You may recall that we published a piece earlier this month about how Elevance and other big for-profit health insurers are refusing to authorize coverage for much of the care ordered by doctors and hospitals that treat Medicaid patients.
First I’m a retired RN with both hospital, rural clinic, and public health experience. I’m quite aware of these practices from personal encounters with patients and having to jump through hoops and pushing some of those Medicaid insurers to get authorization for even the most simple tests in our rural are where healthcare is already inaccessible to many. Honestly, it sometimes came down to getting the “nice” person. I got to know them and started asking specifically for her. It usually worked.
I’m thinking of another issue that has always bothered me. Since implementing the DRG coding system for billing it’s become an art for coders to manipulate the diagnoses that bring the most reimbursement even if they weren’t even seen for that problem. The skilled coder chooses the diagnosis from the patients medical problem list that has the highest reimbursement rate then lists the true diagnosis as the secondary. For instance someone comes in for a simple bladder infection but they also have diabetes. The diabetes has a higher reimbursement than the bladder infection. So a diabetes diagnosis is listed as the primary diagnosis, UTI is secondary. It’s not totally fraudulent because the provider probably asks a few questions about the patients diet and whether they’re taking their meds. But it wasn’t the primary reason for the visit. This is very prevalent in the hospital setting as those reimbursements are often substantial. My mom was hospitalized for a GI issue. She has a history of breast cancer but has been cancer free for years. When we got the bill the primary diagnosis was listed as breast cancer. They were reimbursed over $100,000. I checked what the reimbursement was for the real reason she was admitted. It was at least $40,000 less. She ended up being there almost a month and ultimately died. But the issue was the deceptive billing practices. I imagine private hospitals are more aggressive in their coding practices since private insurance pays much better than those with Medicaid and Medicare.
Maybe a team of medical professionals should routinely make unannounced visits to these facilities and review the medical charts and the discharge diagnosis and compare that to the reimbursement they received for each. You may find quite a few in my opinion.
Ok I’m done. Senator Wyden what are you doing in Ohio? Come visit us in Oregon one of these days! 😉
Most of these articles are focused on patient rights which is highly important but what I don’t see anyone discussing is how these large payer groups are devastating small healthcare practices with completely fraudulent and what should be criminal practices. They make up the rules as they go along & recoup at will. Something has to be done, they are committing fraudulent practices against upstanding practices & business while breaking all of their own “rules”
"Elevance and other for-profits greatly exceeded that average, which is far more than the denial rates in the Medicare Advantage program, which in turn is far higher than denial rates in insurers’ commercial health plans."
Medicare advantage plans paid by CVS Caremark are not what Medicare used to be, all were paid by the government.
These plans are different they're private.
They have a different routine. They pay pharmacy prescription claims just enough, maybe cost (if we don't upset the algorithym) plus 50 cents fee
but...
they also have
AI monitoring processing behavior of each and every pharmacy provider.
Looking at sticking to the formulary
and
refill adherence regarding medications prescribed for diabetes blood pressure and statins.
If the drug prescribed by the prescriber is not in the formulary, CVSCaremark the insurance for the Medicare Advantage plans usually pays less than cost
or
they just write in the computer field a cost less than it actually is in order to pay community pharmacies less than actual acquisition cost of medications and a miniscule dispensing fee.
And then they charge fees, fees for processing, fees to reverse. Too many times triggers a penalty; the algorthym goes haywire.
There is no trying to figure out which brand pays the most. Which is the best brand to make a profit? These private insurers don't let. AI monitors behavior and customer service is really tricky.
If a pharmacy processes reverses processes another brand to compare payments we end up in a different category and they will reference each and every prescription and take back all profits leaving almost nothing 50 cents profit basically.
There's no denials in the Medicare Advantage plans.
It's just fees that are beyond belief.
They don't deny claims; they just pay enough to make community pharmacies lose money.
Then they send a remittance..
pages and pages of prescription numbers
just lists of numbers no names of people no names of medications dispensed just prescription numbers and how much was billed, how much was reversed, how much was paid, and how much was charged pnr fees, dir fees etc.
PNR you ask?
Proactive not Reactive fees
one remittance read
$12,000 claims paid
$23,000 pnr fees
$71,000 projected proactive pnr fees
that will be deducted from future claims processed by the community pharmacy because of our behaviors.
