It's the time of the year when we Medicare patients are allowed to change plans. We can choose a traditional Medicare plan or a Medicare Advantage plan and we can choose a Medicare plan with Part D coverage. These choices can be made when we turn 65 years old, if we move, if a sponsored plan is terminated, or between October 15 and December 7. If we choose the traditional Medicare plan we may choose our own physician and hospital. If we opt for the Medicare Advantage plan we are limited to seeing only the doctors who are part of the plan and must be referred to specialists by our "plan" primary care doctor. The latter plan is less expensive so naturally there are restrictions. But the lower cost to the patient is significant and many people join an Advantage Plan.
But there can be a problem. In the Journal of the American Medical Association Dermatology it was reported that Medicare Advantage insurers overestimate how many in-network dermatologists are actually enrolled in the plan. Many of the "listed" dermatologists were dead, retired or not accepting new patients. Of 4,700 dermatologists listed as participants in various plans 45% were duplicates. More than half, 51%, were not available to see patients.
This problem is not unique to dermatologists. Many plan members have problems finding doctors who will accept them as patients. In their zeal to sell the programs the sponsors exaggerate physician membership, leaving new members struggling to find medical care after they have made the commitment to the new plans. There is a window for changing your mind. If you become disenchanted with your new plan you can disenroll between January 1 and February 14. After that, you are stuck for the rest of the year.
I love a bargain but until there is some oversight of the Advantage Plan sales people I'm sticking with traditional Medicare. I do realize there are excellent Advantage Plans that live up to their promises but it's hard for the non-medical person to know which is which. A personal recommendation would be reassuring. When I decided to seek a second opinion about my broken shoulder I had an appointment with my primary care doctor within one day, an MRI the next day, and an appointment with a specialist orthopedic surgeon a week later. Decisions were made between each doctor and me, there was no plan administrator looking at the statistical cost effectiveness of reverse Total Shoulder
Replacement surgery and deciding if I were worth it.
http://www.youtube.com/watch?v=pl3vxEudif8&sns=em
Archive timeline: 2014: May and June - preparing for surgery, July - surgery and post op problems, August - recovery and physical therapy, September - thinking medically, October - getting back to normal, November - almost there!
Showing posts with label medicare. Show all posts
Showing posts with label medicare. Show all posts
Tuesday, November 11, 2014
Monday, October 27, 2014
My Medicare.gov...PO Day 134
I realized today that I have not received a medicare Summary Notice for the time period from my surgery in June till now. Furthermore that summary is usually just medicare Part B. I don't know what I will receive from medicare Part A. I haven't been an inpatient in a long time. So I decided to look it up on line.
Three or four years ago I signed up with my medicare.gov so I decided to go there if I could remember how. It took a while but I finally figured out my user name and password and logged in. It was all there, names, dates and amounts. Part A charges were mixed in with Part B charges. I continue to be amazed at the negotiated amounts medicare pays for procedures. Everything I've read has suggested joint replacement surgery would run in the neighborhood of $50,000.00. Certainly, considering my additional six days in the hospital due to pneumothrorax, my bill would be exorbinate.
Total approved charges came to about a third of what I expected.That included doctor fees, hospital fees, tons of xrays and a handful of cat scans and MRIs. There were outpatient doctor visits, radiologists who read the scans, and a few doctors I never heard of. I am still stunned. I continue to read how doctors and hospitals are under great pressure due to cuts in fees by managed health care. It has to be true.
I have heard, don't know if it is true or not, that in big cities many specialists will not see Medicare patients because of the low reimbursement. I can believe that if there is a patient base of working age clients, patients with private insurance or even those who pay personally, enough to fill a doctor's schedule, that the physician would choose to not accept Medicare patients. I feel fortunate to live where, if a doctor didn't see Medicare aged people, he wouldn't have anyone to see at all.
I just know I need to bake and take more cookies! Or is it kookies?
http://youtu.be/MT9QZBGyXjU
Archive timeline: 2014: May and June - preparing for surgery, July - surgery and post op problems, August - recovery and physical therapy, September - thinking medically, Octobe
Three or four years ago I signed up with my medicare.gov so I decided to go there if I could remember how. It took a while but I finally figured out my user name and password and logged in. It was all there, names, dates and amounts. Part A charges were mixed in with Part B charges. I continue to be amazed at the negotiated amounts medicare pays for procedures. Everything I've read has suggested joint replacement surgery would run in the neighborhood of $50,000.00. Certainly, considering my additional six days in the hospital due to pneumothrorax, my bill would be exorbinate.
