Re: I don't Understand this $@(&#!~!!

[Guest guest]

We're seeing people get only $11.00 reimbursement for "medicare adjustments" because they have a supplemental or "intermediary" insurance that we have to bill first, and then THEY bill medicare...(and they probably keep the $14.80 for themselves... I guess the question is when did medicare become "managed?" Any medicare gurus have input? (:-)

RR

I don't Understand this $@( & #!~!!

HI Gang,I don't understand this and therefore is it legal?If a patient with medicare that buys a supplemental (and let's say for argument sake it is Healthnet), are they stuck with the limits placed on them by the supplement? Meaning, with medicare there are no limits with chiropractic care and yet with Healthnet there is a limit.By purchasing a supplemental policy does one give up the benefits of medicare to accept the "less" benefits of healtnet?Can one ignore healthnet (or wait for the 5 visit max or $500 limit) and then bill medicare directly?I just don't understand how these companies can sucker people into their benefits when they are less then the plain medicare?Anyone wanna bite on this one?Thank you in advanceGarreth MacEugene

[Guest guest]

Your frustration is echoed here, Garreth .... on top of that, the patient's new deductible is higher than you/I receive! It is so unbalanced! SunnySunny Kierstyn, RN DC Fibromyalgia Care Center of Oregon 2677 Willakenzie Road, 7CEugene, Oregon, 97401541- 654-0850; Fx; 541- 654-0834www.drsunnykierstyn.com Oregondcs From: docgumby30@...Date: Thu, 5 Jan 2012 10:25:44 -0800Subject: I don't Understand this $@( & #!~!!

HI Gang,

I don't understand this and therefore is it legal?

If a patient with medicare that buys a supplemental (and let's say for argument sake it is Healthnet), are they stuck with the limits placed on them by the supplement? Meaning, with medicare there are no limits with chiropractic care and yet with Healthnet there is a limit.

By purchasing a supplemental policy does one give up the benefits of medicare to accept the "less" benefits of healtnet?

Can one ignore healthnet (or wait for the 5 visit max or $500 limit) and then bill medicare directly?

I just don't understand how these companies can sucker people into their benefits when they are less then the plain medicare?

Anyone wanna bite on this one?

Thank you in advance

Garreth Mac

Eugene

[Guest guest]

Dr. Mac -

My first question is whether the other carrier (call it Black Cross) is a supplement or a replacement plan for Medicare?

If it is a supplement, then it pays after Medicare has been billed and pays for the balance of Medicare approved services, typically 20%. On a rare occasion such policies may pay for services or procedures not covered by Medicare (beyond spinal manipulation).

However, if the patient enrolled in Black Cross as a replacement policy for Medicare, Black Cross can impose whatever rules it wants in the contract. Patients will often opt for Black Cross coverage since it may reduce their out of pocket expenses compared to Medicare (co-ay instead of deductible; no 20% owed beyond the 80% paid by Medicare). When they enroll there is a risk some services (chiropractic) my not be covered. The trade off is less out of pocket expense for the health coverage.

There is nothing illicit or unethical about this. It is a legitimate business practice for healthcare insurers. By enrolling the patient, Medicare will pay Black Cross a fee (most likely capitated, much like an HMO). Black Cross hopes that through their network and negotiated fees they will turn a profit. One would assume they do, since there are many companies like Black Cross.

These patients can be limited as to there medical providers as well. They may have to go to Kaiser, Providence, or Wally's Discount Clinic. The patient loses some choice about who can provide services, but saves money joining a program like Black Cross. In many cases the patient wants to stay with Black Cross since their doctor, who treated them prior to becoming eligible for Medicare, is on the panel. The patient may have been happy with Black Cross (or Kaiser, or someone else) and simply wants to stay.

This type of managed care has existed in Medicare for decades. Patients without a chiropractic benefit are not prevented from seeking care, although they will have to pay for it themselves. Their savings with the replacement Medicare program usually offsets their out of pocket expenses for chiropractic.

Since there is no coverage for chiropractic, the patient would be seen on a cash basis. It is an economic decision by the carrier. We as a profession could lobby for inclusion, but it would be unlikely to see reimbursement much different from Medicare since that is the basis of the policy.

