Woot!!! thats revealing - I am on Medicare - got accepted this year and the only reason they didn't turn me down I think {besides having a life threatening condition] is because end stage renal patients have their own lobby in Washington D.C. - seriously....makes a difference...sad though that one is necessary to have any clout...but congress has its hand out and the palms must be greased to get anything done...Gads what a mess...thanks for this info starred and flagged..

I tore the meniscus in BOTH knees severely while on a temp job working for a friend. I didn't want to get him in trouble (since someone else had gotten hurt when he wasn't around and they were blaming him for it) so I kept quiet.

I wasn't sure what was wrong. I thought I would be okay in a couple of months. Six months later my knees were buckling out from under me when I tried to walk.

I used my insurance to get an MRI on one knee. Doc said he'd operate on one knee, let it heal, then work on the other. Did the operation. Then GOT A SURPRISE -

Since I'd not worked in six months (while trying to heal my knees on my own) I was told by the State of California (this is at the start of the financial meltdown) that I was no longer eligible for unemployment. They said it was because I'd not worked in six months. (Not being able to walk might have had something to do with that)

Next, while going back for follow ups at my doctor's I was told that my insurance was CANCELED. Once again, the excuse was I'd not worked in six months and was no longer eligible. So I was stuck with no income, trying to heal from a bad operation on one knee and a torn meniscus on the other.

Today, it's been a year since the operation. Both knees are still painful, but I've been doing all the nutrition and exercise tricks I can to come back from the injuries. Zero help from any insurance company or government.

Cartilage is the most difficult thing to heal, but I think in another year it should be better.

However, had I simply put the money I'd given the government and my insurance company over the past 20 years into an account I could have paid out of pocket for both operations ten times over.

Does the "system" suck? Yes it does. It's designed to squeeze the maximum dollars from individuals for as long as it can. Use it and you may become 'risky' and lose it.

I'd much rather have what my Canadian friends have. It makes much more sense (it just doesn't pad the pockets of insurance companies and the medical establishment).

My insurance company told me they would happily take me back for $1200 per month. How else will anyone be able to charge $15 for a single aspirin? I told them to forget it.

When looking at these figures, you have to take two things into account:

1) They are coming from the AMA, a group who heavily favored eliminating Medicare until about 3 months ago,

and 2) Doctors file many, many, many more Medicare reimbursement claims than they do private health claims. Most physicians who accept Medicare do so with the understanding that there is a larger pool of money in Medicare than in private insurers. If I'm working with a patient who uses Medicare, I would file reimbursement for every bit and piece of equipment and medical care given, as I know that most likely, the cost will average out when you take accepted claims and rejected claims into account. I wouldn't file as many with private insurers, as they are most likely to reject all but the most barebones claims.

These two points could explain rejection rate inflation on Medicare's part.

Originally posted by VneZonyDostupa
When looking at these figures, you have to take two things into account:

1) They are coming from the AMA, a group who heavily favored eliminating Medicare until about 3 months ago,

and 2) Doctors file many, many, many more Medicare reimbursement claims than they do private health claims. Most physicians who accept Medicare do so with the understanding that there is a larger pool of money in Medicare than in private insurers. If I'm working with a patient who uses Medicare, I would file reimbursement for every bit and piece of equipment and medical care given, as I know that most likely, the cost will average out when you take accepted claims and rejected claims into account. I wouldn't file as many with private insurers, as they are most likely to reject all but the most barebones claims.

These two points could explain rejection rate inflation on Medicare's part.

YES!!!

Plus, the way that Medicare is structured and the demographic in which it covers sets the stage for denials...the same denials that private insurance would distribute if these patients were not on the "public option".

[edit on 6-10-2009 by Aggie Man]

Just recently found out that my father was denied coverage due to Sleep Apnea. Problem is, he was never diagnosed. In fact, he was never even tested for it.

First, these aren't just "figures."

The "Report Cards" are 16 pages (2008) and 24 pages(2009) and include in-depth analysis of dozens of criteria. These reports cover SEVEN payers: Aetna, Anthem/BCBS, Cigna, Coventry, Health Net, Humana, United Health Care, AND Medicare.

