http://www.elderauthority.com/does-medicare-cover
Doesn't paint a good picture of Medicare. If anyone has experience with Medicare, please comment on the accuracy of this chart and your opinion of Medicare.
What does Medicare cover?
By Dan8267 Follow Thu, 31 May 2012, 6:42pm 716 views 4 comments
In Boca Raton FL 33433
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Also, what are parts C and D?
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1) The chart looks accurate.
2.1) Medicare part C is the HMO/PPO option, rather than your everyday health insurance.
2.2) Medicare part D is the drug plan that was implemented a few years ago. It sucks.
My opinion of Medicare is that it's the model for many other insurances; like all insurance, the goal is to deny benefits as much as possible.
The difference is that with Medicare, providers guess what Medicare will pay for and if they're wrong, they don't get paid. With other insurances, preauthorizations are needed before procedures are done.
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So there's no preauthorization with Medicare? Seems like a big flaw in the system.
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Yes, and no. The Medicare system is so totally fucked up... but it's still the model for other insurances. Here's a preauth example, Medicare & managed care:
Situation: A 75 year-old patient has chest pains and goes into the ER by ambulance. The patient appears to be stable, but the doctor wants to admit her for further tests due to her past medical history of cardiac failure.
Medicare: The doctor admits her to the hospital and runs all sorts of tests, none of which indicate that she's had a treatable event. She remains in the hosptial for three days, after which she is discharged home. When Medicare is billed, they pay for the following charges: Ambulance & Emergency Room bill. The determination was that the patient appeared to be stable and could have received the treatment on an outpatient basis; another option would have been to admit her under an "observation" level of care for 24 hours which pays less that the full hospital rates. Because the patient couldn't have anticipated that the bill wouldn't be paid and was advised that she must be admitted, she was NOT responsible for the bill. The hospital (one well known for admitting just about everyone, like a crap shoot) ate the bill.
Managed Care: The same patient would have been sent to the hospital via ambulance and a case manager would have reviewed the information, advised that the patient either be treated outpatient or as an "observation" and the hosptial - knowing it wouldn't be paid - would have followed the case manager's directions. They would have set up outpatient care for the patient.
* this is a real life scenario, by the way.
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It's the same thing with skilled nursing: the patient is admitted and the nursing home has to justify to Medicare why the patient requires the care. They have to anticipate what Medicare will pay for. Most of the time it works, but when it doesn't - oh, my god. The shit that they can -and do- get away with!
How I recently worked for a nursing home where the administrator had the staff providing the maximum amount of therapies for patients who not only didn't need it - they were often billed for services they didn't get. She micromanaged everything from admissions to discharge (refusing to allow some patients to discharge until their Medicare days were up rather than when they didn't need therapy), saying "This is WAR!" She was referring to state agencies that advocated for the many patients that filed complaints.
She also directed her staff to send patients with dementia to psych wards so that she could bill Medicare for their stay when they returned (illegal), refused to allow patients their choice of home care providers when they left. She was a total piece of fucking work - and was fired after sweet elliemae reported her.
From what I was told, the company is working on fixing the issues and returning tens or hundreds of thousands of dollars in billed charges - but it's not a publicly held corporation so that info isn't public knowledge (nor did elliemae receive anything from the reporting, other than being fired herself by the bad administrator before she lost her own job). The good news is that she was fired and the company followed suit with elliemae and complained about her to the appropriate agencies for followup.
The bad news is that she is still working in the industry and retains her license. It takes years to get rid of the bad ones.