Obamacare - practical discussion

Chuckle… almost :slight_smile:

2 Likes

Actually, I read Epoch all the time. It’s free to pick up in most Asian grocery store. Some contents are straight forward news and some are anti-communist propaganda (I don’t mean that in a bad way) and some of totally weird quasi-religious blog. But, it’s free and I always pick it up.

It’s weird, even in the main-stream asian news paper, the one that you have to pay for, there are a lot of “miracle drug” ads. I guess the FDA doesn’t non-English publication.

2 Likes

That is a so funny, and at the same time, sadly true.

1 Like

The days of stiffing the hospital on your bill and then just dodging the bill collectors may be coming to an end. Non-profit hospitals are increasingly suing deadbeat patients, seeking their payment directly, collecting judgements, garnishing wages, etc.

https://www.wsj.com/articles/nonprofit-hospitals-criticized-for-debt-collection-tactics-11561467600

Rather than turn over unpaid bills to debt collectors, some hospitals, including nonprofit ones, sue directly to seek payments. But they say they do so as a last resort. They say they offer payment plans, charity care and price reductions for people who are uninsured.

The ACA put some limits on hospitals ability to collect debts, but this mostly just slows down rather than prevents the process.

1 Like

I can vouch for this second hand. I have an acquaintance that had a procedure at the large hospital in town. It is a teaching hospital that is part of a state university. She had no insurance at the time and didn’t bother setting up a payment plan. Her state tax refund each year is garnished by the hospital.

Unsurprisingly, turns out private insurers are terrible at fraud control. Something I’ve long suspected:

Joe Christensen has pursued fraud for both government and commercial insurers, serving as a director in Aetna’s Special Investigations Unit, a team of more than 100 people ferreting out fraud, from 2013 to 2018 and as the director of Utah’s insurance fraud division for 13 years. Fraud in government programs, like Medicare and Medicaid, gets more publicity, he said, and has dedicated arms of agencies pursuing fraudsters. But the losses may be even greater in the commercial market because the dollar levels are higher, he said.

(Although that’s different from saying the loss rate, as opposed to the total losses, is higher. Still, I have more confidence in Medicare’s fraud department – AKA the FBI/DOJ – than the apparent clowns at Aetna or UHC.)

Medicare does bear responsibility for not doing better verification on NPI applications (supposedly due to regulation), but the private insurers can do their own independent verification even if Medicare is prohibited by regulation from doing so. They have no such excuse.

1 Like

Craig Gottwals at Benefit Revolution has the other side of the debate:

As most of the folks running for President in 2020 profess their love for government provided healthcare and sing the siren song of “Medicare for All” you are likely to hear claims about Medicare’s efficiency and efficacy. Here are the facts they like to leave out:

In 1965, government experts projected that in 1990, on an inflation-adjusted basis, Medicare would cost $12 billion. In reality, Medicare cost $107 billion in 1990.

For nearly one-third of calls into the Medicaid/Medicare hotline reporting waste, fraud and abuse, government workers take over 4 months to begin investigation.

Supporters like to point out that Medicare uses 98% of its funding on claims and only 2% on administration while private insurers generally spend 85% on claims and 15% on administration. This, they claim is superior efficiency. This fails to acknowledge the rampant fraud, misuse and abuse within Medicare.

Independent experts tell us that as much as a third to half of all Medicare spending is improper or wasteful. Malcolm K. Sparrow, a professor at the Kennedy School of Government at Harvard University whose book License to Steal is a classic in the field, thinks that Medicare’s fraud-related losses may run “as high as 35%” of its budget.

An infinitesimal amount of Medicare’s budget is spent on fraud detection, so yes, it is easy to get to 98% claim payment when 1 in every 3 claims you pay is fraudulent and you spend little to no time detecting fraud. The less effort Medicare takes to prevent fraud and the more money it lavishes on criminals, the more efficient it looks. (Source for these stats: “Overcharged: Why Americans Pay Too Much for Health Care” by Charles Silver, David A. Hyman Chapter 16.)

Read more at:
Benefit-Revolution

2 Likes

The FBI may have a healthcare fraud squad, but they are not “Medicare’s fraud department.” That’s the Office of Inspector General for Health and Human Services. Regardless, I don’t have any more confidence that the FBI does a better job stopping fraud than the OIG or Aetna. That’s because none of them do. They just catch it after the fact. I doubt the FBI even catches much overall fraud, they just catch the largest schemes by the biggest players (AFTER getting tipped off usually).

I don’t know if my opinion qualifies as expert, but I do run the Fraud hotline for a local government, I’ve worked in law enforcement, and I have friends that are FBI special agents including the best man at my wedding.