It wasn't "targeted" at anybody other than people who pay them for their work.

Every group massages the statistics to make it slant the way they want. Did these figures compare denial of secondary claims versus primary? Did they take into account claims which were denied due to a cancelled scrip? Did they take into account those which were denied because the treatment was contraindicated by a senior physician?

These are the sorts of things the AMA doesn't disclose because then the balance would shift the other direction.

Nope. These aren't total numbers, they are percentages of claims PER payer.

No one said they were total numbers. If you reread my post, you'll see that I explained that a larger percentage of Medicare claims are filed simply as overkill. If I -think- my patient could benefit from an MRI, and he has a fairly comprehensive Medicare package, you better believe I'm filing a claim and shipping him off to imaging. though that claim to Medicare may be denied later, and it may not. If, however, the patient has a private insurer who doesn't like to cover things they don't pre-approve, and I don't think an MRI is absolutely necessary, I'm more likely to go a different route.

Basically, it boils down to knowing that Medicare will often cover things private insurers won't on specific patients. Granted, sometimes the reverse is true, but in my experience, I've had less trouble having claims approved through Medicare, even for relatively pricey and new procedures.

And, not all AMA members participate in Medicare!

Only about 30% of American physicians join the AMA. It's essentially a fraternity with a lobbying arm. When I was in medical school, they tried to get all of us students to sign up with the promise of a free Netter's Anatomy Atlas, but we had to sign up for a credit card first. Lovely organization

Unfortunately, even if you lump all the private payers together, Medicare's RATE of denial is much higher.

Source?



[edit on 10/6/2009 by VneZonyDostupa]

[edit on 10/6/2009 by VneZonyDostupa]

Every claim, public and private, is subject to specific coding and billing requirements to minimize fraud.

This is true regardless of the nature of the source of the money. EVERYONE is subject to fraud, and ALL claims must be substantiated.

Nevertheless, many criminals realize that the Government will not do as good a job of screening, and will pay claims that are blatantly fraudulent.

Government incompetence is the single largest source of medicare and medicaid fraud.

(Want a free electric scooter, hearing aid, or glucose meter? No doctor required. No tests, no 'messy paperwork.' Just provide your Government program info., and it's yours. Guaranteed. (sound familiar?) Try THAT with private insurance.)

Private payers do not just accept any claim at face value.

Would you?
jw

The government doesn't screen as tightly because it is not a for-profit business. I would rather receive smaller reimbursements from my claims if it meant I could provide any treatment I felt applicable without having to argue with minimum-wage phone-monkeys about why I don't want my patient on beta-blockers and am instead opting for a newer medication that has been shown to be more effective in that specific patient population.

Take today, for example. I had one of those lovely phone-monkeys, who didn't sound like they had even gotten a high school degree, tell me that my patient couldn't have the new anti-retroviral for their HIV because it was 'shown' to be 'barely any better', nevermind the fact that my patient had already developed a resistance to current HAART therapies, and thus this was the only option.

I do not know what you asked for. The links include the complete "Report Cards " for 2008 and 2009. There are links within the reports to the AMA and payers own records used in their compilations

The information I asked for is very clearly stated in the tenth post of this thread (see: 10/6/2009 at 05:31 PM). Until you can show me that this information was controlled for in the AMA study, I still call shenanigans on the denial rates as a sign of poor treatment.

Yes, they do: Combine the private payers' denial rates for 2008 and 2009, combined. Take the average.

Take the Medicare rate of denial for 2008. Combine with 2009 rate. Take the average.

Subtract the private payers' combined average denial rate form the Medicare combined average denial rate.

If the result is a postive number, Medicare has a higher combined rate.
If the result is a negative number, Medicare has a lower combined rate.

I learned how to do this from Mrs. Skloss in the 4th grade.
I got an "A."

jw

You should also have learned that saying they have a combined lower number means you add them values, not average them. Saying that all the private insurers combined have a lower denial rate means adding the denial rate of Aetna to the value of BlueCross, etc, giving you a double-digit value. If you meant that the AVERAGE private insurer has a lower denial rate than medicare, than your above schematic is correct.

You may want to get your mathematical terminology correct before spouting off like that. It makes you seem less foolish.