My medicare supplement

[Blues]

On 10/18/2022 at 9:05 PM, sandsys said:

For out-of-network Humana pays half and we pay half--of the amount Humana allowed not what the provider billed. For instance the anesthesiologist billed $3,000. Humana allowed $300. We have to pay $150

Since the out-of-network provider doesn't have an agreement with Humana, why would the provider accept the lower amount, never mind an amount that is only 10% of what's billed?   (Acknowledging that what gets billed is pretty much never what they actually get paid.) 

Could it be that $300 is what Medicare allows for the procedure, Humana offers $300, and the provider says, "Oh, okay, we don't have an agreement with you, Humana, but we'll take what Medicare pays because we take that all the time with our traditional Medicare patients."

But what if the provider is one that doesn't accept Medicare at all, be it traditional Medicare or any Medicare Advantage plans?  If MA PPO plans allow you to see any provider under the sun (with out-of-network coinsurance terms, of course), then a MA PPO member would actually have access to a larger pool of providers than someone with traditional Medicare, which doesn't allow you to go to providers that don't accept Medicare.  That doesn't seem right, but maybe it's a loophole?

But what happens if a MA PPO member goes to an out-of-network provider that doesn't take Medicare?  How does the MA PPO negotiate?  If they say, "This is what Medicare pays," the provider would say, "Yes, I know, and that's why I don't take Medicare patients."  Then what? 

I'm guessing the MA PPO would attempt to negotiate, but really, what's the incentive for the provider to do that?  Just bill the total amount, get the MA PPO's half, and even if the patient doesn't pay a dime of his half, the provider is still way ahead compared to knocking the fee down to 10% of its original amount, with no benefits that come from being in-network for the MA PPO.

And actually, this could happen with providers who DO accept Medicare but don't take any Medicare Advantage plans (i.e., aren't in any Medicare Advantage plan's network).  The MA PPO could say, "This is what Medicare pays" and the provider could say, "Yes, I accept that from Medicare, but I've chosen not to do the same with you, and you know that because I don't participate in your network."  What leverage does the MA PPO plan have?   

[Randyretired]

Our plan pays Medicare Rates  and it pays anywhere Medicare is accepted.  I believe  if they accept Medicare  then they agree to accept Medicare Advantage at Medicare rates.  We go out of network a lot and never a problem.  Of course they can network and accept lower rates.  I've been told by reps. from the Advantage plan that we can go to facilities that don't accept Medicare and they will pay Medicare rates.  We would then be responsible for the remainder.  Probably pay upfront then be reimbursed.   I haven't tried that.

[sandsys]

2 hours ago, Blues said:

Since the out-of-network provider doesn't have an agreement with Humana, why would the provider accept the lower amount, never mind an amount that is only 10% of what's billed?   (Acknowledging that what gets billed is pretty much never what they actually get paid.) 

Could it be that $300 is what Medicare allows for the procedure, Humana offers $300, and the provider says, "Oh, okay, we don't have an agreement with you, Humana, but we'll take what Medicare pays because we take that all the time with our traditional Medicare patients."

I was told anesthesiology is a separate category because you don't get to choose the anesthesiologist--the hospital assigns one. So, even if there is no agreement per se the anesthesiologist has to accept the Medicare rate.

BTW, the entire rest of my surgery was covered except for my $250 copay. $400 for a major surgery ($150 for the anesthesiologist) feels like a win to me.

Linda

[Dutch_12078]

11 minutes ago, sandsys said:

I was told anesthesiology is a separate category because you don't get to choose the anesthesiologist--the hospital assigns one. So, even if there is no agreement per se the anesthesiologist has to accept the Medicare rate.

BTW, the entire rest of my surgery was covered except for my $250 copay. $400 for a major surgery ($150 for the anesthesiologist) feels like a win to me.

Linda

My wife had two valves placed in her lungs this past summer to improve her breathing. The total bill was ~$89,000 including three days in the ICU. Her UHC Advantage plan paid ~$34,000 and her co-pay was $235.

