[Topspinmo]

IMO Health care as we know needs gutted. Single payer the government. Let all those billions in plans be paid to government and not insurance crooks. When you get insurance laws written by lobbyists this what you get. SAFU. ACA just made it worse cause they didn’t read what was in it. Also IMO in person has insurance it should be against law for clinic or medical field to refuse that insurance. Medical industry shouldn’t be steering public to their favorite kick back insurance and refusing care who don’t have that plan. And yes I can have opinion.

[blueash]

Originally Posted by Cliff Fr

Sounds to me like they are over billing so that the medicare advantage company will payout more in the end.

Wrong. The insurance company does not care what the bill total is... they pay exactly the same no matter what the bill, unless the provider charged less than the allowable. So if test A has an allowable of $10, and hospital Z charges $12 for it, they get paid $10. If hospital Y charges $200 for it, they get paid $10. You do not get paid more for billing more

[jmsturm]

It’s called negotiations. The medical groups want more and the insurances want to give less. They are both in business to remain profitable. Eventually they will reach an agreement until the next time!

[blueash]

Originally Posted by rsmurano

Advantage plans are flawed, all of these issues have been known for many years (almost 70% denial rates when Medicare does not deny any procedure), and they keep getting worse

You wouldn't happen to have evidence for that 70% denial would you. Because if it were true nobody would be on a MA plan and everyone would be experiencing denials of over 1/2 their charges. It simply is not true.

Here's one reference I easily found

Nearly 15% of all claims submitted to private payers initially are denied, including many that were preapproved during the prior authorization process. Overall, 15.7% of Medicare Advantage and 13.9% of commercial claims were initially denied.
More than half of denied claims (54.3%) by payers ultimately were overturned but typically only after providers went through multiple rounds of costly appeal

And another article looking at hospital system charges
where the Medicare Advantage initial claim denial was 15% and the TRADITIONAL MEDICARE denial rate was 8.4 %. So your claim that Medicare never denies is also wrong.

Now this is for payment, not authorization. So what is the rate of denial of prior authorization by Medicare Advantage?

Try this highly reliable source using 2022 data, KFF

In 2022, insurers fully or partially denied 7.4% prior authorization requests
The vast majority of appeals (83.2%) resulted in overturning the initial prior authorization denial.

Well that means that for things requiring prior authorization, which most do not, the final rejection rate is 1.3 % not the ridiculous 70% you throw out to scare people. And I suspect 1.3% of people wanted things that were not medically needed... I want an MRI because I had two headaches last year kind of requests.

[blueash]

Originally Posted by snbrafford

...
Medicare drives a lot the entire process but the insurance companies stand between us and Medicare (assuming you are in a MA plan). The insurance companies are held hostage to Medicare paying their claims too in a timely manner.

This is not how MA plans work. They are not between you and Medicare. In fact Medicare is not involved with you once you join a MA plan. Medicare contracts with the MA insurance company and pays that company every month a fixed amount per enrollee who otherwise would have been on traditional Medicare but opted for MA instead.
The amount given to the MA company is rate based on costs in the region, the health of the insured group etc. For almost all MA plans, they are given more than the expected amount Medicare would pay but the MA plans are offering additional benefits including removing CMS from claims processing. MA plans do get a higher monthly payment if the patients are sicker which is why your MA doctor lists every single thing you ever might have had in your diagnosis list.

But the MA plan is not waiting to be paid by Medicare. They have the monthly capitation which is well over 1000 per person and they make money if your care costs less than that amount, and lose if you are more costly.

[PhilR]

Originally Posted by jimjamuser

All this stated confusion naturally brings up the question of National Health Insurance. Is the system used by Canada, Australia, and all other 1st world countries (except the US) superior to the US's confused and inefficient system? Answer, yes they get better care at lower cost. Ask the Canadians why they are afraid to get sick while in the US.

