Posts tagged 'General-Medicare'
Many people are confused about Medicare and Medicaid including the question of what the differences are between the programs. There are some major differences between the two, but they are easy to sort out.
Medicare is a program that is funded by the federal government as an entitlement program, which mainly focuses on the older population. It is a social insurance program for individuals age 65 and over and it also covers medical bills of many individuals with disabilities. Medicare also covers individuals of all ages with end stage renal (kidney) disease.
There are several parts to Medicare. Part A covers hospital bills, Part B covers medical insurance and Part D covers prescriptions. There are other parts, as well, and they act as supplements, however, that discussion is for a different article.
Medicaid is different from Medicare in several ways. Medicaid is also an entitlement program, however, Medicaid is not funded only by federal government, there is a state component as well, and in some states, counties pay part of the cost, too.
Medicaid is based on need and social welfare, with eligibility based on income. If a person has limited income and/or limited financial resources, Medicaid covers a broader amount of services than Medicare does. It usually covers children, pregnant women, parents of eligible children, seniors and individuals with disabilities. Though poverty is used to determine eligibility, a person must fall into one of the other coverage groups in addition to being determined eligible due to being in poverty. Medicaid benefits are paid directly to the provider of services. So, if you go to the doctor, the doctor gets the payment, if you go to the pharmacy, Medicaid pays the pharmacy directly. In addition to covering individuals who meet financial requirements, in some states Medicaid covers individuals who cannot otherwise afford insurance.
Some individuals qualify for coverage by both programs. For more information regarding Medicare and Medicaid, go to www.medicaid.gov or www.medicare.gov or simply go to Google or another search engine and type in Medicare or Medicaid and you will get pages of information.
Right now we are in the middle of open enrollment for Medicare. Open Enrollment will last until December 31, 2008, and it is important that you know as much as possible about Medicare coverage so that you can make good choices for the next year.
Medicare and Medicare Supplements, also called Medigap, have a number of parts and they are not always easy to figure out. In fact, determining how all these parts fit together and what you need for your situation can be totally confusing. This brief overview will give you information on the basic parts of Medicare and what is covered by them.
Medicare Part A and B make up the original Medicare. Part A basically covers in-patient services including inpatient rehabilitation and inpatient psychiatric care. Many services are covered completely, but you will have to pay a co-payment for some of the others.
Part B covers your doctor visits and other outpatient services determined to be “medically necessary” for you. It also covers certain tests to determine if you have an illness. There is a deductible, which is $135 for the year 2008, and there are also some copayments with it.
Medicare Part C is also called Medicare Advantage. The Medicare Advantage Plans are not part of the actual Medicare system, but they work with it. Medicare Advantage is an alternative to Medicare and the plans are run by private companies. There are a variety of plans that all work differently. Some plans work as HMO’s others charge a Fee for Service allowing you to go to any doctor as long as the doctor will accept payment from Medicare as payment in full. It is very important to research and find out whether the Medicare Advantage Plan you are choosing will actually work with your medical needs.
Part D covers Prescriptions. These are covered by private insurance companies approved by Medicare. This coverage is important, and you must determine what type Part D coverage you need. You should figure out what you need in advance so that you can enroll immediately when you are eligible. If not, you will be charged a substantial late fee. If you enroll in a certain Part D plan and feel it isn’t right for you, every year you will have an opportunity to change between November 15th and December 31st which is where we are right now. If you need to change plans, now is the time to do it.
That was the easy part. Now for the Supplements – the Medigap policies. There are 12 policies that cover services that are not otherwise covered. Each supplement is different and covers different things. In addition, it is possible to purchase these supplements from private insurance companies, get them from you or your spouse’s employer or from various government programs.
All Medigap Policies are standardized and approved by Medicare. This means that for policies E on up the alphabet, each lettered plan offers the same coverage no matter what company you purchase it from. An insurance company can charge whatever they want to charge, so compare companies and rates carefully. That way you won’t buy from a company that charges much more as another company for the same coverage.
So, do your research and determine which Medicare Supplemental Insurance is the best for you and find the best price. If you need information, check the web at www.Medicare.gov.
Many Medicare recipients have found themselves in situations where their physician feels they need a particular procedure but Medicare won’t approve it. When this happens, most people don’t know what to do.