[Randyretired]

Sounds as if many of the Advantage plans are really good.  When my DW went for cancer treatment they asked what insurance she had.  When she told them Medicare Advantage there was an immediate look of concern.  Seems some bare bones plans can leave a patient with a large bill.  When we told about her plan and it would pay 100% of Medicare approved billing all was good.  Careful shopping is the key.  Not all plans are the same!

Edited October 21, 2022 by Randyretired

[2gypsies]

2 hours ago, Dutch_12078 said:

My wife had two valves placed in her lungs this past summer to improve her breathing. The total bill was ~$89,000 including three days in the ICU. Her UHC Advantage plan paid ~$34,000 and her co-pay was $235.

So you had to pay approx. $50,000?

[Chalkie]

52 minutes ago, 2gypsies said:

So you had to pay approx. $50,000?

I doubt it, the rest was likely written off. 

[Randyretired]

1 hour ago, 2gypsies said:

So you had to pay approx. $50,000?

When we see a bill the original bill is for the providers normal retail amount.  It is then readjusted to Medicare rates which are significantly less.  The copay probably is all that is due.  Before Medicare we saw the same kind of scheme to make us feel like we got a good deal.

[pjstough]

17 minutes ago, Randyretired said:

When we see a bill the original bill is for the providers normal retail amount.  It is then readjusted to Medicare rates which are significantly less.  The copay probably is all that is due.  Before Medicare we saw the same kind of scheme to make us feel like we got a good deal.

My understanding is that the difference between what a provider charges and what the provider has agreed to accept from Medicare is considered a loss by the provider, and can be deducted from income by the provider.

[Kirk W]

If you are interested in the differences, there has been a lot published on the subject. 

Federal laws and regulations require hospitals to maintain uniform charge structures. Payments, however, do not correspond to those charges. What a hospital actually receives in payment for care is very different. That is because:

• For Medicare patients, about 42 percent of the typical hospital’s volume of patients, the U.S. Congress sets hospital payment rates.

• For Medicaid patients, about 16 percent of the typical hospital’s volume of patients, state governments set hospital payment rates.

• Private insurance companies negotiate payment rates with hospitals. Privately insured patients make up 32 percent of the typical hospital’s volume of patients. Private insurance company payment rates vary widely. Larger insurance companies typically are better positioned to demand bigger discounts.

• Tax-exempt hospitals are prohibited from billing gross charges for those eligible for financial assistance. Under the ACA, tax-exempt hospitals are required to have a written financial assistance policy that is widely distributed in the community. Care is either provided for free, or based wholly or partly on Medicare rates under the Internal Revenue Service (IRS) regulations.

• Those insured patients who are seeking care at a hospital outside their insurance company’s network, as well as patients whose care is paid for by other types of insurance (e.g., worker’s compensation, auto liability insurance, etc.), are billed full charges.

This comes from a Fact Sheet: Hospital Billing Explained from the American Hospital Association. It is only 2 page and worth reading. 

How Differences in Medicaid, Medicare, and Commercial Health Insurance Payment Rates Impact Access, Health Equity, and Cost  from The Common Wealth Fund

And from the Kaiser Family Foundation: How Differences in Medicaid, Medicare, and Commercial Health Insurance Payment Rates Impact Access, Health Equity, and Cost

• Private insurers paid nearly double Medicare rates for all hospital services (199% of Medicare rates, on average), ranging from 141% to 259% of Medicare rates across the reviewed studies.
• The difference between private and Medicare rates was greater for outpatient than inpatient hospital services, which averaged 264% and 189% of Medicare rates overall, respectively.
• For physician services, private insurance paid 143% of Medicare rates, on average, ranging from 118% to 179% of Medicare rates across studies.

 

[Dutch_12078]

3 hours ago, 2gypsies said:

So you had to pay approx. $50,000?

