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Name:   MrHodja - Email Member
Subject:   Simply Unsustainable
Date:   8/24/2018 9:25:36 PM

So a lot of you know I spent my first career in the Air Force, retiring after a little over 22years of service.  Therefore as most of you also know I am eligible for Tricare (a part of the package that convinced a lot of us to stay the course for a career).  I also have enough sunrises under my belt to qualify for Medicare.  Rarely does a provider even ask for a copay.

Here is the rub.  I had an MRI back in June and got my Tricare Explanation of Benefits today.  I should be elated that the "Amount you owe" said $0.00, and I am grateful for that.  However, the hospital bill was $2003.45.  Medicare paid $152.06.  Tricare paid $38.80.  I am sorry, but there is no way the hospital came anywhere close to breaking even with a paltry $190.86.

This simply is unsustainable.  That hospital can't continue offering MRI services with reimbursement at such a paltry rate.  Then what do we do?





Name:   wix - Email Member
Subject:   Simply Unsustainable
Date:   8/24/2018 10:38:23 PM

Oh, don't worry about it.  Think about the o-BAMMIEcare insured family with the $6,000 deductible....they get to pay the inflated $2,003.45, because they haven't reached their deductible limit yet.  MRI's don't cost the hospital anything close to $2,000...more like $350-450, depending on type of scan done.  Can you say cost shifting.





Name:   architect - Email Member
Subject:   Simply Unsustainable
Date:   8/24/2018 11:39:14 PM (updated 8/24/2018 11:44:53 PM)

It is scary that in this case Wix is partially right...cost shifting is SOP for hospitals today in colusion with the insurance companies, but it did not start with Obamacare.  It was going on when Obama was just a boy in ''Kenya''!

Mr H perhaps a little free interprise might help.  About a year ago my wife had a fall resulting in a torn rotator cuff.  Her Orthopedist at a large local clinic associated with a hospital ordered an MRI. He recommended the hospital but told her she could also select another provider if she desired.  The hospital MRI unit, which was miles away from the clinic, had a backlog of several days and the cost estimate was $2300.  There would be no out of pocket because Medicare and her supplemental would pay even though their payment, like yours, would be only pennies on the dollar.  Almost directly across from the orthopedic clinc was a private MRI facility that could take her the next morning with a cost of less than $400 which was also covered by insurance. 

Every major hospital thinks they must have every new high tech piece of diagnostic equipment that comes down the pike along with the increased overhead expense that comes with it because all the other big competing medical facilities have it...the reality is that in most cases they don't.





Name:   Buteye - Email Member
Subject:   Simply Unsustainable
Date:   8/24/2018 11:48:05 PM

I think that Wix's post about deductibles makes a good point. I think that people whose insurance has very high deductibles are caught in a web that leaves them no choice but to pay such large amounts for medical procedures that in many cases may be over priced. It would be interesting to know how the cost of an MRI varies amomg different providers. It is likely that in many cases the high deductibles take care of much of the bill, leaving the lesser amount to be paid by the insurace company. One question Mr. Hodga: Are you at liberty to disclose the medical facility with the high cost for the MRI? Architect's post appears to support my observations. Thx. 





Name:   flyfisher - Email Member
Subject:   Simply Unsustainable
Date:   8/25/2018 7:48:20 AM

Hospital & Doctors know what reimbursement will be in advance of billing; so they write off the difference as a loss on tax returns





Name:   MrHodja - Email Member
Subject:   Simply Unsustainable
Date:   8/25/2018 8:06:29 AM

I understand that the price charged is not really what they expect to get and that Medicare, being such a large insurer, wields a lot of clout in negotiating their reimbursement rates.  My concern is that the Medicare rate (and Tricare uses Medicare rates for their reimbursement decisions) is so low that the provider will stop taking Medicare patients.

One real effect of Obamacare is that I now have to get my CPAP machine and supplies from some huge automated system rather than my local provider.  Under Ocare reimbursement was cut to half of the provider's cost, thus making them lose money on every transaction.  Several such shops in the Montgomery area had to close because CPAP was their primary line of business.





Name:   wix - Email Member
Subject:   Simply Unsustainable
Date:   8/25/2018 8:54:34 AM

Heard somewhere that VA is now qualifying veterans with sleep apnea at a 50% disability rate.  Not sure of what type service qualifies, but might be worth checking out.





Name:   Talullahhound - Email Member
Subject:   Simply Unsustainable
Date:   8/25/2018 12:55:12 PM

One of the problems is that we don't know the true cost of the procedures.  I'm not under Medicare yet - but I do know that Russell Medical is collecting hundreds of dollars from me in advance of any procedure and then I am getting a reimbursement check from Russell.  Since I am insured by BC/BS, wouldn't you think they would know how much BC/BS is going to pay?  

