Thanks don! I have seen a lot of ads lately for the Medicare Advantage and promised myself I'd look into it. I just did. By reading your newsletter. I am in favor of Universal Health Care and I think this is a program headed in the wrong direction. On top of that they have to cheat with upcoding and other shady practices. I keep seeing claims that Americans pay more but are less healthy than countries with universal health care.
Vote blue and elect people who want to represent you, not rule you
Doctors and Medicare get sued by the government for upcoding. Check out the False Claims Act and qui tam legislation. Claims are highly regulated for individual and corporate providers. Meaning: to bill means that certain elements of chart notes must be verified. To bill by time also has specific requirements as well. These are audited. Doctors DO NOT choose what they think an encounter is worth.
Real numbers: I get 10-20 percent of what I bill according to standard billing codes from government payers. Private pay is not much better. The documentation time is at least twice of the the face to face portion ( and is not billable).
What you get with universal health care is heavy emphasis on primary care. In Canada people wait months for a referral to specialists, who are usually based in a few centers around the country. My husband’s sister had lung cancer in Vancouver and was cared for by her PCP while the oncologist was out. Her tumor progressed and was beyond treatment when the oncologist returned.
What I mean by emphasis on primary care is that people who still get sick (everyone) despite healthy lifestyle and every shot in the book may find subspecialty care deferred or delayed. I have seen this over and over.
Until you practice medicine and struggle to make ends meet you have a perspective that is biased and limited. The American system is still the best in the world and serves as an international model of excellence.
I wish I'd read this last year (yes, you would have read my mind about the need for it). I'm switching out of an Advantage plan. It's not been to my advantage to have it at all. And, I've lost respect for doctors who play into the game, scheduling unnecessary appointments -- which I learned to decline doing -- and increasing costs for meds like my thyroid. I'm looking forward to being free of this scam soon.
That’s a real helpful and levelheaded description of how Medicare advantage plans work, not all of which I was fully aware of. It lays out very succinctly various complicated things I was trying to understand when I decided not to join one.
In short, a Medicare (dis)advantage participant exchanges (1) likely medical coverage, most of the time approved by the government under Medicare for (2) sometimes receiving medical coverage along with lower premiums, as decided by the corporate world. The premium savings are a fraction of the extra medical expenses incurred under these plans. So it’s not surprising that their commercials are reminiscent of sleazy barkers at sideshows at old-fashioned 1950s and 1960s carnivals. Only the decade is different.
To round this out, doctors nowadays have plenty of challenges getting what patients need. I remember being able to tell a worried mom, “We will get a CT (or whatever).” Now it’s usually, “ We will get a CT (or whatever) AUTHORIZED.” The peer to peer phone calls toward that end are usually unsuccessful and the “peer” has never once been a pediatric oncologist. Physicians are usually salaried and thus get no kickbacks from particular orders. Even those of us fortunate enough to maintain a private practice operate within fixed reimbursement codes. So the loser is often the patient, whose doctor has probably made a judicious decision in requesting test A, B, or C from the get go.
Hey, Don. I have had a different experience as a patient w a Medicare Advantage plan. I did not consider corporate profits when deciding between many options at age 65. I change plans annually by calling around within Medicare Advantage to expand coverage. Two years ago I had a cancer scare. Without any resistance my plan covered the following consults and tests:
MRI x2, PET/ CT, costly lab panels, and visits with an ER physician, neurologist, cardiologist, and oncologist. My out of pocket was minimal. I didn’t have cancer.
All insurance push primary care. Each to his own about that. My Medicare Advantage plan rep informed me recently on the phone that I was due for an Annual Wellness check. I told her that my physician is in a direct primary care practice and thus not on their roster. This l dear soul kept following her “senior script” by asking me if I wanted her to send a nurse practitioner to my house. I was puzzled and asked why. She said, “to see if you are healthy.” I let her know clearly that: 1. She did not listen to what I had just told her, and 2. I am a provider on their panel.
Posting this piece is a great public service, Don. The low premiums are always so enticing. I've been through it once and belong to the NEVER AGAIN school. Just the idea of being "marketed at" by my medical care people give me the willies.
Thanks for sharing your experience. Sounds very good.
As for the wellness check, pretty soon they'll be replacing live callers with AI. Or maybe they already have!
They already have. I got one of those, too 😀.