Tom Freedland, D.C.

HI Gang,I don't understand this and therefore is it legal?If a patient with medicare that buys a supplemental (and let's say for argument sake it is Healthnet), are they stuck with the limits placed on them by the supplement? Meaning, with medicare there are no limits with chiropractic care and yet with Healthnet there is a limit.By purchasing a supplemental policy does one give up the benefits of medicare to accept the "less" benefits of healtnet?Can one ignore healthnet (or wait for the 5 visit max or $500 limit) and then bill medicare directly?I just don't understand how these companies can sucker people into their benefits when they are less then the plain medicare?Anyone wanna bite on this one?Thank you in advanceGarreth MacEugene

[Guest guest]

This sounds like a Medicare Advantage plan.  This is not Medicare- the patient has signed away their medicare rights for a managed care plan and yes they can limit coverage and deny chiropractic services if you are not a preferred provider.  Providers need to beware that patients will present themselves as Medicare but in reality they are NOT.

For questions and complaints in OregonDepartment of Consumer and Business ServicesSenior Health Insurance Benefits Assistance Program350 Winter Street NE, Room 330

P.O. Box lt1480Salem, OR  97309-0405503-947-7979www.oregonshiba.org

Part C: Medicare Advantage plans

Main article: Medicare Advantage

With the passage of the Balanced Budget Act of 1997, Medicare beneficiaries were given the option to receive their Medicare benefits through private health insurance plans, instead of through the original Medicare plan (Parts A and . These programs were known as " Medicare+Choice " or " Part C " plans. Pursuant to the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, " Medicare+Choice " plans were made more attractive to Medicare beneficiaries by the addition of prescription drug coverage and became known as " Medicare Advantage " (MA) plans. Medicare Advantage plans are offered through private companies known as Medicare Advantage Organizations (MAO). Each of them under the contract from CMS are required to provide an effective compliance program to prevent Fraud, Waste and Abuse issues in healthcare settings.

Traditional or " fee-for-service " Medicare has a standard benefit package that covers medically necessary care members can receive from nearly any hospital or doctor in the country. For people who choose to enroll in a Medicare Advantage health plan, Medicare pays the private health plan a fixed amount every month. Members typically also pay a monthly premium in addition to the Medicare Part B premium to cover items not covered by traditional Medicare (Parts A & , such as prescription drugs, dental care, vision care and gym or health club memberships.[11] In exchange for these extra benefits, enrollees may be limited in the providers they can receive services from without paying extra. Typically, the plans have a " network " of providers that patients can use. Going outside that network may require permission or extra fees.

List of Federal laws that each MAO or Part D sponsor must follow

Conflict of interest

HIPAA privacy laws

False Claims Act

Anti-Kickback StatuteSTARK Anti-referral law

Medicare Advantage plans are required to offer coverage that meets or exceeds the standards set by the original Medicare program, but they do not have to cover every benefit in the same way. If a plan chooses to pay less than Medicare for some benefits, like skilled nursing facility care, the savings may be passed along to consumers by offering lower co-payments for doctor visits. Medicare Advantage plans use a portion of the payments they receive from the government for each enrollee to offer supplemental benefits. Some plans limit their members’ annual out-of-pocket spending on medical care, providing insurance against catastrophic costs over $5,000, for example. Many plans offer dental coverage, vision coverage and other services not covered by Medicare Parts A or B, which makes them a good value for the health care dollar, if you want to use the provider included in the plan's network or " panel " of providers.

Because the 2003 payment formulas overpay plans by 12 percent or more compared to traditional Medicare,[12] in 2006 enrollees in Medicare Advantage Private Fee-for-Service plans were offered a net extra benefit value (the value of the additional benefits minus any additional premium) of $55.92 a month more than the traditional Medicare benefit package; enrollees in other Medicare Advantage plans were offered a net extra benefit value of $71.22 a month more.[13] However, Medicare Advantage members receive additional coverage and medical benefits not enjoyed by traditional Medicare members, and savings generated by Medicare Advantage plans may be passed on to beneficiaries to lower their overall health care costs.[11] Other important distinctions between Medicare Advantage and traditional Medicare are that Medicare Advantage health plans encourage preventive care and wellness and closely coordinate patient care.[14]

Medicare Advantage Plans that also include Part D prescription drug benefits are known as a Medicare Advantage Prescription Drug plan or a MA-PD.