There is a national nonprofit organization called the Medicare Rights Center. They advise that the best thing to do in this situation is to appeal the decision. Medicare is supposed to approve any medically necessary procedures, however, quite often Medicare doesn’t agree with the doctor’s idea of what is medically necessary.
According to the Medicare Rights Center, it is often easy to win appeals for a number of reasons. One thing that often happens is that the denial is based on an accidental coding error, which means that someone put the wrong number or letter into a computer, making the computer think that you are requesting something different than you actually are requesting, and you end up being denied.
The Medicare Rights Center also says that many people don’t know that they have the right to appeal, or they think that the appeal process is too difficult. Everyone has the right to appeal and the process is not too difficult.
To have a successful appeal the Medicare Rights Center suggests:
• Sign the back of the Medicare Summary Notice (MSN) and write on the front of it “Please Review”- send it back to the correct address by certified mail or with delivery confirmation;
• Include a letter with the MSN asking for an appeal and explaining why it should have been covered;
• Have the doctor write a letter explaining why the procedure is medically necessary and why it should be approved;
• Make photocopies of all written and oral communication, including notes, names and dates of phone calls;
• Do all of these things well within the 120 days allowed, so it does not end up too late to appeal;
• If you are in a private plan such as an HMO or PPO you only have 60 days to appeal and some of the steps may be different.
It can be frustrating to get a denial. This information can be helpful if you ever find yourself in this situation. Hopefully, this will not happen to you, but if it does, following these guidelines can assist you in obtaining a successful appeal.
Many cities and towns throughout the country are issuing warnings for seniors and individuals with disabilities about scams aimed at them – especially during this open enrollment period which lasts until the end of the year.
Some of these scams involve people calling Medicare recipients and telling them that they are from Medicare and they are calling to warn the recipient that their benefits will cancel in 30 days. The callers also tell recipients that in order to keep their Medicare benefits, they need to give the callers personal information bank account numbers, social security numbers and Medicare number. Callers will also say that updating this information is free.
These types of scams are becoming more and more common throughout the country. People prey on the elderly and on individuals with disabilities, and these people sound so authentic that they often get the information they are asking for. Once they have this personal information they use it in a fraudulent way.
No matter where you live, Do NOT give out ANY personal information – especially social security numbers, bank account numbers and Medicare or other information that should remain private and protected.
Actual Medicare or Social Security representatives will NEVER ask you for personal information and they will NEVER ask you to pay them over the phone. They may verify your information, but if they are authentic, they already have the information and are trying to make sure that you are who you say you are. In addition, they usually only ask for the last 4 digits of your Social Security number. Medicare sends out information about bills and statements to recipients if there are any amounts due. Most of the time the amount would be set up in advance to be deducted from your bank account and you would receive statement in the mail showing the deduction. Official Medicare, Social Security and banking information is usually sent to you in writing in a statement or letter. If they need information from you, they usually ask for it in writing.
If someone calls you trying to get information that is private, do not give it to them. Try to get their name and number and report them to your local police or sheriff’s department.
Keep yourself and your private, personal information safe. Don’t let scammers trick you into revealing and sharing information that should stay private.
The final Medicare physician fee schedule for 2009 is complete. Doctors are breathing a sigh of release knowing that many of them can now move forward and secure their salary and maybe even a raise for next year's work.
In July legislation reversed a 10.6% cut that took effect at the beginning of that month. Starting in January 2009, a 1.1% across-the-board increase will replace an additional roughly 5% cut that would have gone into effect if lawmakers had not acted, the Centers for Medicare & Medicaid Services said in the final pay rule issued Oct. 30.
"Medicare's new rule confirms that physicians caring for seniors would have faced a harsh payment cut of 15.1% next year if Congress had not stepped in," said American Medical Association President-elect J. James Rohack, MD.
The upcoming 1.1% boost is less than the CMS-projected 1.6% increase in the cost to physicians of providing care next year. Payment freezes and increases in recent years also have come in under the rise in costs. There are two bonus opportunities exist to more than quadruple the raise that doctors will get for the year.
Physicians who successfully participate in the Physician Quality Reporting Initiative will receive a 2% bonus on all of their Medicare payments for the year. Also, the program for the first time will award a separate 2% bonus to physicians who successfully prescribe medications electronically for their Medicare patients. This has been an issue on the table for quite some time and it is now a real possibility.
