Tricare And Mapd Plans
- Thread starter RunnerDude
- Start date
For physicians, while it is not Carte Blanche, there will ALWAYS be those that skirt the lines with embellished clinicals. IE making things sound worse than they are on clinical documentation so that in the event of RAC audits they don’t get paid claims clawed back because proof of medical necessity had not been met. Those doctors are bad and fortunately enough they are the minority.
It’s blatantly naive, or maybe negligent, however to believe that medical providers and not the insurance companies are the problem.
If you read my post to assess blame only on the carrier, then perhaps I should add some clarity.
Padded claims, unfair denials of service, over-charging, etc are just a few of the ways the patient can be short-changed.
Many of the times when the patient is squeezed it is because they are at the mercy of the "system" because they don't know how the game is played.
No doubt and I didn’t read it that way. The pain point, in my eyes, is that patients are shortchanged, doctors are handcuffed in many cases, and the insurance companies are seemingly doing just fine. There needs to be a healthy balance
I will agree with 2 of 3 . . . I don't know the docs are doing "just fine" but most are doing OK.
When I look at my MSN and EOB I shake my head and ask "How do they make money on this?".
My wife had a hip FX last year requiring emergency surgery with screws. Surgeon billed $5600, assistant surgeon billed $6300. Say what??????
Surgeon ended up with $2200, assistant with $200.
Same incident, hospital billed $52,000 allowed amount $22,000, carrier paid $19.000 and we paid $3,000.
Hefty discounts off "retail"
PS
The Assistant was non-par but accepted a pittance none-the-less
Non par is why they billed more for the surgeon assist than the surgeon. The scheme is to bilk as much as possible OON off of usual and customary. I worked in high volume joint replacement practice and that is standard practice. Insurance will come back saying we are going to pay the assistant 150, our billing team gets first offer for payment, negotiate it 2-3 times and always end up with more.
When I say negotiate, it is literally as simple as calling the insurance company and saying “hey, we would like more money - can you do that”. 2 minutes later they will email over a new offer with higher reimbursement. Call back, ask for more again, repeat. It’s nuts.
The billed amounts are really just determined by some dude behind an emerald curtain
Something like that.
It's creative accounting.
Bill $10,000. Patient has no insurance and no money. Provider agrees to accept $300. Bookkeeper writes off $9700 as bad debt. Business shows a net loss but somehow stays in business year after year.
- 4,138
I agree with leaving T4L and Original Medicare alone.
I also second VA for treatment and MA as a great solution as well.
MA is MA. We can debate if it's good for the client or not all day long, but I tell people my job isn't to tell them what to do. My job is to inform them and offer a suggestion.
As long as they understand the risks, the networks, the step treatment, prior authorizations, and MooP they're adults and can do what's right for them. I'll tell them I think they need HI/Cancer for $40 a month.
Truthfully, for me at least, the commission evens out for the first three years. Most MS plans pay me 360 a year and then drop off in year 4 to 4-5%.
That being said, if they're really worried about reducing costs and are willing to take on some risk, HDG is a great solution as well.
You don't get paid nearly as well.. but it's definitely a better overall plan for catastrophic coverage. Which is how I think of MA.
I also second VA for treatment and MA as a great solution as well.
MA is MA. We can debate if it's good for the client or not all day long, but I tell people my job isn't to tell them what to do. My job is to inform them and offer a suggestion.
As long as they understand the risks, the networks, the step treatment, prior authorizations, and MooP they're adults and can do what's right for them. I'll tell them I think they need HI/Cancer for $40 a month.
Truthfully, for me at least, the commission evens out for the first three years. Most MS plans pay me 360 a year and then drop off in year 4 to 4-5%.
That being said, if they're really worried about reducing costs and are willing to take on some risk, HDG is a great solution as well.
You don't get paid nearly as well.. but it's definitely a better overall plan for catastrophic coverage. Which is how I think of MA.
This right here, I find when You do a good job doing this above when someone decides to go MA and has issues they still trust you because you told them beforehand and you do the switch for them and visa verca
I find many of my MA sales are because I told them the negative as well as the positive I often hear no one ever explained it that way and they go in eye open no surprizes
PTAgentInNJ
Expert
- 23
First off--appreciate all the info in this thread--it's been an interesting read and I'm definitely still learning where this issue is concerned (and frankly on all Medicare fronts despite being several years in 
).
I have an appointment today to enroll a veteran with T4L into a Humana Honor PPO MA only plan. Here in NJ the plan offers "up to" $55/month in part B reimbursement. When I discussed the plan with the enrollee and after having left the materials with him for awhile to review, his take was that he wants to enroll for that savings. Appreciate any additional thoughts on that or the PPO network piece.
Here are some excerpts from the 2 page brochure Humana made available for the plan.
The combination of VA healthcare and a Medicare Advantage plan provides more options for coverage and care
Advantages of Medicare Advantage
• Non-VA emergency room
• Choices and access to more providers, second opinions and specialists, Rx formulary options
• Potential savings opportunities
• Plan extras
• A Medicare Advantage plan won’t impact your VA benefits
).I have an appointment today to enroll a veteran with T4L into a Humana Honor PPO MA only plan. Here in NJ the plan offers "up to" $55/month in part B reimbursement. When I discussed the plan with the enrollee and after having left the materials with him for awhile to review, his take was that he wants to enroll for that savings. Appreciate any additional thoughts on that or the PPO network piece.
Here are some excerpts from the 2 page brochure Humana made available for the plan.
The combination of VA healthcare and a Medicare Advantage plan provides more options for coverage and care
Advantages of Medicare Advantage
• Non-VA emergency room
• Choices and access to more providers, second opinions and specialists, Rx formulary options
• Potential savings opportunities
• Plan extras
• A Medicare Advantage plan won’t impact your VA benefits