Thanks don! I have seen a lot of ads lately for the Medicare Advantage and promised myself I'd look into it. I just did. By reading your newsletter. I am in favor of Universal Health Care and I think this is a program headed in the wrong direction. On top of that they have to cheat with upcoding and other shady practices. I keep seeing claims that Americans pay more but are less healthy than countries with universal health care.
Vote blue and elect people who want to represent you, not rule you
Doctors and Medicare get sued by the government for upcoding. Check out the False Claims Act and qui tam legislation. Claims are highly regulated for individual and corporate providers. Meaning: to bill means that certain elements of chart notes must be verified. To bill by time also has specific requirements as well. These are audited. Doctors DO NOT choose what they think an encounter is worth.
Real numbers: I get 10-20 percent of what I bill according to standard billing codes from government payers. Private pay is not much better. The documentation time is at least twice of the the face to face portion ( and is not billable).
What you get with universal health care is heavy emphasis on primary care. In Canada people wait months for a referral to specialists, who are usually based in a few centers around the country. My husband’s sister had lung cancer in Vancouver and was cared for by her PCP while the oncologist was out. Her tumor progressed and was beyond treatment when the oncologist returned.
What I mean by emphasis on primary care is that people who still get sick (everyone) despite healthy lifestyle and every shot in the book may find subspecialty care deferred or delayed. I have seen this over and over.
Until you practice medicine and struggle to make ends meet you have a perspective that is biased and limited. The American system is still the best in the world and serves as an international model of excellence.
Thanks, Don, for this piece and for those who responded. I have been bombarded with agents lately and had no idea what to choose.
I wish I'd read this last year (yes, you would have read my mind about the need for it). I'm switching out of an Advantage plan. It's not been to my advantage to have it at all. And, I've lost respect for doctors who play into the game, scheduling unnecessary appointments -- which I learned to decline doing -- and increasing costs for meds like my thyroid. I'm looking forward to being free of this scam soon.
Thanks, Don. You rock!
Thanks for the very-timely article. And they're off.......
That’s a real helpful and levelheaded description of how Medicare advantage plans work, not all of which I was fully aware of. It lays out very succinctly various complicated things I was trying to understand when I decided not to join one.
In short, a Medicare (dis)advantage participant exchanges (1) likely medical coverage, most of the time approved by the government under Medicare for (2) sometimes receiving medical coverage along with lower premiums, as decided by the corporate world. The premium savings are a fraction of the extra medical expenses incurred under these plans. So it’s not surprising that their commercials are reminiscent of sleazy barkers at sideshows at old-fashioned 1950s and 1960s carnivals. Only the decade is different.
To round this out, doctors nowadays have plenty of challenges getting what patients need. I remember being able to tell a worried mom, “We will get a CT (or whatever).” Now it’s usually, “ We will get a CT (or whatever) AUTHORIZED.” The peer to peer phone calls toward that end are usually unsuccessful and the “peer” has never once been a pediatric oncologist. Physicians are usually salaried and thus get no kickbacks from particular orders. Even those of us fortunate enough to maintain a private practice operate within fixed reimbursement codes. So the loser is often the patient, whose doctor has probably made a judicious decision in requesting test A, B, or C from the get go.
Hey, Don. I have had a different experience as a patient w a Medicare Advantage plan. I did not consider corporate profits when deciding between many options at age 65. I change plans annually by calling around within Medicare Advantage to expand coverage. Two years ago I had a cancer scare. Without any resistance my plan covered the following consults and tests:
MRI x2, PET/ CT, costly lab panels, and visits with an ER physician, neurologist, cardiologist, and oncologist. My out of pocket was minimal. I didn’t have cancer.
All insurance push primary care. Each to his own about that. My Medicare Advantage plan rep informed me recently on the phone that I was due for an Annual Wellness check. I told her that my physician is in a direct primary care practice and thus not on their roster. This l dear soul kept following her “senior script” by asking me if I wanted her to send a nurse practitioner to my house. I was puzzled and asked why. She said, “to see if you are healthy.” I let her know clearly that: 1. She did not listen to what I had just told her, and 2. I am a provider on their panel.
FYI…Patti
Posting this piece is a great public service, Don. The low premiums are always so enticing. I've been through it once and belong to the NEVER AGAIN school. Just the idea of being "marketed at" by my medical care people give me the willies.