Bonuses will not be paid out until 2010 when all the bills are added up and the books are balanced, but they should result in about a 5% or more raise for doctors rather than doctors having to lose money and not be able to continue to serve their patients. The E prescription process is important so that there are less mistakes and less potential health complications to patients.
If you are on Medicare, you can breathe a sigh of relief. This new way of doing business will help you remain with your doctor, and help them remain in business.
After hours care by doctors for patients who are ill or who have an emergency has been a fact of life as long as there have been doctors and patients. After all, as any mother of a sick child knows or any child of a sick or elderly parent knows, the phone call usually comes in the middle of the night, and your child’s fever seems to go up after midnight. We have all spent too much time too late at night trying to get someone to feel better.
These days, most of us end up trying to tough it out all night or, in a more acute situation we end up at the emergency room. Sometimes, a friend or loved one is admitted to the hospital and has to stay. Usually, their doctors come to see them during regular hours, but there are provisions within Medicare that pay doctors extra if they need to see their patients after hours.
Most doctors use these provisions responsibly. It makes sense that once they go home from a day’s work, they really don’t want to return to the office or hospital to see a patient unless it’s a true emergency. There are legitimate times for doctors to make that trek. For instance, my daughter broke her leg and needed surgery which lasted for hours. She was doing well, asleep late at night when she woke up screaming in pain with a high fever. The doctor was called; he came in and found a problem. He corrected the problem that night. Had he not come in at that time, she could have ended up not being able to walk again. That was a legitimate after hours visit.
The problem that Medicare is looking at is the fact that there are some doctors that are billing for after hours visits that are not necessary – or are not actually taking place after hours. As a result, Medicare is considering changing the rules and making it harder for doctors to get paid for this often essential service.
If your doctor tells you in the future that he or she cannot see you after hours don’t be upset with them. You can thank the doctors who abused the system for jeopardizing or eliminating a service that doctors have provided for many years because they care about their patients and their profession.
Medicare is a program designed for seniors and for individuals with permanent disabilities who are younger than the 65 age requirement to sign up for Medicare benefits. Having Medicare benefits helps many millions of people offset medical expenses that they would otherwise have to pay themselves.
There can be issues regarding Medicare, however. With open enrollment period upon us for choosing the type of coverage and supplements that would be best for you, it is a confusing time. However, there is information and there are seminars available to help guide you through the process and help you to pick the most appropriate coverage.
There is another issue regarding Medicare which affects younger individuals who become disabled. The issue is the 2 year waiting period. The waiting period has been around for years and here is how it works.
At any time, about 1.5 million disabled people are waiting to qualify for Medicare coverage. About 40% of these individuals are uninsured during at least part of that wait and 25% percent do not have insurance for the whole 2 years. Some of the rest who are waiting to become eligible might get coverage through Medicaid, but many end up depleting their savings and assets on private insurance and medical bills because Medicaid will only pay if the person is nearly destitute and has no other way to pay for medical care.
A new bill is being sent to lawmakers to help change the situation. Several legislators presented a bill to begin shortening the waiting period gradually over the next 10 years until the waiting period is short enough and other assistance is in place so that people are not stranded without medical coverage. The reason for reducing the wait gradually is that if it was reduced all at once, it would be too taxing on the system.
This has been a long time coming and it may seem that gradually reducing the waiting period over 10 years is also a long time. That is true in some ways, but considering that the waiting period has been a huge issue for decades, at least there is progress. Maybe things will go faster now that serious attention is beginning to be given to the situation.
Every year in mid-November, enrollment for Medicare and Medicare Supplements begins. It can be a confusing time due to changes in coverage, changes in premiums and any fine print that comes along with the process.
Many seniors on Medicare are very worried about premiums going up for 2009. That is understandable, especially if a person is on a fixed income with very little or no wiggle room for extras.
The good news for 2009 is that the Centers for Medicare and Medicaid Services (CMS) has announced that Medicare Part B premiums, which cover some services that Part A does not cover including outpatient services, doctor services and other services. This means that any individual earning under $85,000 per year or any couple earning under $170,000 per year will pay the same Part B premiums that they paid in 2008.
