Tracking code caldwell guardian

Saturday, November 16, 2013

Medicare, Humana and United Health Changes You Need to Know

Each year those of us 65 or older can keep or change Medicare Advantage Insurance plans or simply stay with plain vanilla Medicare Part B, The cost for the basic Medicare is rounded off at $104/month and it comes right off the top of that meager Social Security check.  This year Humana and United Health have thrown a curve ball at Medicare recipients.

Humana is in the process of severing ties with St. Luke's in this area.  If you keep your Humana Medicare Advantage Plan  be advised if you go to St. Luke's you will be on the hook for out of plan costs.  The mutual separation is over reimbursements to St. Luke's by Humana for Medicare Advantage payments. You know... the charges sent to Humana generally get settled for a much lower price than "retail" prices charged by hospitals.

United Health (under the banner of AARP), is dropping thousands of doctors in 10 States according to a Wall Street Journal article in today's edition.  Again it is probably over reimbursements paid v. what the docs submit for their services. 

If you have anyone you know oblivious to these changes in Medicare you might want to give them a heads up.  Out of plan fees and costs can be a real shock to the wallet.


  1. I am fairly computer literate but navigating the sites of all the Medicare Advantage sites is more than a bit overwhelming. It really got down to who has the lowest copay each month for the lowest deductible and amount out of pocket each year.

    I love having Medicare and my current carrier beyond regular Medicare is Regence Blue Shield. Two outpatient surgeries and the hassles were non-existent. They raised the premium this year but I am having nothing to do with HMO Plans. Constant BS with those plans. My advice is to stay with a PPO plan with the options to your liking.

    I am not sure who wins and loses in the duel between Humana and St. Luke's. Heard from a Doc. Humana is loath to pay hospitals and doctors in a timely manner for services rendered. Also, the reimbursements to St. Luke's is significantly more than what is charged and accepted by St. Al's. Could this be the "free market" at work here in the valley?

  2. I am very thankful to have access to Medicare and as a Baby Boomer I had no idea of just how appreciative I would be to have this when I retired. It is not free by any means but it is affordable. The doctors and medical providers I see never seem to mind I am on Medicare and the treatment I get is excellent when I see my doctor. I hear all the complaining about reimbursements but it is not something I deal with when I go to my doctor.

  3. Free market isn't working in the healthcare arena. What IS working is a computer program called "Charge Master" (Google it for more info) which hospitals have been using for 20+ years now to set their "retail" pricing schedules. The average "retail" price is 400% to 600% times the amount which Medicare/Medicaid is willing to pay for the same service or product. The result is that the individual patient who is or has been uninsured or is uninsurable is charged this grossly inflated pricing rate.
    When asked, St. Al's usually offers an instant 33% reduction to those willing to sign a payment agreement, but St. Luke's flatly demands full payment of the bill in 18 months on top of much larger initial "retail" charging!
    It is easy to offer what appears to be large discounts when you have already increased the price over cost by 1000 percent! Some markups are insanely high. Drugs administered in hospitals is often times 10,000% over cost or more. Add a bit of creative billing from the hospital's own medical billing department including upcoding, unbundling, ghost billing, and a dozen more dirty tricks and you have the perfect storm we call health care "costs" in America.
    It is refreshing to see Humana and others refuse to do business with those who price gouge the worst. The consumer suffers of course, but Humana isn't in business of health care provision, they are in the business of making a profit.
    The US government has been able to negotiate the best deal (20% to 25% of ChargeMaster retail billings) simply because they are the largest insurer.
    Take this entire healthcare debate and overlay the "single payer" idea and you have the end of all "for profit" healthcare provision. (Most enjoy a "non-profit" status with the IRS currently anyway, why not make them live up to it!)
    When Obama declared that the ACA would result in overall cost savings, it wasn't based on the current retail pricing schedule of the hospitals.
    ACA is literally legislating the competition out of business. One only has to ask any of the several million Americans who just received cancellation notices on their existing policies!
    "Single Payer" is coming.... mark my words.

    1. If single payer is coming, the cure will be worse than the disease. Thanks for mentioning Chargemaster, I have experienced this crap but didn't know that it had been dignifyed with a name. Some providers billing services (ie Practice Management) don't back off the grossly inflated prices, as you have suggested, if not paid through your insurance co's contract. It takes some pretty clever moves on your own to make them heel, without finding a collection agency trying to collect the total inflated amount.

