When I was shopping for private insurance, I decided to try a different kind of plan. It was most emphatically not “insurance”, the idea was that they essentially funded an HSA for you, they gave you a debit card and you used it to pay self-pay rates. You were reimbursed what they determined to be the typical cost of the procedure in your area,( less 20% until you hit 10K) but there was no deductible.
I fell on my wrist and after a few weeks, it didn’t seem to be getting better. I took my debit card to my local urgent care, were they have a flat rate “patch you up for $199 deal” for minor injuries.
They took an x-ray and determined it wasn’t broken, then the NP took the drugstore brace I’d been wearing, examined it closely and said, it’s a good one, keep wearing it, you don’t need anything else.
I submitted the bill to my health plan, my total out of pocket came out to $24, I think….It was less than 20% because I’d paid less than the going rate for the services.
I frequently told people that was why I liked my health plan, if I’d walked in anywhere with a standard insurance card I probably would’ve paid for an MRI and 10 sessions of PT.
Don’t they value their license more than a few extra bucks? If doctors are committing fraud, seems setting an example for a few of them should make them cut it out.
If it wasn’t effective, then it wasn’t necessary in the first place, seems odd that the patient would want an ineffective treatment, and that the doctor would provide one. Unless it was just that Medicare didn’t think it was effective, even if it actually was.
But, that’s the sort of “fraud” that probably shouldn’t be fraud. If a doctor and a patient agree on a method of treatment, then it should be covered. So long as the doc isn’t pushing woo on uninformed patients (in which case, his license should be in jeopardy), treatment should be covered.
Well, you already talked about how doctors commit fraud to stick a couple extra bucks into their pocket, or to get treatments that are not approved by medicare paid for, it’s not that unreasonable to believe that there are providers that will cooperate to get a patient the care they need even if they aren’t actually eligible.
Anyway, my point is that I only consider the first instance to be fraud from an ethical standpoint, where doctors are stealing money from the Medicare fund with no services provided. I see the latter examples as signs that our healthcare system is broken and people are doing their best to fill in the cracks.
Just because the treatment is ineffective doesn’t mean that the patient believes it is or that the doctor won’t provide it. I don’t particularly want Medicare to pay for penicillin shots for someone with a virus just because the patient and doctor agree.
I may not have been clear .I wasn’t saying doctors never cooperate, just that the fraud wouldn’t be by the patient alone - which might have been possible in the past when providers didn’t ask for photo ID.
In fiscal year 2016, improper payments in Medicare reached an estimated $60 billion. Some improper Medicare payments are due to fraud, which involves willful misrepresentation. […]
CMS relies primarily on prepayment automated checks and postpayment medical reviews to identify and recover FFS [fee-for-service] improper payments. Under the Improper Payments Information Act of 2002 (IPIA), as amended, CMS reported that the FFS improper payment rate was 11 percent for fiscal year 2016.8Two-thirds of the FFS improper payment rate, according to CMS, was a result of insufficient documentation.
[…]
8 Insufficient documentation occurs in FFS when the claim reviewers cannot conclude that the billed services were actually provided, were provided at the level billed, or were medically necessary. Claims are also placed into this category when a specific documentation element that is required is missing, such as a physician signature on an order, or a form that is required to be completed in its entirety.
That works great (and I recommend it) when sitting in a doctor’s office discussing some upcoming test. It doesn’t work as well when your kid is delirious with a high fever, or you’re in so much pain you can’t see straight.
It’s easy to screw the patient, because the patient’s priority is often “fix this problem, now!”, the provider’s priority is to get as much money as possible, and the insurer’s (or single payer’s) priority is to pay as little as possible. By “provider” I don’t necessarily mean the doctor and other medical staff, but the corporation or (frequently) non-profit that just sees patients as ATMs.
I’ve encountered that. Nobody knows how much something will cost until it goes back and forth to insurance a few times. It makes comparison shopping and making informed decisions impossible.
Yet, when we paid cash for intraocular lenses for my wife, all of the costs were completely transparent. Exactly what service would be provided, and the total price were written down in an easy to read pamphlet.
It’s hard to have any real idea without any specifics, but is it actually an ineffective treatment, or is it that Medicare has deemed it to be ineffective? Those two are not always the same.
And I don’t want someone paying for that out of pocket either. It’s not who is paying for it, it’s the creating the conditions for breeding superbugs that I’m concerned about.
One of the other ways our healthcare system is broken is that doctors just don’t have much time to spend with their patients. If a patient says they want “X”, the doc has a limited amount of time and resources to educate that patient, and it’s easier just to go with it. The problem you’ve pointed out isn’t about who is paying for a treatment that does more harm than good, it’s that it happens at all.
No, you were clear, and I never said that it was being done without the provider’s knowledge and cooperation. I was just pointing out that that sort of fraud isn’t being done out of greed, but out of compassion. There are many people who make too much to be eligible for Medicaid, and too young for Medicare, but still don’t make enough to pay for healthcare. If a provider sneaks them in, it’s legally fraud, but it’s not really, IMHO from an ethical standpoint.
The point is that the poster was saying that this money that is siphoned away to fraud could go to pay towards the bills for the underinsured, and my point is is that at least some of it already is.
Of course, I was being silly. I keep thinking I’m part of a society, forgetting we live in Galt’s Gulch (or so many people think, at least until they societal support beyond what their immediate monkeysphere can provide).