I think we are losing a lot of Drs. and specialists due to low Medicare reimbursements.  And I speculate that in Alex City, they can't keep specicalsts because so many of the agin  population is Medicare, Medicaid.  





Name:   Buteye - Email Member
Subject:   Simply Unsustainable
Date:   8/25/2018 3:29:29 PM (updated 8/25/2018 3:30:28 PM)

Not sure that I fully understand how you would fare given the billing information you have provided. Using Mr. Hodga's case for example, if your doctor visit included an MRI for which BC/BS was billed $2003.45, but they only allowed payment of $1000.00, is the remaining $1003.45 taken from the hundreds of dollars that were collected from you in advance of your medical treatment?





Name:   wix - Email Member
Subject:   Simply Unsustainable
Date:   8/25/2018 5:53:18 PM

I have never heard of an insured patient, especially by BC, that has to pay in advance for service.  No wonder Russell Hosp is in trouble.  Looks like they're using patients for short term cash flow.  Maybe the o-BAMMIEcare $6,000 deductibles are making providers very cautious.......but all they have to do is check with insurer to make sure of coverage.  Think I’d find another provider, if they asked me to pay-in-advance.





Name:   Lifer - Email Member
Subject:   Simply Unsustainable
Date:   8/25/2018 7:08:07 PM

All they ask from me and the boss is our copay in advance.





Name:   au67 - Email Member
Subject:   Simply Unsustainable
Date:   8/25/2018 7:20:18 PM

My wife and I have BCBS Blue Advantage and have used Russell Medical for numerous procedures.  The only thing we pay up front is our copay/deductible and that is only because they give a 15% discount if we do so.  If you ask them to bill you, you lose the discount.  We have never been asked to pay our insurance's payment up front and then get reimbursed.





Name:   GoneFishin - Email Member
Subject:   Hound
Date:   8/25/2018 9:08:18 PM

I thought hospitals collect money in advance if one is a dead beat with bad credit. I would contact them on Monday and have them pull the file and tell you why they ask for money up front knowing the overage you have as a retired federal employee.





Name:   MrHodja - Email Member
Subject:   Simply Unsustainable
Date:   8/25/2018 11:15:50 PM

The military didn't cause my sleep apnea, genetics did. I don't expect a disability classification based on it and will only accept it if it is forced upon me. 





Name:   MrHodja - Email Member
Subject:   [Message deleted by author]
Date:   8/25/2018 11:29:41 PM (updated 8/25/2018 11:30:40 PM)




Name:   MrHodja - Email Member
Subject:   Hound
Date:   8/25/2018 11:31:51 PM

Deleted my answer because I thought you were responding to me.  My mistake. 





Name:   Talullahhound - Email Member
Subject:   Simply Unsustainable
Date:   8/26/2018 11:46:08 AM

I think they are accepting what BC/BS is paying, and I don't know why they are collecting money in advance.  Is it in case I haven't met my deductible?  But this has happened 3 times this year.  





Name:   Talullahhound - Email Member
Subject:   Simply Unsustainable
Date:   8/26/2018 11:49:25 AM

And I could understand that - but then why are they sending me reimbursement?  It just makes no sense.  And I have wondered about the cash flow thing.  They have use of my money during the time.  And we're talking routine tests.  I'm used to paying my copay i advance  It's just strange.  





Name:   Talullahhound - Email Member
Subject:   Hound
Date:   8/26/2018 11:58:18 AM

I can assure you I am not a deadbeat.  And I have never asked to be billed.   But three times this year, then I have shown up to register, I am asked for several hundred dollars at the time I register (which I would assume is my co-pay), but then recieve a check a month or so after from Russell.  I've had BC/BS  for 30 years (I'm under the FEP program).  Just thought it odd.  Perhaps they are collecting too much copay?  But then, wouldn't you think they would know what the copay should be?  It's a mystery.  

But I do agree with Hodja.  If the price for an MRI is $2000 and Medicare and Tricare are only paying some part of that, then how is that sustainable?  And I understand that these reimbursements take months.  





Name:   GoneFishin - Email Member
Subject:   2 Actual Examples
Date:   8/26/2018 5:59:36 PM

I have seen some hospital bills and the medicare payments. Here are 2 examples:

$59,000 bill from hospital. Medicare approved for payment $6,600 This was outpacient procedure.

$35,000 bill for 5 days. No surgery. Medicare paid $3,500. This bill as an example had 2 Cat Scans billed for a total of $19,000. I understand a Cat Scan at an outpatient facility would be around $800.

 





Name:   wix - Email Member
Subject:   Simply Unsustainable
Date:   8/26/2018 7:20:38 PM

Hound, go by the Business Office and ask them the “why”.  It could be that you did not sign an agreement for the hospital to receive the reimbursement.  Worth a try....







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