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Medicare rant - its getting bad

Texashiker

Lifer
Dec 18, 2010
18,812
192
106
My wife works for a local doctor, the majority of the doctors business is elderly people on medicare.

A couple of days ago medicare sent the doctor a letter saying some of the procedures he did as far back as 2009 were unnecessary, and medicare wants their money back.

Before the procedures were done, someone from the office called medicare to get pre-approval. Medicare approved the procedures and the surgery was done.

The procedures in question were hip and knee replacements.

Think about that for a minute. Medicare approves procedure, 3 years later wants their money back. Why wait 3 years? Why not deny the procedures when they were pre-approved?

One of the ladies at the office is having to go through the records, and fax everything over to medicare to justify the procedure yet again. The office already did this when the patient was approved for the surgery.
 

Genx87

Lifer
Apr 8, 2002
41,083
490
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I thought the govt insurance program would never deny a claim like private insurance?
 

Hayabusa Rider

Admin Emeritus & Elite Member
Jan 26, 2000
50,874
4,203
126
If it's approved then it was approved. Obama's projected savings in health care are based largely on provider reimbursement cuts. The doc should refuse to send back money for procedures that were given the go ahead and probably necessary. Right now a whole lot of people are considering dropping Medicare patients because of this nonsense.
 

Craig234

Lifer
May 1, 2006
38,584
344
126
The story you tell sounds outrageous.

Doesn't mean government isn't better thatn private insurance overall.
 

fskimospy

Elite Member
Mar 10, 2006
70,098
18,864
136
I thought the govt insurance program would never deny a claim like private insurance?
I thought government insurance always approved wasteful and fraudulent claims?

This is a pointless game to play.
 

fskimospy

Elite Member
Mar 10, 2006
70,098
18,864
136
Are you saying these are wasteful and fraudulent claims?
I don't know, we don't have any information about them. I thought the claim was that government insurance never checked up on claims like private insurance did, making it open to abuse. This is apparently incorrect.

Really though, I was just saying that playing this sort of game with a single anecdote is silly.
 

Zedtom

Platinum Member
Nov 23, 2001
2,146
0
0
My girlfriend is involved with Medicare billing and she has daily horror stories. The levels of approval and denial of claims is mind numbing. The health care reforms are not streamlining the process, rather the government keeps rewriting the rules. It makes the tinkering with the tax code by the Congress and the IRS look like child's play.
 

Darwin333

Lifer
Dec 11, 2006
19,947
2,322
126
If it's approved then it was approved. Obama's projected savings in health care are based largely on provider reimbursement cuts. The doc should refuse to send back money for procedures that were given the go ahead and probably necessary. Right now a whole lot of people are considering dropping Medicare patients because of this nonsense.
It doesn't sound like the Doctor will have to actually give the money back but he does have to spend resources and time to send them all of the paperwork. The local gov tries something similar to that around here with construction contracts. They will wait a few years and say that some change order wasn't approved and they overpaid. If you keep shitty paperwork than you are SOL, if you don't keep shitty paperwork you have to dig it all up and prove that everything was executed properly.

I can only think of 2 reasons, 1. they throw a bunch of this stuff out there hoping that a few people don't keep good records and they get some bonus money for their budgets or 2. they are seriously incompetent in the paperwork department and truly did lose executed contracts that have were completed and paid for years ago. I sort of hope that it is the first one.
 

Genx87

Lifer
Apr 8, 2002
41,083
490
126
I don't know, we don't have any information about them. I thought the claim was that government insurance never checked up on claims like private insurance did, making it open to abuse. This is apparently incorrect.

Really though, I was just saying that playing this sort of game with a single anecdote is silly.
If the OP is correct these were pre approved by the program and now 3 years later they are asking for the money back. If these were fraudulent or wasteful the time to deny them was 3 years ago. The kind of paperwork the health provider will have to go through to prove to medicare that medicare approved the procedures costs them money. Money medicare wont have to spend but the provider will.
 

fskimospy

Elite Member
Mar 10, 2006
70,098
18,864
136
If the OP is correct these were pre approved by the program and now 3 years later they are asking for the money back. If these were fraudulent or wasteful the time to deny them was 3 years ago. The kind of paperwork the health provider will have to go through to prove to medicare that medicare approved the procedures costs them money. Money medicare wont have to spend but the provider will.
Why was the time to deny them 3 years ago? It sounds like this was turned up in an internal Medicare audit for whatever reason, and the whole purpose of such audits is to catch mistakes in the pre-approval process, fraud, etc. I'm pretty sure that literally every single insurer on Earth does this.

I have no idea as to the merits of this claim, but I don't find your argument persuasive. (nor do I find this thread particularly useful, anecdotal evidence is terrible)
 

Texashiker

Lifer
Dec 18, 2010
18,812
192
106
My girlfriend is involved with Medicare billing and she has daily horror stories.
Same with my wife and the doctor she works for.

One week the claims might go through. The next week all of the claims were rejected because medicare changed something in the billing form.

The software developer has to change the forms to what medicare wants, then all of the claims resubmitted. By then, the office is a couple of hundred claims behind.

Or better yet, medicare tells you months later that your claims are not being processed because the doctor did not submit some kind of required form. In 2011, there were several times when the doctor did not receive a medicare check for 2, 3 or even 4 months while all of the paperwork was sorted out.

Every couple of weeks medicare puts up another hoop for doctors to jump through, then another hoop, then another hoop,,,.
 