As the others have said, the difference was adjusted out in what ever manner is most favorable to the facility's bookkeeping. All we paid was the $235 co-pay plus a small sum, $7 as I recall, for the TV, Internet, and phone service in her room.

[Chalkie]

18 hours ago, Dutch_12078 said:

My wife had two valves placed in her lungs this past summer to improve her breathing. The total bill was ~$89,000 including three days in the ICU. Her UHC Advantage plan paid ~$34,000 and her co-pay was $235.

Sometimes I wonder how these hospitals and doctors make any money at all. Clearly they do, but the amount paid is likely why doctor offices seem to run patients through like cattle through a chute. 

When I was hospitalized for COVID I had one of the really bad cases, not ventilator bad but close. Anyhow the bill for my stay just from the hospital was $144,246 and Medicare paid only $14,931, roughly 10%, and I owed nothing.

[Dutch_12078]

2 hours ago, Chalkie said:

Sometimes I wonder how these hospitals and doctors make any money at all. Clearly they do, but the amount paid is likely why doctor offices seem to run patients through like cattle through a chute. 

When I was hospitalized for COVID I had one of the really bad cases, not ventilator bad but close. Anyhow the bill for my stay just from the hospital was $144,246 and Medicare paid only $14,931, roughly 10%, and I owed nothing.

I suspect they set their standard rates high enough that even with the discounted insurance payments they still make money.

[Jaydrvr]

3 hours ago, Chalkie said:

Sometimes I wonder how these hospitals and doctors make any money at all. Clearly they do, but the amount paid is likely why doctor offices seem to run patients through like cattle through a chute. 

When I was hospitalized for COVID I had one of the really bad cases, not ventilator bad but close. Anyhow the bill for my stay just from the hospital was $144,246 and Medicare paid only $14,931, roughly 10%, and I owed nothing.

Not to be a tin hat conspiracy theorist, but there's no doubt in my mind that there is a lot going on behind the scenes that ordinary people are not privy to. I've watched hundreds of millions of dollars worth of hospital expansions and new construction, plus I've seen doctors live very comfortably, in addition to paying off their enormous student loans. I do know there are contracts with teaching hospitals, for example and I'm sure there are other significant revenue streams. There's no way they're making ends meet on the drastically reduced bills we see at the consumer end. What the real story is, I have no idea.. Jay

Edited October 22, 2022 by Jaydrvr

[Kirk W]

2 hours ago, Jaydrvr said:

Not to be a tin hat conspiracy theorist, but there's no doubt in my mind that there is a lot going on behind the scenes that ordinary people are not privy to.

But it is far more fun to jump into conspiracy theories than to actually dig into the facts. Comspiracies have become the favorite passtime of many people today and it must be a lot of fun as the number doing it keeps growing! Some of the same people who poke fun at the https://theflatearthsociety.org/home/Flat Earth Society buy into conspiracies that are just as far fetched. 

[pjstough]

6 hours ago, Kirk W said:

But it is far more fun to jump into conspiracy theories than to actually dig into the facts. Conspiracies have become the favorite pastime of many people today and it must be a lot of fun as the number doing it keeps growing! Some of the same people who poke fun at the https://theflatearthsociety.org/home/Flat Earth Society buy into conspiracies that are just as farfetched. 

Yes, somehow, truth, facts and reality no longer matter to a growing number of people.

[RV_]

Yep KIrk and

On 10/22/2022 at 3:24 PM, Kirk W said:

But it is far more fun to jump into conspiracy theories than to actually dig into the facts. Comspiracies have become the favorite passtime of many people today and it must be a lot of fun as the number doing it keeps growing! Some of the same people who poke fun at the https://theflatearthsociety.org/home/Flat Earth Society buy into conspiracies that are just as far fetched. 

Yep!

[RV_]

On 10/22/2022 at 9:45 PM, pjstough said:

Yes, somehow, truth, facts and reality no longer matter to a growing number of people.

Yeppers!

🤫🖖

Edited October 24, 2022 by RV_