Premiums are based on income so some premiums could be higher if you have a higher income. One important issue to think about is skilled nursing care, since Medicare and sometimes Medicaid will only pay for a specific amount of care. The care has to be administered after a minimum stay in the hospital and it also leaves a person responsible for part of the bill (currently at $128 per day) out of their own pocket after the first 60 days of care.
That is where it is important to look at additional care in the form of supplements, especially since Medicare will only cover 100 total days. Most seniors do not think they will ever need much care such as a nursing home or long term care facility, but statistics show that a high percentage of seniors spend up to 2.5 to 3 years in a nursing home or long term care facility between the time that they become eligible for Medicare and the time that they pass away.
So, during this time of the year while you can choose the coverage you feel is best, be sure to look at what is not covered and research options to fill the gaps.
Dual eligibility is a term that is heard but not always understood by Medicare beneficiaries. What it basically means to have dual eligibility is that a person qualifies for both Medicare and Medicaid.
To qualify for dual eligibility an individual must meet the requirements for both Medicare and Medicaid. Most individuals meet the requirements for only one or the other; however there are quite a number of people who also meet Medicaid guidelines based on income and assets.
Some people qualify for Medicare and partial dual eligibility, meaning that they have Medicare coverage and can also have Medicaid coverage if they pay a very small monthly premium for it. Others qualify for total dual eligibility, meaning that they can be covered by both Medicare and Medicaid and because their income and assets are below a certain point, they do not have to pay any Medicaid premiums.
The importance of having both Medicare and Medicaid is that they cover different things, and when an individual – especially with a low income – qualifies for both through dual coverage, they are basically covered for hospital care as well as doctor visits and medication with low or no copayments. In addition, certain features of dual coverage may help pay your Medicare Part D coverage premiums.
If you have questions about dual coverage, how it works, whether your state provides it and whether you qualify, you can get information from your local health department. You can also find an excellent explanation of how dual coverage works on the Centers for Medicare and Medicaid Services (CMS) website.
For more information go to the CMS website at www.cms.hhs.gov/DualEligible.
In three western states – California, Hawaii and Nevada – doctors who accept Medicare as payment for patients are stuck between a huge rock and a very, very hard place. They are in a situation where Medicare’s payment backlog has created a multimillion dollar problem. They now have to make some vey difficult choices between their patients and their practice.
This is not a small thing. This is a situation where many doctors have not been paid by Medicare since February. How many of us could go through almost a full year with a large part of our salary unpaid?
It is understandable that there can be backlogs from time to time in a system as large and complex as Medicare, but no payments for almost 10 months is much more than a small backlog. It is a backlog of epic proportions.
The situation has forced some doctors to have to drop some or all of their Medicare patients. Other doctors are on the verge of declaring bankruptcy or have already done so. This has hurt the doctors in many ways – including, of course, financially – but it leaves thousands upon thousands of patients without a personal physician who can provide adequate services to keep their health conditions under control.
What does it say when the doctors who are willing to treat the most needy patients are being forced out of business or forced to drop those very patients because the system that is supposed to care for them is hurting them? How can the system be fixed so that the most vulnerable among us get the care they need from the system that they paid into for year after year?
Medicare says that the reason is that doctors who were to switch to a new identification number for claims (sort of like a social security number) did not do so. The doctors say that the numbers were never given to them until they contacted Medicare time after time over several months to finally get their identification number. In addition, Medicare moved processing to another area and there were “glitches” in the move – many of which are still not fixed.
At present, Medicare says they are fixing the problems, but for many of the doctors who were severely affected, the damage has been done, and for their patients, they are left looking for medical care.
Medicare reform is a top priority at this time. With changes that have come to pass recently, Medicare recipients and their doctors can hope that the future goes much better than the present and the past.
There are over 44 million individuals who depend upon Medicare to cover the majority of their medical bills. The problem that the majority of people have with Medicare is that it is confusing and hard to understand.
There is hope for Medicare beneficiaries and it will come through in November and December. Open enrollment period for Medicare runs from November 15th to December 31st. Any new coverage or options that a Medicare beneficiary opts for will go into effect on January 1, 2009.
It makes sense that people want to understand at least the basics about Medicare as Open Enrollment time approaches. They need to have and understand accurate information so they can figure out if they should change coverage.
