House Republicans demand Medicaid recipients prove they're working — even though data shows most already work. Meanwhile, big health insurers, conspicuously untouched by this bill, get a free pass.
First, I will admit we're in a medicaid transition period currently where, due to the pandemic hold on reviewing medicaid eligibility which ran through early 2023 and the subsequent unwinding (lifting that hold) over the past few years, there are FAR more Medicaid enrollees who are rightfully losing coverage than ever before. Medicaid rolls swelled due to the hold and now they're returning to pre-pandemic levels, but the reactions at the state/federal level seem to be that they can use this as an argument to impose more restrictions. I don't buy that justification as we're gradually returning to pre-pandemic levels and many of the people who were on medicaid despite having a higher income were included only because of the pandemic hold.
"Work requirements" are simply a means to add bureaucratic barriers to enrolling and maintaining medicaid coverage that are meant to reduce medicaid enrollments by eliminating those who fail to keep up with the regular reporting requirements. Indiana instituted a very modest payment for medicaid enrollees which served a similar function. They might as well require enrollees to show up at their local medicaid office each month and complete 15 jumping jacks as it would accomplish the same thing: eliminate a certain portion of medicaid recipients who submit incorrect documentation, miss their deadline or don't understand their responsibility under the program.
The worst part or work requirements, payments or other bureaucratic barriers is that the people under the most stress and with the hardest life challenges who often need the program the most are the ones who most often end up losing coverage while those who maybe are less needy because they have plenty of assets, support and capability to navigate bureaucracy are able to jump through the hoops required to keep their coverage. To illustrate, imagine a family of 5 with a single mom and four kids where Mom is spinning a dozen plates just to get through each day vs. an early retiree attorney whose income in retirement is derived from nontaxable sources, like a roth IRA, and is thus eligible for medicaid. The retired attorney, who has plenty of resources and time, is going to be able to be fine whereas the single mom can only spin so many plates.
Our talking points on INSCOs are encapsulated right here.
The same insurance conglomerates that have hollowed out Medicare with Medicare Advantage are doing the same nefarious tactics with “Managed Medicaid”. These managed care organizations are the same gang we see everywhere. They all have a piece of the Medicaid pie, just like they do Medicare and ACA plans.
Here’s some waste, fraud and abuse!
These points may make a difference to true conservative senators, if there are any true conservatives left.
Unfortunately my senators are Ted Cruz and John Cornyn, but at least I can make the excellent points in this article to the staffer who answers the phone.
So many fallacies with this policy. That those who are on Medicaid and can work, don't. NO! If they can work they will. Especially since we have transitional Medicaid (which can delay the switch to ESI or ACA plans for up to a year). People who are on Medicaid who can work usually do. Especially if they also get cash assistance due to those work requirements. The administration of that kind of a program is WAY more expensive than the amount saved. Tell me again how the GOP are for smaller government when they proppose such admin heavy programs as this...
About the upcoding by insurers - Insurers don't code patient admissions, visits and procedures, the provider does. I've long heard of insurers cracking down on the doctors who upcode. I've investigated (as an internal auditor) doctors who were upcoding visits and personally sat with my state's TPA to self-report on behalf of my organization. Why would the insurer upcode when what they reimburse the provider is determined by those codes?
Kelly you’re right about providers being unable to upcode. We would get dinged for up coding, busted for Medicare fraud.
The antitrust violation, UHC’s criminal act prosecuted and won by Lina Khan in ~1923, was that UHC did not pay providers or hospitals the up coded charges, rather they looked after discharge for signifiers in the health record that they could use to justify other, false diagnoses.
For example, they look for a single hypertensive BP reading in the chart and give a secondary, false diagnosis of hypertension to Uncle Sam. Another lucrative example for INSCOs is upcoding for incidental blood sugar elevations with no diagnosis of diabetes, and giving a fake diagnostic code for diabetes to Uncle Sam.
Importantly, in no way was this a quality measure: there was no notification to the doctor or the patient about the possibility of these other diagnoses(that pay so well
So it’s fraud and it was tried and UHC lost, but they’ll never pay we the people back.
It’s fraudulent, but as with everything these days, billionaires walk.
Why? Because some upcoding algorithms actually decrease the price paid based on the proc codes and dxs submitted. In other words, if a clinic submits five different procedure codes, there is a good chance the insurer has a pre-processor that takes those five codes and combine them -- aka upcode -- to a single proc with modifiers. Then they will pay the result. The amount could end up being less than the five combined or a different combo code chosen by the provider. Believe me, the payer will *always* find the least price they can pay (ethical or not)
In privatization, the insurance companies can come back to CMS and ask for "upcoding" due to increased intensity of diseases and there is some support for seeing that Medicare Advantage providers do this to their financial advantage WHEN the patient's record does not support the patient being a sicker patient. I think @WendellPotter has written about this.
Medicare for all act S-1506 has recently been reintroduced to 119th Congress.