2 Likes

While technically correct, what I was really getting at is that law enforcement is going to be involved with pretty much any Medicare-related fraud issue. That is in contrast to at least Aetna, which seems reluctant to involve law enforcement in anything:

[Former Aetna special investigations unit (fraud unit) employee] Christensen said while he was at Aetna, investigators almost never sought to partner with law enforcement agencies to pursue criminal cases.

And UHC didn’t involve law enforcement for about two years after first detecting the fraud… and hilariously offered to offset the fraudulent payments from future fraudulent payments:

In September 2015, United wrote to Williams, noting his lack of a license and the resulting wrongful payments, totaling $636,637. But then the insurer added a baffling condition: If Williams didn’t respond, United would pay itself back out of his “future payments.” So while demanding repayment because Williams was not a doctor, the company warned it would dock future claims he would be making as a doctor.

In the spring of 2017, more than four years after Williams first began billing insurers, one of them, United, finally brought him to the attention of the FBI’s heath care fraud squad.

2 Likes

Seriously?? They should be prosecuted criminally for aiding and abetting and conspiracy to commit health care fraud. It’s mind boggling to me that they weren’t.

5 Likes

More on private insurers’ apparent reluctance to involve law enforcement in fraud cases:

I called the district attorneys’ offices in California’s 14 largest counties, which cover about 80% of the state’s population, or 32 million people. How often, I asked, did a fraud case referred by a commercial health insurer lead to criminal charges in 2017 and 2018?

All told, prosecutors in those counties filed charges in just 22 such cases in the two years.

To put that record in context, take a look at the state’s Medicaid program, which covers about 13 million low-income people. During fiscal 2017 and 2018, the program’s fraud unit filed criminal charges against 321 fraudulent medical providers. It garnered 65 civil settlements and judgments and recovered more than $93 million, according to the state attorney general’s office.

And this is laughable:

I asked the commercial insurers in California for the case numbers of any civil lawsuits they’d filed in those years. Most didn’t respond. United said it had filed “more than a dozen civil arbitrations and lawsuits across the country” over “the past couple of years.”

UHC is the largest private insurer in the country. “More than a dozen” cases over a “couple of years”? What a joke.

4 Likes

That $93 million number makes zero sense considering the numbers preceding it. Cali DAs are saying that 321 fraudsters had $93 million laying around. Come on.

Why do you find this unbelievable ?
We’ve seen medicare fraud cases > $1B
Note its providers who are charged there so thats doctors and clinics. They aint’ poor people to begin with.

2 Likes

And “provider” doesn’t mean one doctor. It can be a practice that includes dozens of doctors. It also makes sense they’d use their resources to go after the big fish.

4 Likes

This article has an interesting walk through of how the price transparency rules would apply to a patient estimate once implemented

1 Like

Insurance has its own problems, but I also don’t attribute the rise in costs solely to insurance companies. Providers are generally bloated and pump up their costs so that they can get the maximum payout from insurance companies… it is basically like student loans, because schools do the same. Insurance companies are also run like garbage, however, and could be 3x more profitable while costing half as much (source: me, I worked for one of the big four and have discussed this with folks that work at the others). They’re basically penny-wise and pound-foolish.

That being said, my options in the past have been to carry dual coverage. It really stinks because of “true” HDHP plans that qualify for HSAs inability to allow dual coverage. PPO plans deductibles are very often over the limits to qualify as an HDHP, so it is frustrating.

Anyhow, it works out well in years where we have more than a basic need for insurance (basically every year). We end up paying nothing out of pocket other than for prescriptions which don’t benefit from dual coverage.

I think it also makes the prospects of retiring early (or at all) very bleak. The cost to buy coverage it ridiculous and one unfortunate event could wipe you out.

I really wish using concierge medical could count towards deductibles, because I would be all over that. Insurance companies should consider it because these folks keep costs low.

1 Like

I’ve found the opposite to be true. My retired income is low enough for subsidies to offset my entire insurance premium. Then I have $X,000 set aside (figuratively) to cover the policy’s out of pocket maximum. As far as I’m concerned, under the current rules I’m setting quite well post-retirement.

1 Like

I don’t intend to have low income in retirement.

1 Like

Nor do I. What matters isnt having low income, but having control over when you realize the income.

9 Likes

ACA makes early retirement a breeze for us, we pay way less than we did at MegaCorp with a better policy. But we do manage income to keep it low enough for cost-shared Silver plans.

As glitch said it’s all about how you structure your investments and income.

6 Likes