Realizing the situation, Health Alliance Plan (HAP), out of Detroit, Michigan, is offering help in the form of a DVD entitled “Making Medicare Work for You.” An article in the Wall Street Journal describes the DVD as a helpful tool to research Medicare, and goes on to state that HAP's new "Making Medicare Work for You" DVD offers helpful information. Local experts, including a physician, a pharmacist and a representative from the Area Agency on Aging 1-B Medicare Medicaid Assistance Program, explain the basics of Medicare, options for extra coverage, how to choose a plan and more. "Making Medicare Work for You" also explains the "A-B-C-s" of Medicare, what Original Medicare doesn't cover, and what to do when your employer cancels your retiree health benefits. The DVD also covers the importance of preventive services and managing chronic conditions.
"This DVD was created for the general public, and is meant to be useful resource for anyone trying to better understand Medicare," said Karen Wintringham, vice president, Medicare and Public Sector Programs. "The DVD also explains how to prepare for the open enrollment period and what to consider when making your decision about a plan for the coming year."
In addition to the DVD, a videotape of the information is available. To get information or obtain a DVD or videotape of “Making Medicare Work for You" Call 1-800-971-7878, or TDD at 1-313-664-8000.
It’s election time. You know what that means – it means that we will hear a variety of predictions as to what will be happening in the country regarding taxes, education and more. And of course, Medicare is in the middle of the mix.
Candidates will say anything and everything from “everything is just fine” to “the sky is falling, but I can save the planet.” It’s not easy to figure out what to believe or who to believe.
What we do know is that Medicare has some issues to deal with. Enrollment is rising while funds are shrinking. As a result, certain aspects of Medicare need to be restructured. There are more out of pocket expenses for Medicare recipients and there are some things that used to be paid for by Medicare that are no longer paid for in the same way.
For all the plusses and minuses, Medicare is still a program that helps many people who need it. Over 44 million people are enrolled in Medicare and are able to get healthcare, medical and other services that many of them would not be able to receive any other way. Some of the most financially vulnerable and health challenged individuals are able to receive continuous care because Medicare is available.
Granted, there will be some changes in the coming years to keep Medicare a viable program. Both candidates and the lawmakers on both sides of the aisle have ideas on what will need to happen to overhaul the Medicare system and the healthcare system to make them work for as many Americans as possible.
One candidate says that taxes won’t be affected, another says that taxes will go up, and then there are the pundits and news people. You can watch news on quite a few 24 hour news channels and hear each person’s show come up with a different analysis about what is going to happen.
The one thing we can all say about the elections and Medicare is that at least the people who are making the decisions in Washington are paying attention to the issues and talking about making sure that everyone has health coverage. That’s a start. All that the rest of us can do is wait until after the elections are over and see what actually gets done.
During the past few years, Medicare Advantage has become a more integral part of seniors’ health planning. Using basic Medicare and adding Medicare Advantage has been helpful to many Medicare beneficiaries including giving them some perks, such as gym memberships which could otherwise cost thousands of dollars. The added benefit to both seniors and Medicare is that the extras, such as gym membership encourages healthy living and can help prevent illness.
It is important that individuals who are thinking of enrolling in Medicare Advantage compare rates and coverage carefully. Since Medicare Advantage is private insurance and is not offered through Medicare, there can be issues that arise. Instead of paying your claims directly, the government pays private companies to do this through the Medicare Advantage plans.
Over 10 million seniors are enrolled in Medicare Advantage. Experts advise that especially during these difficult financial times seniors should look beyond some of the perks offered and compare private coverage to their traditional Medicare coverage.
There are various problems that seniors run into when they have left traditional Medicare for private coverage. One of the most common problems is that many physicians don’t accept Medicare Advantage; therefore many seniors are finding that they are in a position where they have to change doctors. For many, this can be traumatic for many reasons. Finding a new doctor who doesn’t know you (and who you don’t know) can be quite an ordeal. It has taken some people several months to either find a new doctor or go back to their old Medicare plan. Some individuals have had to go without medication during that period of time.
Many individuals are happy with Medicare Advantage. It is important, however, to determine what the plusses and minuses would be for you. Just because the agent tells you that you can continue with your old doctor, does not mean that it will be possible for your doctor to continue seeing you. Also, some individuals are finding that some medications and other out of pocket expenses are not covered as well as they were by their old Medicare policy, therefore costing them more money.