Hayabusa Rider

Admin Emeritus & Elite Member
Jan 26, 2000
50,874
4,203
126
I don't know, we don't have any information about them. I thought the claim was that government insurance never checked up on claims like private insurance did, making it open to abuse. This is apparently incorrect.

Really though, I was just saying that playing this sort of game with a single anecdote is silly.
Does the government provide statistics on it's own abuse? If you were in the medical field this would have been common knowledge. In NY state a few years ago we had a witch hunt that cost pharmacies millions. The now governor working under Spitzer at the time came up with this great idea. He knew that many rules and regs were self contradictory so he created this "anti fraud" squad consisting of temps with directions on how to find violations. Of course some outright fraud was found but the vast majority was for things like not writing the time of a phone call down or in the case of conflicting regs picking the one violated. It was a win/win for the state because they got to boast how they were fighting crime and take back millions upon millions of dollars for services rendered in good faith.

It was the perfect scam and of course few had the money to fight it in court. It was nicely done.
 

blankslate

Diamond Member
Jun 16, 2008
8,466
422
126
You guys should be glad... The roadblock republicans are making inroads toward destroying medicare... instead of letting people fix it.
 

fskimospy

Elite Member
Mar 10, 2006
70,098
18,864
136
Does the government provide statistics on it's own abuse? If you were in the medical field this would have been common knowledge. In NY state a few years ago we had a witch hunt that cost pharmacies millions. The now governor working under Spitzer at the time came up with this great idea. He knew that many rules and regs were self contradictory so he created this "anti fraud" squad consisting of temps with directions on how to find violations. Of course some outright fraud was found but the vast majority was for things like not writing the time of a phone call down or in the case of conflicting regs picking the one violated. It was a win/win for the state because they got to boast how they were fighting crime and take back millions upon millions of dollars for services rendered in good faith.

It was the perfect scam and of course few had the money to fight it in court. It was nicely done.
Well please provide links to some stories about this then! That's a far more interesting (and useful) story than 'I know a guy'. It's things like this that are important to clear up when we hopefully move to a single payer system.
 

PokerGuy

Lifer
Jul 2, 2005
13,652
199
101
It was the perfect scam and of course few had the money to fight it in court. It was nicely done.
Kind of like they say "what do you do when the criminals wear a badge and uniform?"... what do you do when the government is the only game in town for healthcare and they screw it up like they do everything? Answer: nothing, you're screwed.
 

Hayabusa Rider

Admin Emeritus & Elite Member
Jan 26, 2000
50,874
4,203
126
Well please provide links to some stories about this then! That's a far more interesting (and useful) story than 'I know a guy'. It's things like this that are important to clear up when we hopefully move to a single payer system.
Wait, the government does a shakedown and the solution is to hand the whole thing over to a more powerful authority even further distanced from the people?

The worst of the local cases

Note that there was no mention of a single prescription filled with the intention of not providing the correct medication to the correct patient. There is also no explicit rule which deals with delivery documentation. It was an interpretation of a rule which did not mention deliveries at all, but the auditor said it should. The other issue of MD identifiers is that there are several IDs in use and they aren't always updated by the software vendor. The correct doc was on the label however rather than rejecting the claim Medicaid if there was incorrect information it allowed it to go through and after the fact the "analysis" gave ammunition to attack the owner. Nothing was billed for which wasn't provided.

In the end the owner went out on a limb and at considerable expense fought this and won.

The "crime"? Failing to follow rules which aren't there and having an incorrect number is a computer system that the powers that be could have stopped like any other insurance company but allowed to go through to profit by later.
 

BoberFett

Lifer
Oct 9, 1999
37,587
9
81
My girlfriend is involved with Medicare billing and she has daily horror stories. The levels of approval and denial of claims is mind numbing. The health care reforms are not streamlining the process, rather the government keeps rewriting the rules. It makes the tinkering with the tax code by the Congress and the IRS look like child's play.
My ex-wife is in medical billing as well. She says dealing with private insurers is cake walk compared to dealing with government organizations.

But remember, cutting out all of this private insurers will save us money by decreasing administration costs... LMFAO!!!!
 

Ausm

Lifer
Oct 9, 1999
25,215
13
81
My ex-wife is in medical billing as well. She says dealing with private insurers is cake walk compared to dealing with government organizations.

But remember, cutting out all of this private insurers will save us money by decreasing administration costs... LMFAO!!!!
That somehow doesn't surprise me...well back on topic.

Whitehouse recover a record of 4.1 Billion in mediscare fraud.

http://www.hhs.gov/news/press/2012pres/02/20120214a.html
 

Hayabusa Rider

Admin Emeritus & Elite Member
Jan 26, 2000
50,874
4,203
126
That somehow doesn't surprise me...well back on topic.

Whitehouse recover a record of 4.1 Billion in mediscare fraud.

http://www.hhs.gov/news/press/2012pres/02/20120214a.html
The government in NY collected $551,000,000 against pharmacies in 19 counties for "fraud" as well, fraud being whatever the government deems it to be.

How much of that 4.1 billion is due to willful misrepresentation and how much due to the types of things I've mentioned?
 

Ausm

Lifer
Oct 9, 1999
25,215
13
81
The government in NY collected $551,000,000 against pharmacies in 19 counties for "fraud" as well, fraud being whatever the government deems it to be.

How much of that 4.1 billion is due to willful misrepresentation and how much due to the types of things I've mentioned?
Here is the break down of the fraud and the return in revenue.

It's 97 pages so you better loadup the printer before hitting "print" ;)

http://oig.hhs.gov/publications/docs/hcfac/hcfacreport2011.pdf
 

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