    2. A 2010 an Idaho Appellate Court decision held that healthcare providers are subject to the same contractual requirements as all other service providers of any kind. For the hospital or doctor to claim a definite price after the fact requires a PRIOR meeting of the minds regarding PRICE (which is a "material term" of the contract.) Any material term not included in a contract which is an unspecified quantity, cannot magically become a finite amount after the fact. This Court held that such tactics are NOT enforceable merely because a hospital's billing staff, collection hounds or attorneys say so. The upshot of this court decision is that most Hospital's current "Consent for patient services" contract is only a promise to pay, not a promise to pay ANY amount billed to you. This means that all billings are negotiable because no agreement on price was had prior to rendering of service. To be lawfully enforceable, all eventual charges must satisfy the legal definitions of "customary and usual",..."reasonable and like" (for same services rendered in our locale).
      With widely varying "ChargeMaster" prices, such subjective terms make it difficult for hospitals to make a case for fairness in their billing practices. The collection agency in the case above lost two summary judgment decisions before they finally settled the case for NO money. There are other protections in the law for consumers regarding related predatory pricing schemes.
      One is the modified "Robinson-Patman Act" which demands that all similarly positioned consumers of "services" pay the same price for the same service.
      The punitive penalties for violating this Act are as much as 1000 times the actual price difference overpaid by a consumer. The Act has never been applied to medical services, but it has been applied to rail shipping prices which at one time were being manipulated by the railroads to the benefit of large consumers of rail freight. If I can figure this out, you can be sure that those Washington DC looking to regulate health care cost have done so as well. IMO, healthcare should not be a "for profit" business. Every dollar which goes to pay for executive salaries is one which could reduce the cost of everyone's healthcare. FYI: In 2008, St. Luke's "Chief Medical Officer" was paid total salary and benefit package of $910,168 while St Al's C.O.O. received 463,997. With the current "Let them eat cake" attitude of hospitals, I have no sympathy for their collective "non-profit" largess.

  4. I have a simple solution for Anonymous if you feel that hospitals charge too much. Don't use their services. Go out and spend 12 years of your life and at least a $100,000 getting a education and then you would need to build your own medical facility and hire a staff. Then you could provide your own medical care at what ever price you think is fair.f. Isn't it interesting how someone wants a service but thinks they should set the price. How many times have you paid $1 or more for a bottle of water when you could have provided your own for free? Personally I think Dodge should have to sell me a new 1 ton diesel pick up for $5000 but I don't't suppose that is going to happen.

    1. Again Bob you have completely missed the point.

  5. Medical costs in this country are eating up 18% of our GDP. Everyone knows or should know this is not sustainable. Insurance companies know it, doctors know it, hospitals know it. Yet I keep seeing billboard ads for "EMERGENCY CARE" and clocks with times to wait if you do come in for "emergency care" lower case this time because those without insurance have the system figured out. They show up on the doorway of any ER and they get treatment without having to pay a dime up front. The use the ER's as their primary care doctor and there is no stopping this nonsense. The hospitals get paid by taxpayers for any services rendered to the medially indigent (illegals, and societal parasites). The welcome mat is rolled out and those of us who aren't in the 47% who don't pay taxes get to pay the bills for this service.

  6. Critical analysis[edit]

    Chargemasters gained national attention from a critical Time magazine cover story published February 20, 2013, titled "Bitter Pill: Why Medical Bills Are Killing Us".[3] Reporter Steven Brill examined the overlooked role that chargemasters play in the American health care system's cost crisis, asserting that they routinely list extremely high prices "devoid of any calculation related to cost", and are generally regarded as "fiction" in the healthcare industry, despite their significant role in setting prices for both insured and uninsured patients alike.[3]

    "The 'full charges' reflected on hospital Charge Masters are unconscionable", wrote George A. Nation III in a 2005 piece for the Kentucky Law Journal.[18] Health care economist scholar Uwe Reinhardt noted in a 2006 article for Health Affairs that the approach to chargemasters by hospitals would have to be modified to become more transparent, in order to encourage a form of consumer-driven health care to help improve the system.[19] University of California, Berkeley professor of health economics James C. Robinson pointed out prior criticism of the chargemaster, "Much ink has been spilt bemoaning that incomprehensible foundation of hospital cost accounting and prices, the redoubtable chargemaster."[20] Robinson called for greater transparency as well as increased price standardization as steps to help remedy the situation.[20]

    In a 2007 article for Health Affairs, Gerard F. Anderson observed, "Without knowing what services they will use in advance, it is impossible for patients to comparison shop."[21] Anderson also noted the esoteric nature of the language on the chargemaster made it difficult for patients and anyone other than hospital administrators to understand.[21] Anderson emphasized the difficulty of patients' ability to interpret the chargemaster in a subsequent 2012 article: "Furthermore, most of the items on the charge master file are written in code so that only the hospital administrators and a few experts in the field can interpret their meanings.".[22]