Total approved charges came to about a third of what I expected.That included doctor fees, hospital fees, tons of xrays and a handful of cat scans and MRIs. There were outpatient doctor visits, radiologists who read the scans, and a few doctors I never heard of. I am still stunned. I continue to read how doctors and hospitals are under great pressure due to cuts in fees by managed health care. It has to be true.
I have heard, don't know if it is true or not, that in big cities many specialists will not see Medicare patients because of the low reimbursement. I can believe that if there is a patient base of working age clients, patients with private insurance or even those who pay personally, enough to fill a doctor's schedule, that the physician would choose to not accept Medicare patients. I feel fortunate to live where, if a doctor didn't see Medicare aged people, he wouldn't have anyone to see at all.
I just know I need to bake and take more cookies! Or is it kookies?
http://youtu.be/MT9QZBGyXjU
Archive timeline: 2014: May and June - preparing for surgery, July - surgery and post op problems, August - recovery and physical therapy, September - thinking medically, Octobe
Thursday, October 23, 2014
Hospital compare site...P O Day 130
CMS, the government administrative arm of Medicare, has created "the Hospital Compare" data base. This allows the Medicare patient to compare the rate of unplanned readmissions or deaths within 30 days of being in the hospital of their choice with the rate of those unfortunate events at other hospitals locally or nationwide. The purpose is to improve the quality of care with a measurement that is easy for the consumer to understand. The goal for the hospital is to anticipate and prevent problems that lead to readmission or even death following hospitalization for certain conditions.
"Hospital Compare" records and reports instances when the patient is readmitted to the hospital within 30 days of discharge if they were initially treated for 1. heart attack, 2. heart failure, 3. pneumonia, 4. hip/knee replacement surgery, or 5. hospital-wide readmission to include internal medicine, surgery/gynecology, cardiorespiratory, cardiovascular and neurology services.
Also reported is the 30 day death rate from heart attack, heart failure or pneumonia.
They keep track of surgical complications such as: pneumothorax, blood clots, postoperative wound dehiscense, accidental puncture or laceration, pressure sores, venous catheter related infections, postoperative hip fracture due to a fall, and postoperative sepsis.
Ultimately this data serves two purposes: First, the patient can go to the Hospital Compare Home Page and compare the record of three hospitals of their choosing. This rate is also compared to national averages. Second, Hospital Compare is part of the Hospital Quality Initiative whose intent is to help improve hospitals' quality of care by distributing objective, easy to understand data on hospital performance. both for the benefit of the patient and the hospital.
This is a great way to be able to compare your local hospital with other nearby facilities and even nationwide statistics. To go to the Home Page of Hospital Compare by clicking on this link
http://www.medicare.gov/hospitalcompare/search.html:
I briefly mentioned this medicare site on P O Day 83 so if you have already checked it out thoroughly, forgive the repetition.
Archive timeline: 2014: May and June - preparing for surgery, July - surgery and post op problems, August - recovery and physical therapy, September - thinking medically, October--
"Hospital Compare" records and reports instances when the patient is readmitted to the hospital within 30 days of discharge if they were initially treated for 1. heart attack, 2. heart failure, 3. pneumonia, 4. hip/knee replacement surgery, or 5. hospital-wide readmission to include internal medicine, surgery/gynecology, cardiorespiratory, cardiovascular and neurology services.
Also reported is the 30 day death rate from heart attack, heart failure or pneumonia.
They keep track of surgical complications such as: pneumothorax, blood clots, postoperative wound dehiscense, accidental puncture or laceration, pressure sores, venous catheter related infections, postoperative hip fracture due to a fall, and postoperative sepsis.
Ultimately this data serves two purposes: First, the patient can go to the Hospital Compare Home Page and compare the record of three hospitals of their choosing. This rate is also compared to national averages. Second, Hospital Compare is part of the Hospital Quality Initiative whose intent is to help improve hospitals' quality of care by distributing objective, easy to understand data on hospital performance. both for the benefit of the patient and the hospital.