Enrollment in Medicare Advantage plans grew from 5.4 million in 2005 to 8.2 million in 2007. Enrollment grew by an additional 800,000 during the first four months of 2008. This represents 19% of Medicare beneficiaries. A third of beneficiaries with Part D coverage are enrolled in a Medicare Advantage plan. Medicare Advantage enrollment is higher in urban areas; the enrollment rate in urban counties is twice that in rural counties (22% vs. 10%). Almost all Medicare beneficiaries have access to at least two Medicare Advantage plans; most have access to three or more. Because of the 2003 law's overpayments, the number of organizations offering Fee-for-Service plans has increased dramatically, from 11 in 2006 to almost 50 in 2008. Eight out of ten beneficiaries (82%) now have access to six or more Private Fee-for-Service plans.[15]

Each year many individuals disenroll from MA plans. A recent study noted that about 20 percent of enrollees report that " their most important reason for leaving was due to problems getting care. " [16] There is some evidence that disabled beneficiaries " are more likely to experience multiple problems in managed care. " [17] Some studies have reported that the older, poorer, and sicker persons have been less satisfied with the care they have received in MA plans.[18] On the other hand, an analysis of the Agency for Healthcare Research and Quality data published by America’s Health Insurance Plans found that Medicare Advantage enrollees spent fewer days in the hospital than Fee-for-Service enrollees, were less likely to have " potentially avoidable " admissions, and had fewer re-admissions. These comparisons adjusted for age, sex and health status using the risk score used in the Medicare Advantage risk adjustment mechanism.[19][20]

In December 2009 the Kaiser Family Foundation published a report that rated Medicare Advantage organizations on a five star scale. The ratings were based on data from CMS, the Consumer Assessment of Healthcare Providers and Systems (CAHPS), Healthcare Effectiveness Data and Information Set (HEDIS) data, and the Health Outcomes Survey (HOS). New plans did not receive ratings, because data was not available. Almost six out of ten (59%) of MA plans did receive ratings, and these plans represented 85% of the enrollment for 2009. The average rating was 3.29 stars. Twenty-three percent of enrollees were in a plan with four or more stars; 20% were in a plan with fewer than three stars.[21]

Twenty percent of Black-American and 32 percent of Hispanic-American Medicare Beneficiaries were enrolled in Medicare Advantage plans in 2006. Almost half (48%) of Medicare Advantage enrollees had incomes below $20,000, including 71% of minority enrollees.[22] Others have reported that minority enrollment is not particularly above average.[23] Another study has raised questions about the quality of care received by minorities in MA plans.[24]

The Government Accountability Office reported that in 2006, the plans earned profits of 6.6 percent, had overhead (sales, etc.) of 10.1 percent, and provided 83.3 percent of the revenue dollar in medical benefits. These administrative costs are far higher than traditional fee-for-service Medicare.[25]

Newport Avenue Chiropractic

Glenn J. Asti D.C.

1052 NW Newport Avenue 

Suite 101

Bend,  OR  97701

541-330-5737

www.newportavenuechiropractic.com

email: 

dr.asti@...

 

Chiropractic

is health insurance. Premiums small. Dividends large.

                                                                               B.J. Palmer

 On Thu, Jan 5, 2012 at 10:25 AM, g macdonald <docgumby30@...> wrote:

 

HI Gang,

I don't understand this and therefore is it legal?

If a patient with medicare that buys a supplemental (and let's say for argument sake it is Healthnet), are they stuck with the limits placed on them by the supplement? Meaning, with medicare there are no limits with chiropractic care and yet with Healthnet there is a limit.

By purchasing a supplemental policy does one give up the benefits of medicare to accept the " less " benefits of healtnet?

Can one ignore healthnet (or wait for the 5 visit max or $500 limit) and then bill medicare directly?

I just don't understand how these companies can sucker people into their benefits when they are less then the plain medicare?

Anyone wanna bite on this one?

Thank you in advance

Garreth Mac

Eugene