Quote:
Originally Posted by OrangeBlossomBaby
A regular checkup gets billed as P1301 - for $200. Advantage covers it, patient pays nothing.
A regular checkup that the doctor discusses a skin lesion the patient points out is billed as P1302 - also for $200. Advantage covers it, patient pays nothing.
A separate visit to the doctor because the patient is concerned about a new skin lesion is billed as P1462 - for $170. Advantage covers it, patient pays nothing.
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But in your example, Advantage covers it. As I understand it, Advantage pays claims out of their capitation payment. If the payment per patient is less than the capitation payment, Advantage pockets the money. If they pay more, Advantage loses money. That is why Advantage has an incentive to deny claims. See the posting about the doctor trying to get authorization from UHC for a procedure
Medicare wasn't defrauded - Advantage was. Why isn't UHC on of the biggest creditors?