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pgbMDSBDMatthew Holteric NovackPeter Recent comment authors
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SBD
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SBD

Thanks for your response. Here is what happened in my case which seemed odd to me. Although it doesn’t have anything to do with Medicare, per se. I received a bill from Sharp Hospital that said the balance was the amount owed by the patient which is the balance not paid by my insurance. The amount was $15,000. Well, my plan has a $5,000 per year maximum out of pocket expense. So I called Sharp Hospital and they referred me to Sharp Community Medical Group. Sharp Community tried to refer me back to Sharp but I said that would not… Read more »

Eric Novack
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SBD– the article does not have all the info necessary to give you a perfect answer. But my sense is that the medical group must have an exclusive contract with Pacificare (now UHC) which calls there medicare advantage plan ‘secure horizons’. In this case, UHC only contracted with the one medical group, and the group must not have any contracts with other medicare advantage plans. I do not think the negotiating was necessarily for a higher rate, given the low medicare rate ceiling, but rather to have exclusive access to a larger pool of patients. The medical group and the… Read more »

SBD
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SBD

Thanks Eric, that does help a lot. Not sure what ‘smell-o-vision’ is though? So I get it now, but still have the question regarding the Medical Group. Here is a quote from an article last February in the San Diego Union Tribune. “Dozens of doctors are protesting a Sharp physician network’s demand that their senior patients enroll in one health plan, Secure Horizons, if they want to use Sharp’s services in San Diego County. Some 22,000 patients could be caught in the cross hairs, the doctors said.” “These 45 doctors have until Tuesday to accept or reject Sharp’s ultimatum. If… Read more »

Eric Novack
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SBD– (i am glad this is not ‘smell-o-vision’…) I will try to briefly answer your questions, but will change the order and add a little additonal information: A. Medicare advantage is the reincarnation of medicare+choice of the 1990s. This is an alternative to the standard fee-for-service standard medicare program (which has certain hospital components and a 80/20 plan for outpatient services). Thus it fits well with everyone’s idea of a medicare part A,B, C(hoice),D(rug). B. In its initial version, medicare+choice providers (private insurers) were given an adjusted capitated amount based upon the yearly average costs of medicare in the area.… Read more »

Peter
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Peter

Posted by: pgbMD “I hear so many physicians complaining of the Medicare cuts but no one cutting and running yet. What gives?” I think there are a lot of reasons, many docs just see it as another part of their business, those patients using Medicare also have relatives not on Medicare so a doc really doesn’t want to risk loosing all parts of the family generated business. And believe it or not I think some docs actually believe they have an unselfish community duty to look after all aspects of healthcare for different patients. There I said it, and it… Read more »

pgbMD
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pgbMD

I hear so many physicians complaining of the Medicare cuts but no one cutting and running yet. What gives?

SBD
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SBD

I have tried to understand the Medicare reimbursment process and am more confused now than I was before I made the attempt. Can someone briefly explain how it all works?
Here’s an example situation.
Patient is a member of a HMO Medicare Advantage Plan and is a member of the RRR Medical Group. Patient has surgery at the USA Hospital Center. Medicare Advantage HMO says total cost was $77,000.
How does USA Hospital get paid?
How does RRR Medical Group get paid?
How does the the HMO get paid?
How does the surgeon get paid?
How much would the patient be expected to pay?
Thanks

Peter
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Peter

“Of course those who see individual responsibility” Not all health problems are related to personal responsibility; genetic factors, environmental exposure (diminished government regulation), culture, your parents financial situation, the other guy not showing personal responsibility, just bad luck, all of these and more will put you in the financial meat grinder called U.S. healthcare. “diminished government regulation” Sure that works great as we’ve seen, Big Pharma and FDA, ecoli and USDA, mine disasters and dead miners, cigarette smoking and lung disease, WR Grace and asbestos, fast food and fat people, marketing junk food to children, skyrocketing diabetes. “and genuine market… Read more »

Eric Novack
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Matthew- I amm surprised that only Peter is weighing in on this… this should be fodder for the anti-AMA, doctors are the problem folks.
Apparently, in Peter’s view, no matter what the ‘private sector’ is the problem. Of course those who see individual responsibility, diminished government regulation, and genuine market forces (not those driven by excessive protection of certain groups) will be to blame.

Peter
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Peter

“Not that I am against quality, rather I think the government is incapable of identifying and monitoring it.” Who is capable of identifying and monitoring it? I would think the AMA would play a LEADING role here?? Instead they look to shield themselves from lawsuits for poor quality. I agree that this disconnective tinkering with separate parts of healthcare serves no one properly. If this does bring “collapse”, then maybe we can get on with the job of designing a properly functioning system. But I’ll bet any collapse will bring the “free marketeers” out to rail against gov. run systems,… Read more »

Matthew Holt
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Sorry to goad you Eric. We both know that this type of cut is not the way to rationally control costs and improve quality. We may disagree on what the right answer is, but the AMA’s head in the sand/threat mode is, I dont think, productive.

eric Novack
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Using my name is a good way to get me to put up a quick post. Other roles have limited my participation lately… The latest addition to the medicare rules and regs registers only…. 1500 pages. I think we are now upward of 120,000 pages of often contradictory rules… Though cutting docs payments by 6-20% for nearly half of docs (while raising hospital payments 3% under part A) is getting us closer to the collapse of the system, the proposals on the table to link payments to a doc paid for/ doc inputed and then potentially doc punished P4P system… Read more »

Peter
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Peter

I bet docs are meeting with their accountants and office managers right now to see how they can game the system to keep the billings the same. Maybe Eric’s idea of writing contracts with his medicare patients will be covered under the new rules.
“But in an effort to give more personalized care, the government will pay physicians more to counsel patients on ways to improve their health.” So why are docs complaining – can’t make money off healthy people?