Before you change your coverage make sure you research to determine what will happen to your benefits in advance.
Studies that were just completed showed some interesting – and critical – facts about hospital care for those on Medicare.
Just as there are differences in the quality at various restaurants and hotels from 5 stars on down, the same is true of hospitals. There are hospitals that provide the best service and they are considered 5 star hospitals and there are hospitals that run all the way down to 1 star. The ratings are based on performance and outcomes.
The studies show that hospitals that treat mainly individuals on Medicare do not do nearly as good of a job as the ones that treat individuals with other forms of healthcare coverage.
The 11th Annual HealthGrades Hospital Study in America found that nearly 240,000 deaths of people covered by Medicare could have been prevented between 2005 and 2007 if the patients had been treated in higher level rather than lower level hospitals. This number represents 12% of all Medicare patient deaths.
Overall death rates declined during that period, however, the hospitals performing at the 5 star level reduced deaths much more quickly than those performing at lower levels. The higher performing hospitals had substantially fewer deaths than the lower performing ones.
The study did not publish names of individual hospitals, however the conclusion was that the best place to have treatment or surgery was in the “rust belt” the area of the Midwest where General Motors and Ford are located, which includes Illinois, Indiana, Michigan, Ohio and Wisconsin. The worst place for good outcomes was the Deep South, especially in Alabama, Kentucky, Mississippi and Tennessee.
Most of the deaths were related to preventable issues that are caused by the hospital in the vast majority of cases. The hospitals that performed more surgeries did better at controlling these issues. The more experience a surgeon has, the better choices they make and the less complications arise.
The study concluded that the chances of a death in the lowest rated hospitals is 70% higher than that in a 5 star hospital. The chances of death in a 3 star – or middle grade - hospital are 50% higher than in a 5 star hospital.
If you have to go to the hospital be sure to check the quality rating before you go, if possible. Before an emergency presents itself, check the ratings for all the hospitals in your area.
To check hospital ratings, you can look on the web at www.HealthGrades.com, a website designed to help people find hospital performance.
The Centers for Medicare and Medicaid Services (CMS) have been providing information regarding Medicare for a long time. Most of the information is geared toward individuals who are Medicare beneficiaries
Though this information is essential, CMS has realized the importance of providing information for caregivers. They have designed a web page for this purpose. The web page, www.medicare.gov/caregivers, discusses accurate information regarding many aspects of Medicare including what the Medicare program covers, access to services and resources to help care for a beneficiary.
Many times caregivers are family or close friends, and though they save the Medicare system over $350 billion per year (figures from 2006), they often don’t think of themselves as “official” caregivers and, until now, have not had access to information and tools specifically designed to make their caregiving easier.
The new web page will help in many ways. A caregiver’s job is exhausting. There is a lot for a caregiver to learn about benefits. A caregiver must be a staunch advocate. To help with these and other responsibilities, which can be quite overwhelming, there are direct links to other organizations who can help the 4.4 million unpaid caregivers who are simply trying to find enough information to help their loved ones.
Some sections of the page include “Navigating Medicare”, “Help with Billing” and “Care Options.” For caregivers who are overwhelmed and need help or support themselves there is a section that lists various options for help. A newsletter will come out on a bi-monthly basis starting in November of 2008.
An essential part of the goal of this web page is to lighten the load for caregivers, making it easier to care for the people they love. If you are a caregiver – paid or unpaid – take the time to check into this new web page. You may find the support you are looking for to help your loved one and yourself.
With the economy in a mess these days and the presidential elections only a few weeks away, candidates and lawmakers are saying all sorts of things about what they will be doing to fix the problem. They are “debating” about raising and lowering taxes, bailing out insurance companies and banks, and a thousand other ways to help the economy get straightened out.
One question that is continually asked by the public – especially seniors – is: What is going to happen to Medicare? We know that Medicare has its own financial struggles and needs support to stay solvent. The candidates say that they will continue to support Medicare.
The reality, however, is that there may be support for Medicare in the beginning – to get elected – but over time, there could be problems. For instance, John McCain has a record of trying to cut Medicare benefits and has stated that if he becomes president, he will cut $1.3 trillion from Medicare during the next 10 years to fund his healthcare plan. $1.3 trillion is a ton of money!
