The big "20% that Medicare doesn't pay" Lie

Investment Analysis Clubs Macro Economic Trends and Risks
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I just got the bill for that MRI of my head last month to rule out anything besides “age-related hearing loss”.

The imaging lab charged $4,500. The Medicare reimbursement was a little over $360. My “20% that Medicare doesn’t pay” was the princely sum of $72.22. (i.e., 20% of the Medicare reimbursement)

I note that $72 is 1.6% of the $4,500 that was billed. And this work was performed under Medicare Part B, not the Part A hospital insurance where the numbers are even more favorable to the Medicare beneficiary.

People just don’t understand how much they’re getting screwed under pre-age 65 health care.

I may have another test of Medicare billing in a week or two.

Over the last 2 weeks my right leg has been swelling up if I walk more than 500 feet or so. I’m visibly limping by 1,000 feet and ready for a wheelchair at the 1,500 foot marker. Since I was comfortably walking 5 to 10 miles per day a month ago, this is concerning. (Note: When I took Amtrak to Seattle on Monday to pick up the Tesla, I would have normally walked a half mile to the City Bus that will for a fare of 60 cents drop me off in Downtown Vancouver where it’s then a one-mile walk to the Amtrak station. A 1-1/2 mile walk is just a small portion of my daily activity. The fact that I opted for a $37 taxi ride illustrates the depth of the problem. {{ LOL }} )

I had a half-hour visit with my new Certified Physician Assistant primary care doctor today and after much time spent on the computer gave me a diagnosis of “intermittent claudifcation”. Then she asked with a look of concern, “Are you on a Tier 1 plan?”

Assuming she was asking about the quality of my Medicare Advantage, I replied, “I’m on the VIP Plan – regular Medicare. I can see any doctor you send me to without insurance company interference.”

She said, “That’s great. I was afraid I was going to need to treat you for a couple of months of less effective remedies before sending you to a vascular surgeon.”

She wrote a referral noting I needed to be seen on an urgent basis, and said I’d likely have an appointment with a vascular specialist in a week or two. In the meantime she warned me that if the symptoms worsen, to get to the Emergency Room right away.

From a bit of googling on my own, I’m hoping that the fix is no worse than a few hours in a cauterization lab to place a stent. But since I don’t have any of the diseases that typically lead to claudication (i.e., high blood pressure, high cholesterol, or diabetes) it could be something else.

intercst

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If you do need a stent, double check you’re in a catheterisation lab first…not cauterisation.

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You can probably expect a fair bit of preliminary testing before any definitive treatment gets underway (especially allowing for the fact that there’s a possibility your issues are due to something other than PVD)…including,
maybe some of the more extensive lipids testing you’ve had the opportunity to read about over the past 3 years. Including, but not limited to Lp(a). Thinking of my mum’s experience back in about 1980, Intermittent claudication was the presenting sign and symptom of very widespread ASCVD. I cannot believe that I was dumb enough to think her problems were solely due to smoking…especially since, on reflection, her siblings died suddenly and somewhat prematurely.

This has been going on for a while, correct…I seem to remember you mentioning one leg measurably larger than the other (I believe Wendy said something along the lines of getting it checked and you talked about having the problem for a matter of years)

This…and the constellation of life altering problems that developed afterwards for mum …is the #1 reason I’m addressing my belatedly diagnosed ASCVD as aggressively as I am. Not because I’m fearful of dying, or any of that sort of twaddle… but rather to remain as healthy and asymptomatic in my marginal decade (this may well be it, for all I know) as I am now.

Good luck with the vascular guy

P.S…a Red Flag on the PA’s comment of being willing to treat you ineffectively. That’s not good clinical acumen

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That’s the result of Medicare Advantage forcing doctors to do what’s good for the insurance company rather than the patient. She was alluding to the fact that a Medicare Advantage plan would have her treat this “conservatively” for a couple of months before approving the referral to a vascular specialist.

Since I’m on traditional Medicare, I get to see a vascular specialist without insurance company interference.

intercst

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Well, I guess that’s as good an excuse as any.

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I doubt it’s ASCVD. When I had that abdominal aortic aneurysm screening exam over a year ago the ultrasound tech commented that “I’m not even seeing any calcium deposits on your aorta. That’s very unusual for someone your age”. And the lipids test the kidney specialist did last month is still in the normal range.

intercst

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Why would you say that? It’s not the doctor wanting to do the ineffective treatment, it’s the insurance company.

intercst

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@intercst best wishes on getting a quick, painless, effective treatment for your leg problem. Please follow up on @VeeEnn’s advice since there may be a serious underlying issue.

I received an invitation to volunteer with SHIBA (WA State Statewide Health Insurance Benefits Advisors). This comes with intensive training about Medicare, even more than the training for AARP Tax Aide (this is my 7th year of volunteering).

Since the tax season is only 3 months in the spring I am considering volunteering for SHIBA since their busy season is at the end of the year (when Medicare renews). During training I will get the inside scoop on the arguments you have made many times about skipping Medigap insurance.

However, I may not be able to volunteer for SHIBA as DH had a (free, Medicare-paid) low dose CT scan because he is a 50-year smoker. The CT scan detected 4 lung nodules (scattered in both lungs), one of which is 25 mm X 12 mm (rated 4B, highly suspicious). Since DH is my #1 priority I won’t take on any commitments until his situation is clarified.