This bill would cover all care for United States citizens.
First, I will admit we're in a medicaid transition period currently where, due to the pandemic hold on reviewing medicaid eligibility which ran through early 2023 and the subsequent unwinding (lifting that hold) over the past few years, there are FAR more Medicaid enrollees who are rightfully losing coverage than ever before. Medicaid rolls swelled due to the hold and now they're returning to pre-pandemic levels, but the reactions at the state/federal level seem to be that they can use this as an argument to impose more restrictions. I don't buy that justification as we're gradually returning to pre-pandemic levels and many of the people who were on medicaid despite having a higher income were included only because of the pandemic hold.
"Work requirements" are simply a means to add bureaucratic barriers to enrolling and maintaining medicaid coverage that are meant to reduce medicaid enrollments by eliminating those who fail to keep up with the regular reporting requirements. Indiana instituted a very modest payment for medicaid enrollees which served a similar function. They might as well require enrollees to show up at their local medicaid office each month and complete 15 jumping jacks as it would accomplish the same thing: eliminate a certain portion of medicaid recipients who submit incorrect documentation, miss their deadline or don't understand their responsibility under the program.
The worst part or work requirements, payments or other bureaucratic barriers is that the people under the most stress and with the hardest life challenges who often need the program the most are the ones who most often end up losing coverage while those who maybe are less needy because they have plenty of assets, support and capability to navigate bureaucracy are able to jump through the hoops required to keep their coverage. To illustrate, imagine a family of 5 with a single mom and four kids where Mom is spinning a dozen plates just to get through each day vs. an early retiree attorney whose income in retirement is derived from nontaxable sources, like a roth IRA, and is thus eligible for medicaid. The retired attorney, who has plenty of resources and time, is going to be able to be fine whereas the single mom can only spin so many plates.
Bingo! Right on!
Our talking points on INSCOs are encapsulated right here.
The same insurance conglomerates that have hollowed out Medicare with Medicare Advantage are doing the same nefarious tactics with “Managed Medicaid”. These managed care organizations are the same gang we see everywhere. They all have a piece of the Medicaid pie, just like they do Medicare and ACA plans.
Here’s some waste, fraud and abuse!
These points may make a difference to true conservative senators, if there are any true conservatives left.
Unfortunately my senators are Ted Cruz and John Cornyn, but at least I can make the excellent points in this article to the staffer who answers the phone.
Thank you📞☎️
Thank you for this excellent commentary!!
So many fallacies with this policy. That those who are on Medicaid and can work, don't. NO! If they can work they will. Especially since we have transitional Medicaid (which can delay the switch to ESI or ACA plans for up to a year). People who are on Medicaid who can work usually do. Especially if they also get cash assistance due to those work requirements. The administration of that kind of a program is WAY more expensive than the amount saved. Tell me again how the GOP are for smaller government when they proppose such admin heavy programs as this...
About the upcoding by insurers - Insurers don't code patient admissions, visits and procedures, the provider does. I've long heard of insurers cracking down on the doctors who upcode. I've investigated (as an internal auditor) doctors who were upcoding visits and personally sat with my state's TPA to self-report on behalf of my organization. Why would the insurer upcode when what they reimburse the provider is determined by those codes?
Kelly you’re right about providers being unable to upcode. We would get dinged for up coding, busted for Medicare fraud.
The antitrust violation, UHC’s criminal act prosecuted and won by Lina Khan in ~1923, was that UHC did not pay providers or hospitals the up coded charges, rather they looked after discharge for signifiers in the health record that they could use to justify other, false diagnoses.
For example, they look for a single hypertensive BP reading in the chart and give a secondary, false diagnosis of hypertension to Uncle Sam. Another lucrative example for INSCOs is upcoding for incidental blood sugar elevations with no diagnosis of diabetes, and giving a fake diagnostic code for diabetes to Uncle Sam.
Importantly, in no way was this a quality measure: there was no notification to the doctor or the patient about the possibility of these other diagnoses(that pay so well
So it’s fraud and it was tried and UHC lost, but they’ll never pay we the people back.
It’s fraudulent, but as with everything these days, billionaires walk.
Luigi is innocent. UHC is guilty.
Why? Because some upcoding algorithms actually decrease the price paid based on the proc codes and dxs submitted. In other words, if a clinic submits five different procedure codes, there is a good chance the insurer has a pre-processor that takes those five codes and combine them -- aka upcode -- to a single proc with modifiers. Then they will pay the result. The amount could end up being less than the five combined or a different combo code chosen by the provider. Believe me, the payer will *always* find the least price they can pay (ethical or not)
In privatization, the insurance companies can come back to CMS and ask for "upcoding" due to increased intensity of diseases and there is some support for seeing that Medicare Advantage providers do this to their financial advantage WHEN the patient's record does not support the patient being a sicker patient. I think @WendellPotter has written about this.