With Medicare struggling as it is, cutting this amount of money would severely limit the amount of new enrollees to the program and would create the need for extensive changes in coverage in order to save money. With the system running slim right now, how much more could we cut?
This would also cause individuals with private insurance to pay for many things out of their own pocket. Individuals who are retired and on limited incomes and who rely on Medicare are not usually in a position to do so. There would also be ramifications to individual states and to their Medicaid and CHIP programs.
In addition to all of this, there are hidden taxes that we don’t see. Besides shifting the cost of many types of care and procedures to the private insurance companies, the public would end up with the tax burden of funding the shortfall.
This may or may not be a good plan. It is not for the writers of this column to decide. It is important, however, before you vote, that you determine what the candidates propose to do regarding Medicare. They have finally laid out their plans to rescue the economy and somewhat deal with Medicare. Do your research so that you know what you will be voting for.
It stands to reason that the most vulnerable individuals in the United States who have some of the most extensive health problems and have paid into Social Security and Medicare while they worked for years, should not have to worry about how they will be able to get their medication. In their minds – and most of the rest of the nation’s – they have paid their money dutifully, month after month and year after year, and they were told that they wouldn’t have to worry when they got older and retired. They have been thinking that Medicare would take care of them and they would have the medical treatment – and medication – that they need to live as full a life as possible with their medical symptoms controlled as much as possible.
Unfortunately, for individuals who are in this situation and happen to have a very low income, it is not working out that way. What has happened is that with the “new and improved” Medicare prescription coverage, things have changed.
The new Medicare drug plans were introduced three years ago. At that time, numerous health insurance companies made bids to provide prescription coverage for low-income Medicare recipients because Medicare paid for part of the premiums, therefore the company was reimbursed, theoretically making money, not losing it.
Companies started realizing that they were not making the money on low-income individuals – especially those with serious or chronic illnesses – so they began bidding higher rates so that they would not get chosen to supply this coverage. Last year 1.2 million people had to be moved from one plan to another due to lack of companies providing prescription coverage. This year, the number will be even higher because there are even fewer companies offering low cost prescription coverage for low-income Medicare beneficiaries.
As a result, many of these Medicare enrollees could be left without enough coverage. They could be in a position where not all of their prescriptions are covered, yet they are among the sickest among us, and they cannot afford to be without their medication because it will seriously compromise their health and could lead to fatalities.
Studies have been done showing that this is the case, however, Medicare says that there will still be several choices of companies and prescription plans for low-income Medicare beneficiaries. The government automatically assigns these individuals to a plan that should cover their needs.
If you are on a limited or low income and have prescription drug coverage you can contact Medicare and/or your prescription plan and ask what will be happening for 2009. You are allowed to change plans at any time during the year. Make sure that you are covered. If you are not sure, contact your local Office on Aging, Medicaid Office or talk to your doctor’s billing office to get your questions answered.
Medicare fraud is not a new thing. It has, unfortunately, been going on for years. The problem is that years ago the amount of money at stake was not nearly as high and the Medicare system was not in nearly as much trouble financially. When you put those two factors together in today’s system, fraud is hitting Medicare harder during its most difficult time in the last 60 years.
For one thing, Medicare fraud has become a multi-billion dollar business. There are people making multiple millions of dollars defrauding Medicare every year. With Medicare funding being cut and with lawmakers trying to keep payments to doctors and healthcare professionals competitive enough so that they can afford to continue treating Medicare patients, just eliminating part of the fraud could provide the funding for the shortfall.
CMS, the Centers for Medicare and Medicaid Services, has been looking into the situation for quite some time now and is in the process of enhancing its anti-fraud efforts. They have announced that they will be implementing some aggressive new steps in cracking down on fraud.
Some of the changes CMS will be making include enlisting program integrity contractors who will study billing trends throughout the Medicare system. In doing so, when it finds providers whose billing is higher than or otherwise out of sync with the majority of other providers in their region, these providers will be audited. Since it is impossible for Medicare to look behind every claim, this is a cost effective way to look at any red flags that are going up.