And they lived happily ever after

[golfing eagles]

Originally Posted by Topspinmo

IMO Health care as we know needs gutted. Single payer the government. Let all those billions in plans be paid to government and not insurance crooks. When you get insurance laws written by lobbyists this what you get. SAFU. ACA just made it worse cause they didn’t read what was in it. Also IMO in person has insurance it should be against law for clinic or medical field to refuse that insurance. Medical industry shouldn’t be steering public to their favorite kick back insurance and refusing care who don’t have that plan. And yes I can have opinion.

Is that because we all know government is far more efficient and far less wasteful than the private sector??????

And please let me know where I can sign up for those "kickbacks"----especially since in 40 years I never saw one or heard of one----except from the "experts" on social media.

[Topspinmo]

Originally Posted by golfing eagles

Is that because we all know government is far more efficient and far less wasteful than the private sector??????

And please let me know where I can sign up for those "kickbacks"----especially since in 40 years I never saw one or heard of one----except from the "experts" on social media.

Maybe you wasn’t looking cause you wasn’t in insurance business while making millions and lobbying. UHC good example.

[golfing eagles]

Originally Posted by Topspinmo

Maybe you wasn’t looking cause you wasn’t in insurance business while making millions and lobbying. UHC good example.

Too bad, I could have cashed in 😂😂😂

[elevatorman]

Originally Posted by blueash

This is not how MA plans work. They are not between you and Medicare. In fact Medicare is not involved with you once you join a MA plan. Medicare contracts with the MA insurance company and pays that company every month a fixed amount per enrollee who otherwise would have been on traditional Medicare but opted for MA instead.
The amount given to the MA company is rate based on costs in the region, the health of the insured group etc. For almost all MA plans, they are given more than the expected amount Medicare would pay but the MA plans are offering additional benefits including removing CMS from claims processing. MA plans do get a higher monthly payment if the patients are sicker which is why your MA doctor lists every single thing you ever might have had in your diagnosis list.

But the MA plan is not waiting to be paid by Medicare. They have the monthly capitation which is well over 1000 per person and they make money if your care costs less than that amount, and lose if you are more costly.

Very good post. For a healthy person in 2025 MA Plans will receive an $1191.56 capitalization payment each month per enrollee. They get that whether you go to a doctor or not. As per the rate book. 2025 | CMS

[CoachKandSportsguy]

The behind the scenes rejectors of medical procedures denials. . .

EviCore, the Company Helping U.S. Health Insurers Deny Coverage for Treatments — ProPublica

[MX rider]

Originally Posted by PhilR

And they lived happily ever after

Originally Posted by Laraine

I lived in Canada for five years, and found it just the opposite. As a personal example, I was having what appeared to be heart problems, and failed a stress test. It took me about 4 months to get a heart scan and see the cardiologist. I also had back problems, and the doctor signed me up for pain management. About six months later, I returned to FL, and a couple months after that, I got a call from Alberta Healthcare saying they were ready for me to start my pain management (don't know how they got my FL telephone number). A co-worker's mother had a steel rod in her spine that snapped, leaving her humped over in terrible pain. It took her 1.5 years to get into pain management, which immediately (finally) solved her pain. The main hospital in Edmonton was overcrowded, had roof leaks that impacted their operating rooms, and long waiting lists (which were jumped by people with the right connections). Wealthy Canadians went to the U.S. to get treated. And free healthcare isn't free--income taxes were about double, to pay for it.

Exactly! I worked with a guy from Canada. When I asked him how he liked the healthcare system there his answer was, "if you like waiting 3 months for an mri it's great. That's why the pro hockey players go to the US for medical care."

Be careful what you wish for, the government healthcare system is the UK is in big trouble as well.

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[MplsPete]

Originally Posted by elevatorman

Very good post. For a healthy person in 2025 MA Plans will receive an $1191.56 capitalization payment each month per enrollee. They get that whether you go to a doctor or not. As per the rate book. 2025 | CMS

Yup, shocking isn't it? >>$1000 per month for every person in an Advantage plan.
The funny thing is, on average, the government spends nearly that much for EVERY Medicare eligible citizen, no matter what their plan: advantage, supplement, or straight / plain / original Medicare.