Wendy

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I looked into volunteering for SHIBA a couple of years ago and reviewed their syllabus for the training. Basically they had you reading from scripts with canned answers to questions, kind of like what you’d expect in a telemarketing operation.

There really isn’t any “inside scoop” on whether or not it makes sense to skip a Medigap plan. It’s just an understanding of what your “20% co-pay” is actually based on, and whether you can comfortably handle that. Many have the same misconception that you held (i.e., I’m going to be responsible for 20% of the $500,000 surgery bill I had pre-age 65 while on an employer’s plan). What’s a $500,000 bill pre age-65 is going to be a fraction of that in terms of a Medicare reimbursement, and you’re only paying 20% of that.

It’s just a matter of understanding the numbers – something that the for-profit insurance industry would prefer you not understand.

intercst

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Of course! {{ LOL }}

intercst

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Well, in a nutshell, it’s a bit of a crock.

For sure, third party payers place contraints on ad lib medical care…not unreasonable, really, given that too many patients being treated House-fashion with every and any diagnostic being thrown at them would quickly drain coffers. That’s a long way from compelling doctors…or PAs as I believe you stated in the OP…to need to treat you for a couple of months of less effective remedies before sending you to a vascular surgeon.

With your presentation of a recently worsening condition, whatever accompanying signs were there and the warning given about visiting the emergency room, referral for an accurate diagnosis was the only option to appropriately be discussed. To weasel out of this with a “the insurance company made me do it” is, as I say, a total crock. You were being treated by someone who ought to know better…maybe inexperience or inadequate training is responsible but, it’s a bit unnerving to think that there are practitioners who’re so willing to avoid the work necessary to make sure all patients are presented with the options for treatment that conforms somewhat to standard of care.

I’m wondering what sort of less effective remedies would be on offer when there’s no definitive diagnosis in the first place.

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With this in mind, I’d like to make a plea on behalf of those of us who’re Medicare beneficiaries and are hoping for a decent lifespan… along with those who aren’t yet but soon will be…to maybe be a little more circumspect about how loudly you crow about the better deal we’re all getting as compared with those poor dabs who have an employer provided group health plan or whatnot.

It’s an fact that cannot be refuted that fee for service Medicare (aka traditional Medicare) no longer reimburses at anywhere close to an adequate level. Not even going to mention MA. As a consequence, we’re all being subsidised by those no-longer-generous group health plans and that state of affairs may not continue should those plans continue with the trend to cut costs even more.

It’s already happening that some hospital systems are dropping Medicare Advantage plans. They may start coming for “us” sooner rather than later.

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That’s what I got.

Surely you haven’t missed the trouble people on Medicare Advantage have in getting referred to a specialist?

intercst

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That may be true, but Medicare Advantage doesn’t give providers a higher reimbursement. It just makes them jump through more hoops to get paid, while letting the health insurer skim more off the top by denying care.

intercst

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Regardless, that doesn’t remove the ethical and medico-legal obligation of any individual healthcare provider to do the right thing for the patient. Mistakes and poor care due to ignorance are bad enough, but deliberately and knowingly making choices that are believed to be second rate is indefensible…and might well be just that in a court of law, should piddling about doing something ineffective “because the insurance made you” cause harm to the patient and some enthusiastic personal injury lawyer gets in on the act. Stranger things have happened.

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True…but irrelevant. Which is why I specifically stated that I wasn’t even going to mention MA in the very next sentence after the one you quoted here I think most folk would’ve inferred that was because Medicare Advantage reimburses at an even lower rate and with a higher denial rate than fee for service Medicare…and the reason that some hospital groups are no longer accepting Medicare Advantage. If that was not obvious, I’ve repeated it for anyone who didn’t.

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Less effective not ineffective.

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I don’t think you’re understanding what I’m saying.

The doctor and I agree that sending me to see the specialist is the proper course of action. There is no for-profit insurance company standing between me and the specialist preventing that from happening.

If I had a Medicare Advantage plan, there was a good chance that the insurance company would randomly deny the referral and ask that the provider to document a month or two of more conservative remedies like exercise, or elevating the leg at rest, etc., (you know, stuff I’d been doing on my own before seeing the doctor) before then approving it. That’s what she was talking about.

She was relieved that it was not necessary for me to run the gauntlet of those roadblocks in order to receive care.

Why is that so hard to understand?

intercst

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Exactly! {{ 15 characters ))

intercst

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I think it’s wonderful that she was relieved but here’s the thing…you don’t have a definitive diagnosis, do you? You require a referral…and received one. This is exactly what every patient with your condition requires before any treatment…effective or otherwise…is even contemplated.

Now, if you read your original post (and this is the only one I’m commenting on) the PA (not doctor) who you saw appeared to state that it was a referral or less effective treatment depending upon insurance coverage. This is unethical. Regardless of whether it’s becoming the norm as a younger generation steps up to take care of us or whether it’s a feature of a PA run service…it’s unethical. Srsly. It is! It’s one thing as a provider to discuss what might be necessary in case of any denial or delay in approval for payment…and temporary band aid type remedies whilst this takes effect might be necessary (and that could conceivably happen with traditional group plans and fee for service Medicare) but your narrative doesn’t suggest that.