies have screwed up the healthcare in this country with their negotiating tactics, but the insurance companies are a business. They are out to make money, as well as every other business in this country. Why are you against business' making money?

Now that I have made myself clear on the fact that I am not against a reform, just the one proposed I will follow up with the fact that I like some of the things in the proposed bill. I would like to see a reform in healthcare, but there are to many things in that bill that I dislike to be for it.

[sinkingfeeling]

29. Wrong. In the draft of HR3200, discussion of the Public Option isn't until page 116: Title II,

Subtitle B. On page 119, you will see that premiums and details about deductibles are not established. There is a discussion of $5K for a single person and $100 increases on page 29, which refers to 'essential benefits' to be covered by for-profit insurers (Title I, Subtitle B).

I think it's more than fair to fine somebody a lousy 2.5% of income for choosing not to be covered. If you make a $100K a year, that's only $2500, which is much less than you'd pay for insurance. Something has to cover you when you're hit by a bus crossing the street or get swine flu.


I'm not against business' making money. As a liberal Democrat, I'm against a business killing 22,000 or more of my fellow citizens every year so that their execs can cart home $millions in bonuses. What we need, like every other civilized country in the world already has, is universal, single-payer care. The poor, dear for-profit insurers will still be able to make money by providing the 'extras' some folks want (just like in Canada and England). The only way America will ever get to universal care is by passing a bill with a strong public option.

[yost69]

33. Let me put this in a way that you understand

What if the government passed a law that states you must pay for and take a firearms class and carry a firearm at all times, otherwise you will be fined 2.5% of you income.

What if the government passed a law that states you must pay for and take a farming class once a year or you will be fined 2.5% of your income.

If those two didn't work for you how bout this one

What if the government passed a law that states you must give a reasonable donation to a republican of their choice once a year or you will be fined 2.5% of your income.

Something has to cover you when you're hit by a bus crossing the street or get swine flu

It's called cash. Why is my money not as good as the governments messed up healthcare reform?

[sinkingfeeling]

34. OK, why are you even on DU? You are so wealthy that you will be able to pay

for all your medical bills throughout your life. I hope you realize that any provider will charge you whatever they desire and you can't act like an insurance company and only pay part. Cancer or a major heart attack will cost you somewhere between $150,000 and $1,000,000.

Your 'mandatory' laws are insane and exhibit a fear of government and since the current reform plans are all from Democrats, who do you support?

[yost69]

41. So my mandatory laws are insane but the one in the bill is not?

I don't exhibit a fear in shit. I was trying to put it so you would understand my point of view. Any law that takes away a freedom of a law abiding citizen is not a good one.

I support any government figure that has common sense. Not one that wants to take over the country and feel all powerful because they can make you do something you do not want to do.

[sinkingfeeling]

45. So do you advocate driving on public streets without auto insurance? That's a government mandate.

Again, why are you on DU? "I support any government figure that has common sense. Not one that wants to take over the country and feel all powerful because they can make you do something you do not want to do." would seem to say you oppose not only Obama but all the Democrats working for health reform.

[yost69]

46. NO

If you are driving on the road you should have insurance to cover the other person. There is no law that says you must have insurance to cover your assets.

Why should there be a law that punishes you for not having health insurance? Who are you hurting except yourself if you choose not to have it?


You can not compare health insurance to auto insurance. It's comparing apples to oranges.

With auto insurance you are protecting the other person on the road, you choose to protect your property by paying extra premiums.

With auto insurance your rates go down as you get older.

With auto insurance you can choose not to pay for it by not driving a vehicle that requires insurance.


For the last time I am not against a reform. I am against certain aspects of the reform proposed. If they would simply state what the premium is and do away with making it mandatory that you get health insurance I don't see many other problems with it.

would seem to say you oppose not only Obama but all the Democrats working for health reform.

So are you implying that Obama and all the Dem's working for health reform don't have any common sense?

[kath]

31. $5k deductible for a SINGLE person?! Jeebus, that's outrageous.

Way, way more expensive than what the Canadians and the pinko commie Yurpeens have to deal with...

None of the bills I've heard of so far have a REAL, robust public option, nor do they provide for access to TRULY affordable care...