This is a great way to be able to compare your local hospital with other nearby facilities and even nationwide statistics. To go to the Home Page of Hospital Compare by clicking on this link
http://www.medicare.gov/hospitalcompare/search.html:
I briefly mentioned this medicare site on P O Day 83 so if you have already checked it out thoroughly, forgive the repetition.
Archive timeline: 2014: May and June - preparing for surgery, July - surgery and post op problems, August - recovery and physical therapy, September - thinking medically, October--
Sunday, October 12, 2014
Go home or go rehab? PO Day 119
It is definitely more common to have a friend who has had knee or hip replacement than total shoulder replacement surgery, reverse or not. We might even have visited the knee or hip patient in the rehabilitation facility where many of them went when they left the hospital. While we all would rather be home in our own surroundings under these circumstances, sometimes a nursing home, Rehabilitation facility, can be the best choice. If we live in a multistory home, if we don't have someone at home to help us immediately post op, or if we have concurrent health issues that make our recovery more complicated...we might be better off taking advantage of our medicare allotment for inpatient nursing care. Even in spite of my hospital orthopedic coordinator's admonition that one's risk of contracting post surgery infection is greater in a nursing facility than at home!
But, we shoulder surgery patients insured by medicare do NOT qualify for this coverage! Unlike the knee or hip patient, we are considered perfectly ambulatory. Our shoulders might hurt, it might be hard to dress, we might be sleeping in a recliner for a while, we might even feel a bit wobbly for the first few days. But we can walk and that makes all the difference. So clear a path from the bed to the bathroom, remove those hazardous items from the stair steps, and pick up that throw rug that everyone trips over.
As a matter of fact, your recovery will be faster and easier the more you walk around. Just be careful.
http://youtu.be/RGQmvPSjrpk
Archive timeline: 2014: May and June - preparing for surgery, July - surgery and post op problems, August - recovery and physical therapy, September - thinking medically, October--
But, we shoulder surgery patients insured by medicare do NOT qualify for this coverage! Unlike the knee or hip patient, we are considered perfectly ambulatory. Our shoulders might hurt, it might be hard to dress, we might be sleeping in a recliner for a while, we might even feel a bit wobbly for the first few days. But we can walk and that makes all the difference. So clear a path from the bed to the bathroom, remove those hazardous items from the stair steps, and pick up that throw rug that everyone trips over.
As a matter of fact, your recovery will be faster and easier the more you walk around. Just be careful.
http://youtu.be/RGQmvPSjrpk
Archive timeline: 2014: May and June - preparing for surgery, July - surgery and post op problems, August - recovery and physical therapy, September - thinking medically, October--
Friday, October 3, 2014
The Two-Midnight rule...PO Day 110
I am quite in over my head in trying to talk about this subject. Furthermore, iOS 8.0 (recent upgrade in Apple operating system) is giving me a fit and some very basic functions on my computer are not working right for me.But I'm going to give it a try...
In 2013 Medicare instituted some new rules regarding the status of patients as either in-patient or out-patient. They were so confusing that the the application of the new law was postponed a few times, most recently until October 1, 2014. Even now there are governmental committee meetings going on to 1. define the rules and 2. change the rules. Florida Senator Bill Nelson chairs the committee.
Member Sheldon Whitehouse, Senator from Rhode Island, confessed he was not sure he understood the two-midnight rule and was immediately supported by Senator Susan Collins of Maine who said she was not sure anyone understood it. I feel like I am, therefore, in good company. It is referred to as the two-midnight rule because the patient has to spend two nights in the hospital to qualify as an in-patient. However, when the clock starts running on those two nights is confusing and a person can actually be lying in a hospital bed in a hospital gown eating hospital food for days and not meet the inpatient criteria.
Medicare reports the new rules are to clarify the status of patients "in" the hospital. Previously there was a lot of hind-sighting going on and hospitals were being asked to retroactively change a patient's classification. Why did anyone care? An outpatient's bill is typically $3000 to $4000 less than that of an inpatient due to the fact that outpatient services are paid at a lower rate than inpatient. At first it seemed that this inequity had the effect of causing an increase in patient admissions but CMS (the Medicare administrator) began scrutinizing hospital admission rates and penalizing them for admitting patients unnecessarily just to get paid better. In some cases Medicare has demanded repayment of millions of dollars in what they consider over payments. In self defense the hospitals took the opposite approach and they are now often less inclined to "admit" a patient for fear of being audited.