In addition, another way that CMS will fight fraud will be to actually contact beneficiaries to be sure that they received the equipment or supplies that Medicare is being billed for and that these were the right equipment and were in good condition. Billing will be reviewed before and after payment and physicians who order an unusually high number of the same or related item(s) will be audited and/or reviewed as well.
These ideas alone, when implemented, should save Medicare millions of dollars. They should also discourage some individuals from engaging in fraud, as the penalties will be quite stiff and will be handled by local, state and federal law enforcement agencies, including the FBI if necessary. With this new program and the strength of law enforcement, hopefully fraud will decrease and the money saved by Medicare will be used to help the beneficiaries who need it.
Just when we are talking about going back to the basics of house calls on one end of the spectrum, the other end of the spectrum is beginning a pilot program in telemedicine.
House calls will begin being expanded soon and paid for by Medicare for those with multiple serious conditions and other situations that make house calls the best form of care for them.
Now, with that out of the way, Medicare is still looking for ways to provide effective and adequate treatment to patients while containing costs. They are finally looking at telemedicine.
Telemedicine has been around for quite some time now. Some private insurers have paid for certain treatment by telemedicine. For example, I have a nephew who was born with serious heart problems and had a pacemaker installed when he was younger, nearly a decade ago. Once his initial treatment was completed, telemedicine was used to keep him in sync of his heart surgeon and keep his heart surgeon abreast of his condition.
At the time, what would happen was that we would call a particular phone number and use our phone and another instrument to measure my nephew’s heart rate, heart rhythm, blood pressure and other vitals, as well as whether the pacemaker was working. The doctor would get the reports and then we would have a conference by phone. If there were problems or complications we would go to the local emergency room where my nephew’s doctor would communicate with the emergency room doctor by phone and computer. If things got too serious, we would get my nephew up to the Children’s Hospital where his doctor was on staff.
Today’s telemedicine is more advanced than it was a decade ago. There are cameras and TV screens that allow doctors and patients to see one another. Patients have some of the instruments such as stethoscopes, so that they can be instructed by the doctor when and how to use them so he can help them remotely. There are also touch screens patients can use to answer doctor’s questions to aid in a diagnosis.
Now that insurance companies – and Medicare – have realized what doctors and patients have been saying for years, they are finally trying telemedicine out. Doctors and patients have been telling insurers that it is better for everyone that telemedicine evaluations, where appropriate, cost under $1,500 on average as opposed to a hospital admission or other tests that often add up to somewhere between $2,500 to $15,000.
It is good news that Medicare is now looking at ways to see if telemedicine will work well for certain patients. If it only keeps a few patients out of each hospital, Medicare can save potentially over $100,000 per hospital while patients receive quality care. This is an issue to keep an eye on.
We have been hearing a lot lately about a new way that Medicare plans to keep the highest quality of procedures and services in hospitals. Most of the feedback has been excellent, except for – you guessed it – a few hospitals whose track records aren’t so great.
The new rules are considered a bold new plan to help the elderly, seniors and those who are ill. Basically, the rules have been put into place so that hospitals can and will be more careful in the way they perform everything from drawing blood to inserting a catheter to performing serious surgery.
Any and all of these procedures can cause complications such as serious infections, blood clots, pneumonia, the need for another surgery due to mistakes during the original surgery and more. Medicare has proposed not paying for these avoidable issues for a long time now, and the rules regarding the situation went into effect today.
It is important for patients to know that hospitals are not allowed to charge the patients for these types of issues that Medicare will not pay for. The reason that Medicare will not pay for them in these cases is because the hospital was at fault due to negligence or carelessness and should have to absorb the cost. It is hoped that if this happens in a particular hospital enough times, the amount of errors, problems and complications will decline.
This is a great step toward hospitals providing higher levels of service and keeping patients safer with better outcomes. Unfortunately, some states are not following Medicare’s lead and they are reimbursing certain hospitals – especially in low-income areas – anyway. Even though Medicare states that these complications and other issues are not acceptable, some areas are reimbursing them which lets them know that some losses are acceptable, service does not have to get better and in low-income areas you get what you get.
Most states are following Medicare’s lead and looking to hospitals to make the necessary changes to become safer. Hopefully this will eventually take place throughout every state in the country. Until then, depending upon where you live, you are most likely a lot safer in the hospital today than you were yesterday before the rules went into effect.
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