[sinkingfeeling]

35. Fortunately, it's also not true.

[abumbyanyothername]

14. who would waste 7 years and more of their life to become a doctor?

Exactly the kind of person that we want to be a doctor. That is, one that is motivated by a desire to help and heal people rather than by a desire to get rich and have unlimited power over people.

[tinkerbell41]

18. My kid wants to be a vet.

The decision wasn't about money. I put the thought of the cost of school out of my head. I am focused on her being happy. She has always loved animals, I knew when she switched her major to Biology we would end up here. She will be doing it, out of her care and concern, and love for all creatures, this I know.

[yost69]

26. Well said. But

What if those said people that go into the profession to help people don't have the equipment to help with because of cost cuts made by the hospital? What if those said people get so stressed out that they are no longer willing to work in that profession because the hospital they work for has cut staffing to make up for the cost cutting done by the governement.

Do you think they will open a private practice? How are they going to be able to afford to open a private practice with no money because the government decided they do not need to make that much money a year?

I recently went in for my DOT physical and it cost me $135. Two years ago it cost me $95 and two years before that it was $65. That is just a basic physical, in and out in about 20 minutes. Is it worth it? Probably not. I don't know what they charge for other stuff but as a private practice their expenses go up so they must recoup the costs somehow. So they pass it on to the customers.

With a government run plan they do not have an option to raise their prices to cover expenses so they will not buy thise new piece of equipment that they could use, they will get rid of employees and just put more of a workload on the existing ones. They will continue to trim the fat until they have nothing else to cut and have no choice but to go out of business.

[ItNerd4life]

27. I think you are confusing doctors with politicians

Politicians want power and wealth first. Look at how many are rich.

I have many friends who are doctors or are studying to be doctors, they are not overpaid for the hours they work and the knowledge they have. It takes high intelligence and diligence to be a doctor, they deserve to be well paid. If they didn't we wouldn't have any doctors. Even the countries with nationalized healthcare understand that you have to pay doctors well.

[justgamma]

9. Does she work in a large city office or a small

rural office? There is a reimbursement inequity in Medicare. The larger cities and hospitals get paid more for patient than the smaller ones.
HR 3200 changes that. They have a provision that the payments should be based on quality and not quantity. They are striving to make it more fair to the rural areas where the procedures cost the same but are reimbursed less.

[tinkerbell41]

16. Large city.

It was Medicaid. Public Assistance. You know people who don't deserve help. Based on the answers here I see the shit they are saying is shit.

[peace13]

11. Here's another way to look at it...

My son had his wisdom teeth out, $2000.00 cash up front, out of pocket because we did not have dental insurance. The bill would have been $1200.00 if the insurance were to pay it. Now tell me who is financing this screwed up system? By the way, there are doctors that support health care for all Americans, but hey, they might just be the left wing loons!

[tinkerbell41]

15. See, I wish I was prepared.

I get it. I just have a hard time coming up with facts when I am not thinking. I guess it's like
debate team where you write up your talking points and memorize the speech for a few days. That's what i need. I just flippantly said,"That's why we need Healthcare reform" when my brother mentioned in Cincinnati the Tradesmen gave up their health insurance to compete with non-union sector, and out came these talking points, among other things he said "people will take advantage of it."
How is that? What, you break an arm on purpose? Willingly get cancer?? WTF? I swear I think I am blinded by the fact he was the "smart one" in the family. Top of his class etc...

[peace13]

19. I hear what you are saying...

don't kid yourself that he is the smart one. Fire your response back in writing so you will not be intimidated. Good luck! Peace, Kim

[tinkerbell41]

22. I have questioned that more lately.

All of my thoughts and ideas have been discounted. The strange thing being I have always turned out to be right. Why they never grasp that is beyond me. I guess I come off as the happy-go lucky
ditz, but I am the one with my nose always in a book, or journalistic mag. It is always non-fiction for me, i am catching up on what they didn't teach in school.
I desperately tried to warn my dad of what was happening in the markets, he ignored me and lost
half, I saved mine. After researching the way of College admissions, and ways to pay for it I talk to anyone who will listen, because no one tells you school really doesn't cost 35,000 a year if you don't have the means. Sorry to rant, but I am aggravated that they never take my advice.

