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Post by redwolf on Jan 24, 2009 11:05:06 GMT -6
What a mess. The prices set by private insurance depends on the "bargaining strength" of the hospital. How Do Hospitals Get Paid? A PrimerBy Uwe E. Reinhardt 'Critics of the federal Medicare program routinely call Medicare a “dumb” price setter. Perhaps it is. But it stretches one’s cerebral processes to conclude that the varied prices emerging from the cumbersome private market process described above are any smarter or more conducive to a rational, efficient health system. This does not mean, of course, that some economists and other defenders of the system would not try.'economix.blogs.nytimes.com/2009/01/23/how-do-hospitals-get-paid-a-primer/?em
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Post by unlawflcombatnt on Jan 24, 2009 16:54:53 GMT -6
The author provides a link to a list for outpatient services from Dameron Hospital in California. The fees listed are absolutely insane, and bear no relationship to reality whatsoever. Those fees are many times the Medicare allowable reimbursement rate. And insurance companies base their fees on Medicare reimbursements. Though they are not identical, Medicare and private insurance reimbursements are fairly close. In an extreme case, a private insurer may pay 20% more than Medicare. But such cases are very rare.
I happen to know what some of the Medicare reimbursement rates for certain procedures are, since I perform some of them, and since my biller has billed for them. And I've seen the EOBs (Estimation of Benefits). For example, for inhalation therapy code 94640 (for asthma or COPD), Medicare pays ~$12, not the $596 listed by Dameron. Though my biller may submit a charge for as much as $75, we were never paid more than $12. (Sometimes we weren't paid at all.)
But if my biller had ever submitted a charge of $596 for code 94640, someone would have been arrested by the FBI (Probably me.)
The Dameron list also gives a fee of $125 for an Electrocardiogram (code 93005). Medicare will only pay $20 for a code 93005 electrocardiogram (If they pay at all.) Again, these Dameron "fees" are insane. No one is paying those amounts, or anything even close.
Dameron lists an "Arthroscopy, Shoulder, with partial acromioplasty" (code 29826) with a fee of $20,236. That's insane. And I know more about this one than any of the others. I've had 6 shoulder surgeries myself, and none of them have even cost 1/2 that amount. Furthermore, the last shoulder surgery I had -- I paid out of my own pocket. Cost: $8,000.
The Dameron list is an egregiously dishonest attempt to deceive the public and defame doctors. There are no doctors anywhere on the planet that are getting the fees Dameron has listed.
The author of the article should check with an actual medical professional (like a doctor, not an administrator) before he cites such a dishonest source as Dameron.
It's little wonder people are concerned about all of the "waste" there is in Medicine. It's easy to see why they feel that way, when such a fallacious source is used and cited in a New York Times article.
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Post by graybeard on Jan 24, 2009 17:05:50 GMT -6
BUT, if you have not insurance, you are billed the full retail price.
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Post by unlawflcombatnt on Jan 25, 2009 20:18:14 GMT -6
BUT, if you have not insurance, you are billed the full retail price. Yes, you are. But you are NOT billed amounts anything like what Dameron claims.
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