How does this affect the patient? The patient and family may not realize there is any difference. An "outpatient" is often in a room and apparently receiving the same care as an "inpatient." The difference lays in whether they are there for observation or treatment and for how long. No one thinks to ask and wouldn't know the ramifications if they did. But observation is billed under Medicare Part B and treatment is charged under Medicare Part A. That's another big subject and there is not time to go into it here. Suffice to say, it makes a difference in what someone is going to have to pay and that someone might be you.
The greatest possible cost to the patient may come as they leave the hospital. Outpatient treatment does not qualify one for follow up nursing home care. If not covered by Medicare this can run into thousands of dollars. When added to other costs not covered, medications and co-pays for example, there can be a significant financial blow to the patient.
So step one is to ask why you are in the hospital. Are you there for observation or for treatment? This must be indicated on your admission papers and the doctor is the one who makes the determination. Make him explain his choice. If you are told you are there for observation, be sure you understand why you are not undergoing treatment, what alternatives there are, and what financial burden you are incurring as a result of this clasification. That's step two. And step three, talk with your family so everyone understands the situation.
Hopefully the Senate Committee will come up with some clarification of the new laws and perhaps force some changes or at least require full disclosure.
http://youtu.be/FGVGFfj7POA
In 2013 Medicare instituted some new rules regarding the status of patients as either in-patient or out-patient. They were so confusing that the the application of the new law was postponed a few times, most recently until October 1, 2014. Even now there are governmental committee meetings going on to 1. define the rules and 2. change the rules. Florida Senator Bill Nelson chairs the committee.
Member Sheldon Whitehouse, Senator from Rhode Island, confessed he was not sure he understood the two-midnight rule and was immediately supported by Senator Susan Collins of Maine who said she was not sure anyone understood it. I feel like I am, therefore, in good company. It is referred to as the two-midnight rule because the patient has to spend two nights in the hospital to qualify as an in-patient. However, when the clock starts running on those two nights is confusing and a person can actually be lying in a hospital bed in a hospital gown eating hospital food for days and not meet the inpatient criteria.
Medicare reports the new rules are to clarify the status of patients "in" the hospital. Previously there was a lot of hind-sighting going on and hospitals were being asked to retroactively change a patient's classification. Why did anyone care? An outpatient's bill is typically $3000 to $4000 less than that of an inpatient due to the fact that outpatient services are paid at a lower rate than inpatient. At first it seemed that this inequity had the effect of causing an increase in patient admissions but CMS (the Medicare administrator) began scrutinizing hospital admission rates and penalizing them for admitting patients unnecessarily just to get paid better. In some cases Medicare has demanded repayment of millions of dollars in what they consider over payments. In self defense the hospitals took the opposite approach and they are now often less inclined to "admit" a patient for fear of being audited.
How does this affect the patient? The patient and family may not realize there is any difference. An "outpatient" is often in a room and apparently receiving the same care as an "inpatient." The difference lays in whether they are there for observation or treatment and for how long. No one thinks to ask and wouldn't know the ramifications if they did. But observation is billed under Medicare Part B and treatment is charged under Medicare Part A. That's another big subject and there is not time to go into it here. Suffice to say, it makes a difference in what someone is going to have to pay and that someone might be you.
The greatest possible cost to the patient may come as they leave the hospital. Outpatient treatment does not qualify one for follow up nursing home care. If not covered by Medicare this can run into thousands of dollars. When added to other costs not covered, medications and co-pays for example, there can be a significant financial blow to the patient.
So step one is to ask why you are in the hospital. Are you there for observation or for treatment? This must be indicated on your admission papers and the doctor is the one who makes the determination. Make him explain his choice. If you are told you are there for observation, be sure you understand why you are not undergoing treatment, what alternatives there are, and what financial burden you are incurring as a result of this clasification. That's step two. And step three, talk with your family so everyone understands the situation.
Hopefully the Senate Committee will come up with some clarification of the new laws and perhaps force some changes or at least require full disclosure.
http://youtu.be/FGVGFfj7POA
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