It used to be if we filled prescriptions too soon they would charge fees
but now
they want adherence to diabetes meds, blood pressure meds and statins.
If we don't pressure patients to adhere to these prescriptions we get more pnr fees. If we refill later than 32 days they have customer service people calling prescription customers to get them to refill or change to mail order.
I totally disagree with adherence to statins. CVS Cardmark is trying to influence medical practice by imposing a philisophy of adherence to medications that may no longer be needed and are causing more problems than helping.
CVS Caremarek wants adherrnce so they can keep charging proactive not reactive pnr fees.
Statins are not appropriate for long term use, in addition to decreasing cholesterol and lipids, statins shut off coq10 production and usage in mitochondria, causing muscle atrophy and pain, increasing insulin resistance and blood sugar and making people lose their minds. Statins make people having a stroke go deeper into cell defense response and deeper into a coma instead of waking them up. Statins do not help recovery from stroke or prevent future CV events.
The prescription profile tells everything about a customer.
When I see new pain meds, new psych meds, new blood sugar med, its time to stop the statins. Its not time to insist on adherence and long term use. Please don't go to mail order. We have resources for you...
Statins shouldn't be used long term because eating whole plant foods fruits vegetables legumes and whole grains and drinking tea ( ideally organic non gmo ) really does increase bowel movements which eliminates cholesterol
making today and everyday perfect. Bless the Creator. B"H
For Canadian readers, we have a Calgary-based company offering premium health insurance for an incredibly affordable price. Visit our page here https://www.klarityvip.com/ Don't wait to die waiting!
Long ago hospital billing software companies automated DRG flipping in claims - the 'feature' was called 'revenue maximizer' and it should be illegal because it's fraud. But doctors are also trained and coached to maximize revenue as well and those who have a financial relationship incentive structure will stack on as many expensive drugs and procedures as they can possibly justify as medically necessary, regardless of whether lower cost alternatives are available. Fee for service, for-profit healthcare and insurance has got to go.
First I’m a retired RN with both hospital, rural clinic, and public health experience. I’m quite aware of these practices from personal encounters with patients and having to jump through hoops and pushing some of those Medicaid insurers to get authorization for even the most simple tests in our rural are where healthcare is already inaccessible to many. Honestly, it sometimes came down to getting the “nice” person. I got to know them and started asking specifically for her. It usually worked.
I’m thinking of another issue that has always bothered me. Since implementing the DRG coding system for billing it’s become an art for coders to manipulate the diagnoses that bring the most reimbursement even if they weren’t even seen for that problem. The skilled coder chooses the diagnosis from the patients medical problem list that has the highest reimbursement rate then lists the true diagnosis as the secondary. For instance someone comes in for a simple bladder infection but they also have diabetes. The diabetes has a higher reimbursement than the bladder infection. So a diabetes diagnosis is listed as the primary diagnosis, UTI is secondary. It’s not totally fraudulent because the provider probably asks a few questions about the patients diet and whether they’re taking their meds. But it wasn’t the primary reason for the visit. This is very prevalent in the hospital setting as those reimbursements are often substantial. My mom was hospitalized for a GI issue. She has a history of breast cancer but has been cancer free for years. When we got the bill the primary diagnosis was listed as breast cancer. They were reimbursed over $100,000. I checked what the reimbursement was for the real reason she was admitted. It was at least $40,000 less. She ended up being there almost a month and ultimately died. But the issue was the deceptive billing practices. I imagine private hospitals are more aggressive in their coding practices since private insurance pays much better than those with Medicaid and Medicare.
Maybe a team of medical professionals should routinely make unannounced visits to these facilities and review the medical charts and the discharge diagnosis and compare that to the reimbursement they received for each. You may find quite a few in my opinion.
Ok I’m done. Senator Wyden what are you doing in Ohio? Come visit us in Oregon one of these days! 😉
I’m no expert in billing but I know this much, healthcare in the US will not change till hospitals and insurers are brought under control.