    In May 2013, the Centers for Medicare and Medicaid Services published inpatient prices for hospitals across the country in a publicly available format.[23]

  7. Bob,
    Healthcare is a necessity which places the consumer at a extreme disadvantage when it comes negotiating price while water and diesel trucks are elective purchases with prices clearly posted allowing you to make an informed decision. Try to get a straight price answer about a pending healthcare need from any healthcare provider. It is virtually impossible. Recently, a friend was given a "firm estimate" of 24K for an elective procedure at a local hospital only to get the final bill and find it had increased to 96K!! The procedure was uneventful with no reason for the increase given. Now what do you do?
    The hospital business model isn't to demand payment upfront of anyone who seeks their services. Scaring you to death afterward is so much more fun! The fact remains that between deductibles and co-pays, everyone must pay some amount out of pocket for healthcare. Even these remaining "non-covered" costs are never demanded of insured patients in advance of service in a hospital.
    Doctors and hospitals may be mutually dependent on each other but doctors shouldn't be painted with the same brush of culpability for the pricing schedules of hospitals. Doctors have no say in what a hospital charges. The Statesman recently documented widely varying price schedules between the two largest healthcare providers in the valley for same services rendered. Hospitals have historically engaged in active "cost shifting" (raising prices to those who can pay to pay for those who can't or won't). You are correct about taxpayer participation in this arbitrary pricing scheme, but it comes as a matter of law. Face it, everyone in Idaho benefits from some other taxpayer's contributions, whether it be healthcare or highways etc. We receive far more in return than what we pay to the Federal government. Just ask Butch whether Idaho wants to lose highway matching funds or Medicare assistance. We are all on the government dole in some way or other. When you retire will you expect your social security checks like all the rest of current 47% who do not pay taxes? The only answer is never stop working and never get old. Good luck.

  8. My point is that if the free market was allowed to function as it should prices on everything including medical care would be more reasonable. When we create a false market for medical care by providing it to people who refuse to be responsible for themselves there is very little intensive to keep costs at a reasonable level. Why should someone who is capable of but refuses to provide for themselves be rewarded with free medical care free food free rent free utilities free education and many other benefits that most of us must work for? For every person that is truly unable to take care of themselves there are thousands that are milking the system.

  9. Health is not an "entitlement" any more than pickups or any other product It is the result of someone making an investment of their time and money.As such it is worth what the market will bear. economics 101 true vale of any thing is determined by what one person will sell for and what another person will pay. If you feel something is over priced you have the god given right to not buy it.

  10. Medical care is one of the few things where a doctor or other provider writes down a number and that is what we are stuck paying after the fact. Every other purchase I make is negotiable in one form or another. I can buy new at the store with the price tag price up front., I can go online and buy it, I can buy one used, or I can simply do without. Medical services are a big secret until we get the bill. I think if more people asked what medical services cost before they go in the front door it would be a better world for all of us.

    Insurance companies have taken on the roll of negotiating prices for their policy holders. Pity the fool who does not have insurance and gets stuck with the full bore " charge master" prices. No wonder there are so many medical bankruptcies. It is all the after the fact billing that just destroys a lot of people. I read a few months ago that 75% of the people gong medically bankrupt actually had insurance. Somehow this is just wrong.

  11. Thanks for sharing this great article.Great information - thanks a lot for the detailed article.That is very interesting I love reading and I am always searching for informative information like this.
    Medicare Billing

  12. Thanks for shearing about this I thinks its very hopeful post and very important post for us.thanks for your great and helpful presentation I like your good service.I always appreciate your post.I’m really amazed with your posting skills as well as with the layout on your blog site.
    Medicare Billing

  13. Great information, I am very happy to your post,That is very interesting I love reading and I am always searching for informative information like this.thanks for your great and helpful presentation I like your good service.I always appreciate your post.
    Medicare Billing


A public discourse on the issues of the day makes the world a better place.

We welcome comments but they will be moderated and edited if too long or do not have anything to do with the post.
Agree or disagree just do it without profanity or it won't get posted. Try to keep your comments to no more than 300 words. Too long and I will try to edit it down or simply delete the comment. The whole idea is to get people to read your comment. Don't use 10 words when one will do the job.

It's OK to have a difference of opinion but keep it civil. I have used the "delete" feature on myself at times.

The ANONYMOUS feature for comments seems to be the most user friendly. People have commented they have difficulty with the other methods of posting comments.