My cousin is a doctor. He once (twenty years ago) described the payment system as
I want to get paid $200 an hour
You want to pay nothing
I go work for a giant corporation, and you go work for an employer that provides health insurance
Between all the components, you and pay $1,000 an hour for my time.
I get $150 an hour.
Someone is happy, but it’s not you or me.
The satirical Max Gilles in his eponymous The Gillies Report , in between bucketing the pollies regularly took aim at the Painters and Doctors Union. (the play is on the Federated Ship Painters and Dockers Union which ran as an organised crime syndicate exposed by the Costigan Royal Commission as involved in tax evasion, drugs, standover and hitmen particularly on the Victorian waterfront),
“It works like this, the GP works out what your life is worth to him. As the specialist, I work out what your life is worth to me. Then we split the difference.”
A lot of it is done by people who sell durable medical equipment, like wheelchairs and the like. Many of them aren’t even health care professionals; they simply see a cash cow and try to milk it.
That notorious pharmaceutical compounding place in Massachusetts was taken down in large part because of this (and that they did their “sterile compounding” in a nonsterile facility next to a toxic waste dump and killed or disabled a lot of people).
In my old town in the 00s, air ambulance insurance for the local company was something like $40 a household per year, and was free for people who worked at my hospital, so of course I had it. Of course insurance would bill, but this insurance would pay anything that wasn’t covered.
Many billing services auto-bill before the office even filed the insurance claim. If they hassle you, pay some nominal amount, like $5, until it gets settled.
My wife uses an electric wheelchair for getting around outside. This is not provided by the NHS (we could have had a manual one) so we had to buy privately.
When I started looking I was astonished by the huge variation in prices. We wanted one that folds and is reasonably lightweight, so it fits in the car. Prices range from £800 to £3000+, and there seems to be little difference in utility or quality. We bought the £800 model and have no complaints.
There are always going to be limits to what the NHS can do. There will never be enough money to satisfy every conceivable need and opinions are divided about where lines should be drawn.
An example is cosmetic surgery: No one would argue that someone who is disfigured should not be offered the best treatment possible, but should a young woman be offered breast enlargement or reduction surgery? There are times when that’s appropriate, but only when the need is more than fashion.
It’s true. But scripts, dental and eye care are often employee benefits that may come with your job. Or not.
In my province seniors are covered for meds, everything over the first $100, each year. They are currently looking to make accommodations for seniors and low income families to get their dental care covered.
I believe initially, dental and eye care were excluded because of the blur between what’s deemed necessary, and what is cosmetic.
I wonder who you’d report that behavior to? There must be some watchdog organizations, since I keep hearing about doctors getting nailed for Medicare fraud etc.
When my son was born, the hospital billed for me staying 2 nights in the hospital afterward. This was fraudulent - may have just been a mistake, but there was no way I was staying an extra day in that hellhole.
I called the insurance company. They said “the hospital billed us, so we have to pay”. In short, the insurance company was not going to take any action to protect itself.
I called the hospital, and supposedly they reversed the bill. I have no clue whether they actually paid the money back to insurance.
I had a situation where an injury was treated inappropriately in the ER (according to another doctor in the same hospital who saw me for a 48 hour followup). I wanted to get better, I hadn’t even thought of suing.
They admitted me for treatment. I expressed concern about my insurance coverage, and the doctor who saw me told me not to worry. I stayed in hospital for ~72 hours, but every ~12 hours they put me in a wheelchair and took me downstairs to discharge. I was discharged, then immediately readmitted.
So your former employer is still paying a substantial portion of the $1700 a month premiums? That’s a pretty sweet deal. You must feel tremendously lucky.
And you might have waited an inordinately long time for treatment of an urgent condition. When my mom was 82, she developed terrible stomach pain. Her doctor said to take her to Urgent Care; his office would call to ensure she’d be seen right away. We waited 45 minutes, which, relative to the 2 hours the sign said was that day’s wait time, constituted “right away,” I guess. Turns out she had appendicitis. The UC doc told me to drive her to the hospital, which was only a few blocks away. Meantime, an ambulance was summoned for a baby with a rash from antibiotics. Guess which one was seen immediately at the hospital, and which had to wait an hour? In that time, Mom’s appendix ruptured. She survived, but the surgeon said it was a helluva mess.
Of course, we patients shouldn’t be forced to consider how to trim our own costs in a time of a medical crisis like a septic liver or a ruptured appendix. It’s a bizarre and barbaric system.
Yes and no. I know it’s a better deal than most people have- but I also knew that would be the deal when I started work there and made decisions based on that knowledge.
Hasn’t been my experience - it’s true that people coming in by ambulance don’t wait in the waiting room with walk-ins , but that doesn’t mean that someone with a rash who comes in by ambulance is treated sooner than someone with who walked in with chest pains. It just means the person with a rash waits in a different area. Your experience might be different .
At any rate, my point is if the doctor is telling me to go home, pack a bag and the ambulance will pick me up in an hour (which is what the person I was replying to described) , it’s really not that urgent and I must not actually need medical care on the way to the hospital. If it was urgent and/or I needed care on the way to the hospital, the ambulance should have been called to the doctor’s office - which I have seen happen more than once. Otherwise, it’s just an expensive taxi ride in the hopes of being seen sooner (which in my experience won’t happen)