Most of these articles are focused on patient rights which is highly important but what I don’t see anyone discussing is how these large payer groups are devastating small healthcare practices with completely fraudulent and what should be criminal practices. They make up the rules as they go along & recoup at will. Something has to be done, they are committing fraudulent practices against upstanding practices & business while breaking all of their own “rules”
"Elevance and other for-profits greatly exceeded that average, which is far more than the denial rates in the Medicare Advantage program, which in turn is far higher than denial rates in insurers’ commercial health plans."
Medicare advantage plans paid by CVS Caremark are not what Medicare used to be, all were paid by the government.
These plans are different they're private.
They have a different routine. They pay pharmacy prescription claims just enough, maybe cost (if we don't upset the algorithym) plus 50 cents fee
but...
they also have
AI monitoring processing behavior of each and every pharmacy provider.
Looking at sticking to the formulary
and
refill adherence regarding medications prescribed for diabetes blood pressure and statins.
If the drug prescribed by the prescriber is not in the formulary, CVSCaremark the insurance for the Medicare Advantage plans usually pays less than cost
or
they just write in the computer field a cost less than it actually is in order to pay community pharmacies less than actual acquisition cost of medications and a miniscule dispensing fee.
And then they charge fees, fees for processing, fees to reverse. Too many times triggers a penalty; the algorthym goes haywire.
There is no trying to figure out which brand pays the most. Which is the best brand to make a profit? These private insurers don't let. AI monitors behavior and customer service is really tricky.
If a pharmacy processes reverses processes another brand to compare payments we end up in a different category and they will reference each and every prescription and take back all profits leaving almost nothing 50 cents profit basically.
There's no denials in the Medicare Advantage plans.
It's just fees that are beyond belief.
They don't deny claims; they just pay enough to make community pharmacies lose money.
Then they send a remittance..
pages and pages of prescription numbers
just lists of numbers no names of people no names of medications dispensed just prescription numbers and how much was billed, how much was reversed, how much was paid, and how much was charged pnr fees, dir fees etc.
PNR you ask?
Proactive not Reactive fees
one remittance read
$12,000 claims paid
$23,000 pnr fees
$71,000 projected proactive pnr fees
that will be deducted from future claims processed by the community pharmacy because of our behaviors.
It used to be if we filled prescriptions too soon they would charge fees
but now
they want adherence to diabetes meds, blood pressure meds and statins.
If we don't pressure patients to adhere to these prescriptions we get more pnr fees. If we refill later than 32 days they have customer service people calling prescription customers to get them to refill or change to mail order.
I totally disagree with adherence to statins. CVS Cardmark is trying to influence medical practice by imposing a philisophy of adherence to medications that may no longer be needed and are causing more problems than helping.
CVS Caremarek wants adherrnce so they can keep charging proactive not reactive pnr fees.
Statins are not appropriate for long term use, in addition to decreasing cholesterol and lipids, statins shut off coq10 production and usage in mitochondria, causing muscle atrophy and pain, increasing insulin resistance and blood sugar and making people lose their minds. Statins make people having a stroke go deeper into cell defense response and deeper into a coma instead of waking them up. Statins do not help recovery from stroke or prevent future CV events.
The prescription profile tells everything about a customer.
When I see new pain meds, new psych meds, new blood sugar med, its time to stop the statins. Its not time to insist on adherence and long term use. Please don't go to mail order. We have resources for you...
Statins shouldn't be used long term because eating whole plant foods fruits vegetables legumes and whole grains and drinking tea ( ideally organic non gmo ) really does increase bowel movements which eliminates cholesterol
making today and everyday perfect. Bless the Creator. B"H
Thanks for these informative articles!
We wrote an article about the crippled state of the Canadian healthcare system:
https://klarityvipwriters.substack.com/p/waiting-for-healthcare-in-canada
For Canadian readers, we have a Calgary-based company offering premium health insurance for an incredibly affordable price. Visit our page here https://www.klarityvip.com/ Don't wait to die waiting!
Long ago hospital billing software companies automated DRG flipping in claims - the 'feature' was called 'revenue maximizer' and it should be illegal because it's fraud. But doctors are also trained and coached to maximize revenue as well and those who have a financial relationship incentive structure will stack on as many expensive drugs and procedures as they can possibly justify as medically necessary, regardless of whether lower cost alternatives are available. Fee for service, for-profit healthcare and insurance has got to go.