[rhett o rick]

See the link

http://progressivecongress.org/PC_HealthCare_080409.pdf

[JVS]

20. She has a vested interest in the status quo

[dugaresa]

21. I worked in medical billing and let me explain

Doctors/Hospitals/Providers of Pharmaceuticals and Medical Equipment can charge what ever the hell they like for a service or object.

However!, any insurance company both private and public (and please note that insurance companies are the ones who actually get the contracts to run Medicaid and Medicare) have what they call "allowables" for services/objects.

So if the rate being charged is:

$250/month for a wheelchair, insurance companies (private and public) may have set the allowable at $30.

Same for a general doctor's visit.

Dr. may charge $150 per visit but allowable may only be $45.

The general rule is that the providers of medical care set their rates so high hoping that the allowables will increase from year to year (and they do), and also different regions of the country have different allowable rates. Problem is that the uninsured get screwed by this system because they get charged these unfair rates. In fact, buying health insurance is what gets people into the game which is why paying for health insurance is like paying "protection money", because you get protected from those ridiculous rates so that even if your insurance is 80/20 you will only pay 20% of the allowable charge not the crazy high rate.

The interesting part is that some insurance companies set the allowables and then only pay 80% of the allowable (like Medicare) and I am not sure how that system came to be.

Clearly this young woman is just to new to the game to understand how the system works and how it is gamed.

[tinkerbell41]

23. Aha!

Thank you! I know she doesn't have a complete understanding, and I couldn't figure out how to explain she was wrong. I won't talk out of my ass just to make a point. I always want to be sure of my reply.

[dugaresa]

24. I did consulting in the billing industry for years

and there were loads of folks like that woman who didn't understand the "game" and their employers played off of their lack of understanding by saying "if only i could get what I deserved, I could pay you gals more"..etc. As you can imagine this would infuriate people who were processing claims because they felt cheated by the insurance companies. In reality their employer was playing them, while laughing all the way to the bank.

It was kind of sad and pathetic to see the "serfs" getting upset on behalf of the lord of the manor, and it shows you how trusting people are without questioning the situation.

I never met anyone who ran a medical care business that wasn't raking in the cash.

[ItNerd4life]

28. Now that is an intelligent post.

So if we don't get nationalized care and go with a more free market system, is there a way to stop the gaming?

I think part of the problem is people don't shop around. They have health insurance provided by their company so they don't care about what costs/charges are being made.

[dugaresa]

30. Shopping for insurance is not easy unless you understand what you are doing

and few people understand how the market works or can understand the fine print.

Employer based coverage is typically the best because you get accepted no matter what pre-existing conditions you have. The problem is that some employers subsidize their healthcare in that they use an insurance company to handle their claims but they pay the actual costs of care and that means that if your employer gets wind that you are a medical drain, you will lose your job.

When you buy insurance through a carrier as a self-payer, they have to assess whether you are worth the risk of insuring. They want to make a profit off of you. So they are hoping you pay in but never look to get any services. That is why the absolutely love young healthy people who pay but never go to the doctor (contrary to what they tell you)

If you are a bad risk, like an asthmatic, you will find that the rates are so high or they will flat our refuse you.

This is because the insurance business is "for profit".

In reality the folks who should make money are the hospitals, providers and folks who make medical supplies and some of them (hospitals) should be non profit. Insurance companies exist soley to make money and that is it and they somehow got this cushy position of being between you and the provider of services.

A national system would be best but I fear it will be contracted out to private insurers and they are going to try and scheme the system to make profits. The key would be to create a large goverment agency to handle claims to eliminate profit motives and then have an oversight board to keep tabs on claims and processing and costs. Problem is that the private insurance lobby will fight that tooth and nail.

[peace13]

36. Do you shop for your insurance?

Our company that we had been with for 22 years dumped our health policy. Trust me, it's no picnic!

[livetohike]

32. "how it is gamed"

:toast: for spelling this out for everyone. Good job :-).

[cbdo2007]

37. Also, aren't there "provider write offs" which allow the doctors to "write off" the amount not

covered by insurance?

I don't know for sure...but there are two rates, the billed rate and the allowable. Please correct me, but I think the doctor can "write off" the difference between the billed rate and the allowable as a loss. So the higher the billed rate vs. the allowable is good for them come tax time.

