Medicare for All

[chuckman]

Cash "settlement" still occurs. According to our business folks, it still happens, and it's not a small percentage, either. If you are an international patient they require you to sign a waiver saying you will front for all the costs, sometimes international patients can get their respective insurers or whoever to pay for it on the back end, some will pay for it upfront. What is interesting is if patients want to pay out-of-pocket for our procedures, even international patients, it is cheaper than the cost of the procedure with insurance.

I don't know if hmac even touched on the provider peer-to-peer which adds more administrative time and decreases the amount of time a provider can spend with a patient. We hired a mid-level to do peer-to-peer calls and that takes half of her day, everyday.

[Hmac]

I don't know if hmac even touched on the provider peer-to-peer which adds more administrative time and decreases the amount of time a provider can spend with a patient. We hired a mid-level to do peer-to-peer calls and that takes half of her day, everyday.

Peer-to-peer is a joke. It's basically a conversation with the insurance company's Medical Director wherein I have to justify to him/her why a given operation or treatment that they have denied is justified. We have not had a high success rate letting that conversation take place between the Medical Director and an APRN. Those Medical Directors are generally a primary care doctor (not surgeon) who has been long out of active practice and may or may not even have an active medical license. They have not seen or examined this patient and usually have no clue about the nature of the operation that that patient needs. They exist to bring the "credibility" of an MD to the insurance company's denials, which was usually issued initially by a non-medical reviewer basing the denial off a list of criteria in a book on their desk. These Medical Directors typically don't read ANY current medical literature, let alone surgical literature so my discussion with them is a general review of the anatomy, physiology, and current literature that supports the proposed operation. They tend to be frustrating, time-consuming phone conversations that often end up with an arbitrary denial despite the evidence. I actually get very few denials these days, ever since I started opening the conversation by saying "Doctor, this conversation is being recorded to make sure there are no misunderstandings if we end up taking the case to the State Insurance Commissioner's office...".

[JoshNC]

Peer-to-peer is a joke. It's basically a conversation with the insurance company's Medical Director wherein I have to justify to him/her why a given operation or treatment that they have denied is justified. We have not had a high success rate letting that conversation take place between the Medical Director and an APRN. Those Medical Directors are generally a primary care doctor (not surgeon) who has been long out of active practice and may or may not even have an active medical license. They have not seen or examined this patient and usually have no clue about the nature of the operation that that patient needs. They exist to bring the "credibility" of an MD to the insurance company's denials, which was usually issued initially by a non-medical reviewer basing the denial off a list of criteria in a book on their desk. These Medical Directors typically don't read ANY current medical literature, let alone surgical literature so my discussion with them is a general review of the anatomy, physiology, and current literature that supports the proposed operation. They tend to be frustrating, time-consuming phone conversations that often end up with an arbitrary denial despite the evidence. I actually get very few denials these days, ever since I started opening the conversation by saying "Doctor, this conversation is being recorded to make sure there are no misunderstandings if we end up taking the case to the State Insurance Commissioner's office...".

Yep. And as a surgical Subspecialist I am frequently talking to a family medicine “peer” doing the peer to peer, who tells me in short order that he has no idea what I’m talking about and needs to refer this to someone in my specialty.

[Business_Casual]

Just FYI, this is the door that opens your front door. Literally. If the State pays for your healthcare and you have kids, the State will take the right to enter your home under the guise of monitoring the health of the children. I lived in a country with socialized healthcare and we had a little red, I kid you not, book that we had to keep on our kid and the social worker would visit your home and check it.

[grnamin]

Just FYI, this is the door that opens your front door. Literally. If the State pays for your healthcare and you have kids, the State will take the right to enter your home under the guise of monitoring the health of the children. I lived in a country with socialized healthcare and we had a little red, I kid you not, book that we had to keep on our kid and the social worker would visit your home and check it.

"A government big enough to give you everything you want is a government big enough to take from you everything you have." -Gerald R. Ford


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[JoshNC]

Just FYI, this is the door that opens your front door. Literally. If the State pays for your healthcare and you have kids, the State will take the right to enter your home under the guise of monitoring the health of the children. I lived in a country with socialized healthcare and we had a little red, I kid you not, book that we had to keep on our kid and the social worker would visit your home and check it.

What country? What was in the book that they were checking?

[chuckman]

Yep. And as a surgical Subspecialist I am frequently talking to a family medicine “peer” doing the peer to peer, who tells me in short order that he has no idea what I’m talking about and needs to refer this to someone in my specialty.

We're one of 3 places in the country that does what we do. NONE of the docs on the other end of the line for the peer-to-peer understand a single thing we do. Then the amount of documentation and background me and my colleagues have to provide to my docs and our hospitals insurance people is voluminous and the huge time suck.