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comment by kleinbl00
kleinbl00  ·  6 days ago  ·  link  ·    ·  parent  ·  post: Hidden audits reveal millions in overcharges by Medicare Advantage plans

    Auditors flag overpayments when a patient's records fail to document that the person had the medical condition the government paid the health plan to treat, or if medical reviewers judge the illness is less severe than claimed.

This is legit "we're combing through all of our claims to see if we can reject them after the fact."

You shouldn't be happy about this. Nobody should. It costs us $70 to buy the rhogam we are mandated by state law to give all new mothers. Medicaid reimburses us $8. We are mandated by the state to lose $62 every time someone has a baby. Can we negotiate that? no. Can the state negotiate that? yes, but they don't. Does this sort of nonsense encourage you to play ICD Bingo with every fucking thing you do with the patient? Goddamn right.

Took my naturopaths to lunch a couple weeks ago. One of them said "I have a hard time with vaccine visits because they're so short and my patients always ask me questions" to which the other said "then you answer their questions and bill them for a visit." Now - if she accidentally forgets to code that as an acute visit? Medicaid doesn't pay us anything. Not, they don't pay us for the vaccine (which we make $3 on - I pay our naturopaths $25), we get nothing.

Here's this week's fun one. I have reason to believe that the Department of Justice came down on a colleague for using gray-market IUDs. Everyone uses gray-market IUDs. Are they labeled in English? yes. Are they made in the same factories as white-market IUDs? yes. Are they labeled "not for sale in the US?" no. But because there's a law from 1867 about labeling, there's the possibility that billing Medicaid for an IUD intended for the European market constitutes $11k worth of medical fraud. So why would you use gray market IUDs?

Because Medicaid will pay you $600 to put in an IUD. The IUD costs $200 gray market and $1100 if you buy it in the US. So now? Now we're not putting in IUDs. 'cuz if I have a choice between losing $500 on every single one, making $400 on every single one or possibly losing $11k for each and every single one? That's a no-fucking-brainer.

'ZOMFG medicaid is paying for things it shouldn't' is the Welfare Queen of the modern era.

c_hawkthorne  ·  6 days ago  ·  link  ·  

A few legitimate questions, not trying to attack you or anything, just further understand your viewpoints.

(1) Why is this a medicaid reimbursement problem and not a manufacturer charging too much problem? It's almost certainly a bit of both and it's a disgrace your population isn't able to be served appropriately because of this, but I appreciate your insight. Insurance reimbursement in this country is atrocious.

(2) The article was about Medicare Advantage plans, not Medicaid. Medicare Advantage plans, for those who don't know, are Medicare (federal healthcare in USA for 65+), but run by private insurances. Couldn't this be a problem not of physician mismanagement, but private insurance to CMS mismanagement? The article is certainly framing it as an issue of insurance companies lying to the federal government about the patient's health to gain higher reimbursement due to the reimbursement rates differing on patient health.

(3) Have your views on Medicaid for all (we had that discussion a long time ago in chat) changed at all or do you still view that as the best option for a national healthcare system? And if you are still in the Medicaid for all camp, as I recall when we were discussing it all that time ago (my memory is shit and I could be misremembering), you'd mentioned if people want better healthcare they just have to move to new states. Do you still believe that part of it? My viewpoint has been that moving is difficult, a lot more so if you have social support but minimum wage job and low skills, the bulk of Medicaid members, that moving may be impossible and the Medicaid for All just works to keep those without the ability to leave in a worse position, a kind of white flight all over again. We haven't discussed this in a long time and I'd be interested to see if your views have evolved at all.

kleinbl00  ·  6 days ago  ·  link  ·  

And a few answers. not feeling attacked, the system is just bullshit. Never charge elastic prices for an inelastic good, never divorce the negotiators from the purchasers, etc.

1) Because the contracts are between the providers and the insurance companies, not the providers and the manufacturers. A contract between the provider and the manufacturer would be considered vertical integration and is a violation of the Sherman Antitrust act. FUN FACT: any collective action by individual businesses towards price discovery of insurance contract is also a violation of the Sherman Antitrust act and considered insurance fraud. In other words: we are legally banned, in very strong language, from asking a competitor "is Primera ripping you off on Rhogam, too?" Not that we don't? Just that we're committing a felony when we do. Because it's worth it. Saying things like "a little birdie told me you should check page 78 through 87 of the Aetna contract they're sending around because they substituted pages and cut your rates by 90% without disclosing any changes. It was a very talkative bird."

2) medicare advantage and medicaid are both run by private insurance companies. We rarely work with medicare because it isn't our focus. Medicaid, in Washington State at least, is administrated by about 11 different insurance companies. In our county there are seven choices. The prices are the same, the reimbursement is the same, but the schedule is published. I'm aware of the article's framing, that's because they're lazy. With medicare/medicaid the prices are set - you make your money by administrating the plan. So when the patient scheduled a vaccine visit and you let her ask questions without an acute appointment? BILLING FRAUD. It's this bad: two or three of the medicaid providers will call you up and say "hey I need to see a doctor in the next two weeks" and when we say "we're booked out" they send a nasty letter letting us know they're canceling our contract because we're not seeing their patients. Then they tell the state "yeah, we're not able to make money at these rates because there just aren't enough quality providers, looks like we're going force majeure on the contracts."

3) M4A is far and away the best option for a national healthcare system. If your state feels that medicaid should be a punishment for doctor and patient, having it be a low-price option available to anyone will illustrate that it's the same punishment at a third the price and it gives you something to vote for. Vote Jerry for governor he's dropping copays to $15. Vote Rebecca she's decreasing out-of-pocket on birth control. My basic argument is that if your governor is Ron DeSantis you're pretty much fucked anyway and if "Floridians are fucked therefore nobody else gets M4A" then fuck Florida.

spencerflem  ·  6 days ago  ·  link  ·  

That's absurd -_+

Is the IUD change a sneaky anti-birth-control thing or the same money grubbing grift as the rest of it?

kleinbl00  ·  6 days ago  ·  link  ·  

spencerflem  ·  6 days ago  ·  link  ·  
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