[dugaresa]

39. to be honest they can't really write off that amount because

it would probably result in tax fraud. I was involved in the actual profit (what they received) side of the business and how to use computer systems to keep track of billing. A lot of what I did was to make sure that people used existing systems they way they should to make sure that they billed properly and that they would get their payment.

As far as I know and I worked in that industry for over 5 years and my spouse is still working in it, they don't get to write off that difference. I don't know that they even get to write off a percentage of that. It would be really hard to justify to the tax man that the rate they view as "justifiable" versus the allowable is truly a loss. They agree to that allowable when they agree to accept that insurance as payment.

The providers adjust their rate each year and then petition to have adjustments to the allowables. I think the big price differences are pretty much there to make sure that they are over all possible allowables for the varying insurance companies. Plus it is part of the game. Those high prices are a way to coerce people into paying for insurance. Imagine if the doctor really only charged $45 for a visit to people without insurance? People might not need that "middle man" which is the insurance company.


on edit: they may be allowed some write offs but with the vast differences between billed and allowable amounts, it would easily allow them to show a negative profit and that is something the IRS would frown upon.

[cbdo2007]

40. Thanks for responding - also, where does "reasonable and customary" come into play?

See, I was on the insurance side for 5 years in billing in finding claims payment issues, but that was a few years ago now so I'm not as fresh on all of this as I need to be during the health care debate also.

Are you familiar with "Reasonable and customary" charges? I think that a doctor can't just come up with the rate on their own, well they can, but the insurance company typically will not consider more than the "reasonable and customary" amount that is put together by some company that takes the average amount for that CPT code in that zip code and then considers that the target "billed rate" that most providers should use. I believe the providers get a write off up to that "reasonable and customary" amount so they can bill way more but the govt. isn't responsible to make up the difference...or something like that.

See, it's not all just as easy as more health care for less money...there are many, many factors here and we're just scratching the surface.

[dugaresa]

42. I just put a call into a friend who works at a doctor's office

and then also found this web site which provides the rules for write offs.

My friend told me the only stuff her doctor can write off are the payments he doesn't receive from clients

http://www.physicianspractice.com/index/fuseaction/qa.details/qaID/527.htm

This backs up what I thought which is that they can't really write off those difference between what they charge and what the insurance company allows.

"
To my mind, you should have:


One pile for contractual allowances/allowables/discounts (these aren’t really “write-offs” of course, but many like to track them anyway).


Another for patient write-offs — money you couldn’t collect from patients.


Another for payer write-offs, by payer — money you were legitimately owed but you didn’t collect because of some problem of yours — late filing, sloppy registration, etc.

"

I consulted to hospitals and outfits that provided equipment along with nursing agencies. The rules are basically the same.

[dugaresa]

44. I also want to add that many physicians get capitation payments

from insurance companies. That means the physician gets a small payment every month for accepting that person into their practice from the insurance company. So if the capitation rate is $3, that means for every XYZ Health Insurance patient in the practice they get $3 x the number of patients. So if they have 100 patients from XYZ Health, they get $300 a month for doing nothing.

[cbdo2007]

38. One more thing - for people that don't have insurance...the rates are negotiable...

Tell the docs you don't have insurance and many times they'll lower the amount they bill you so you CAN actually get the "allowable" rate rather than the "billed" rate.

Even after people get the stuff done, the rates are negotiable for people without insurance so if you owe a $5,000 ER bill. Call the hospital and tell them you can't pay it and ask them if they'll take $2,000. MANY times they will cause the difference is just a write off to them anyways.

[treestar]

43. Her employer is convincing her she will lose her job

And that means her health insurance, too.

This always happens. Whenever a state proposes no fault auto insurance, the trial lawyers who make money from auto accidents fear a loss of livelihood, and pass that down to all of their employees and suppliers.

When a military base is proposed to be closed, everyone in the military town sees a loss of income. Naturally they begin to believe that particular base essential to the defense of the nation.

Doesn't matter what it is. The thing to focus on is that she can get another job - if anything, the government will hire more people, it will handle what she is handling now. The rich are going to pay her instead of the yacht manufacturers, for example.