Won't the "public option" plans still just make the insurance companies richer? please read...

[cbdo2007]

I've been trying to read up on the new public option they are proposing to improve Health Care and have yet to see anything mentioned about who will actually be managing the benefits and paying the claims.

I used to work at BCBS in Kansas City and even though Medicare and Medicaid are government run, they were actually managed by us and we paid the claims. So, if the government is just going to have BCBS and the other companies bid on this business, they will still be the ones interpreting your benefits and deciding whether or not your claims get paid. Sure, your "benefit packet" that you get will explain your benefits but it will most likely be the same people who are denying service now for whatever stupid reason they find that will be trying to deny them then.

Seriously this is a hundreds of Millions of $$$ per year boost for the health insurance companies. They're playing both sides of the coin and it's really a win/win for them.

[GreenPartyVoter]

1. I am certainly not a fan of for-profit health care.

[City Lights]

2. Nor am I. nt

[valerief]

3. I don't like the idea that my employer provided insurance, which

is keeping me from the public option, can still deny my claim whenever it wants to, just like now. I wanted the public option to dodge that.

[cbdo2007]

4. Yeah, see I doubt that it will.

They will just have your local BCBS "manage" the Public Option, so you will still call them to see if stuff is covered or not and they will hopefully quote and pay things correctly according to the benefits.

We would have times where we would be interpreting Medicaid benefits a certain way, then we would get a call that we had been interpreting them incorrectly and had been denying claims when we should have been paying them, then we wouldn't go back and pay the claims, we'd just start interpreting them correctly from then on.

Nothings going to change. This new "Public Option" is a scam and all of our Senators and Reps are the scam artists.

[GreenPartyVoter]

6. Claim denials are a big issue in healthcare reform, and if they aren't

truly being addressed it means that this healthcare reform isn't really amounting to much.

[kath]

18. Bing - looks like we're going to get "non-reform" reform, which will be worse than nothing because

it will push back by 20-30 years any possibility for us to have REAL national health care, like every other developed nation besides us has had for friggin' DECADES. :banghead: :banghead:

[lumberjack_jeff]

5. Would a single payer system outsource management?

I don't think there's anything inherently wrong with outsourcing the claims approval process, provided it's to a US company, and they company use the guidelines established by the government in consultation with medical experts.

[county worker]

10. I'm pretty sure it would be farmed out.

The government is not set up to become a health insurance company. It would be foolish to start something new when Medicare is already in place.

[valerief]

12. This is America. Of course, it would! And it would not only be outsourced, but

it would also be off-shored. Just like rich people's money.

[county worker]

7. Medicare is farmed out to corporations.

The one we use is called Palmetto GBA. They in turn sub contract it to someone else.

They handle the claims processing and we file our cost reports to them.

http://www.palmettogba.com/palmetto/palmetto.nsf/DocsCat/Home

Welcome to Palmetto GBA
Palmetto GBA administers Medicare health insurance for the Centers for Medicare & Medicaid Services (CMS). We have been a Medicare contractor since the inception of the program in 1966 and provide service throughout the United States and its territories. Palmetto GBA is a wholly owned subsidiary of BlueCross BlueShield of South Carolina and is based in Columbia, South Carolina.


If a medicare claim is filled correctly it will be processed and paid. They do not pay if the claim is not filed correctly.

Like all insurance companies they pay based on a fee schedule. Every type of health care service is a procedure and there is a procedure code for every procedure. The fee schedule stipulates what Medicare will pay for each procedure.

Also payment now is outcome based, meaning the better the outcome the more the reimbursement. Doctors can decide to take Medicare patients or not take them. It is the same with an insurance company. Insurance company fee schedules are based on the same procedure codes and they reimburse as a percentage of Medicare. Some times it is more and some times it is less than Medicare. It depends on the insurance company.




My guess is the public option will be an expansion of Medicare and will operate like Medicare does now.

[Hoyt]

9. Exactly.

"My guess is the public option will be an expansion of Medicare and will operate like Medicare does now."

I think you are right. No need to recreate the claims processing end of the health care system -- except to start paying benefits to those who don't get any now or who have poor health plans.

[Hoyt]

8. Claims admin doesn't pay as much as assuming risk.

Yes, the Medicare program is administered by private insurance companies like BCBS, United, CIGNA, etc. -- always has been.

But, if they deny a Medicare claim, they don't get to keep the funds that would otherwise go to health benefits. That removes a lot of the incentive private insurance companies have when a substantial part of the "savings" from a denied claim goes into the execs bonuses and stockholders' profits. That's the cancer of that ravages much of the current system.

For administering the public option, they would likely be paid a relatively low amount for administration. That's fine with me. In fact, I think they might well face penalties if they were to unfairly deny claims.

[Romulox]

11. Nobody seems to know just WHO will be eligible for the Public Option in the first place.

Is there going to be a means test, as in previous proposals?

[valerief]

13. Federal employees. nt

[Cleita]

14. Although my Medicare is managed by CMS I have never been denied a claim. n/t

[county worker]

15. Medicare does not deny claims. They may not pay a claim if it was filed incorrectly.

The provider then has to refile the claim correctly to get reimbursed. If you have Medicare and go to the doctor, the doctors write up their notes and it goes to a certified coder who writes up the claim and it gets filed electronically with Medicare. Usually if a claim is not paid the first time it is for a problem with the filing. Either the doctors notes are not sufficient or the coder made a mistake or it was billed wrong. If you have a good organization things don't usually go wrong and Medicare pays generally in 1 or two weeks. The payment is a reimbursement to the provider not a payment to the patient. The doctor is the one who can deny service to someone on Medicare. That is because they feel that Medicare doesn't reimburse them enough.

[Cleita]

16. I've had no problems getting doctors to accept traditional Medicare but

those same doctors won't accept Medicare Advantage programs, the ones that people sign their Medicare rights to a private insurer or HMO. As a matter of fact, there isn't a single doctor in my county who accepts those but they do accept traditional Medicare.

[timeforpeace]

17. They're not rushing it through just to help us get health care.