Posts Tagged ‘Medicare’

The Truth About Ron Wyden’s Medicare Plan

August 21, 2012 1 comment

What You Should Know About Ron Wyden‘s Medicare Plan

On August 11th, GOP Presidential Candidate Governor Mitt Romney introduced Representative Paul Ryan as his choice for Vice President. Once this was announced, media outlets “freaked out” over the Medicare plan Senator Ron Wyden (D-OR) wrote with Representative Paul Ryan (R-WI, Chairman of U.S. House Budget Committee). The plan is a bipartisan plan officially called “The Guaranteed Choices to Strengthen Medicare and Health Security for All: Bipartisan Options for the Future” and it is a roadmap for how to strengthen and fix or failing Medicare system. Senator Wyden and Representative Paul focus their plan on choice, affordability, and protecting seniors. You can read more about the plan by clicking HERE


Starting in 2022, a new Medicare program will begin offering seniors a choice among private plans and the traditional Medicare plan – much like plans Members of Congress have. Any senior at or above age 55 today will see no changes in their Medicare. (Page 2)


Coverage will be guaranteed through a new “premium support” system that encourages plans to provide high-quality care more efficiently. Private plans will compete directly with traditional Medicare based on their ability to provide quality coverage at an affordable lower cost. Low-income seniors shopping for coverage would be offered the same range of high-quality options offered to all other seniors. They would be guaranteed the ability to choose a traditional fee-for- service Medicare plan, or they could choose a private plan on the Medicare Exchange with a fully- funded account from which to pay premiums, co-pays and other out-of-pocket costs. (Page 2,9)

Protecting Seniors
To ensure ample protection from scam-artists and bad actors, the program will not only require insurance coverage protections such as guaranteed issue and risk adjustment, but it will also require the Centers for Medicare and Medicaid Services (CMS) to actively review marketing practices and benefit adequacy. Plans that fail to comply with established standards of participation would have their contracts terminated. Building upon Medicare’s current marketing rules, all plans would also be required to have their marketing materials approved annually by CMS. (Page 2, 10)

Above are the facts of Senator Ron Wyden’s Medicare Plan. Keep in mind that is only a proposal and it can not become reality without passing Congress first. You can read more about the plan by clicking HERE


The Physicians Prescription for Health Care Reform

July 17, 2012 Leave a comment

In the U.S. Congress, there are currently 21 physicians.  The physicians are  Senator John Barasso,
Rep. Dan Benishek,Rep. John Boustany, Rep. Paul Broun, Rep. Michael Burgess, Rep. Larry Buschon, Rep. Bill Cassidy, Rep. Donna Christensen, Senator Tom Coburn, Rep. Scott DesJarlais, Rep. John Fleming, Rep. Phil Gingrey, Rep. Paul Gosar, Rep. Andy Harris, Rep. Nan Hayworth, Rep. Joe Heck, Rep. Jim McDermott, Senator Rand Paul, Rep. Ron Paul, Rep.Tom Price, and Rep. Phil Roe. One of the physicians is an anesthesiologist, one is a dentist, one is an emergency medicine physician, four are family practitioners, one is a gastroenterologist, four are obstetricians / gynecologists, one is a psychiatrist, and four are surgeons (cardiovascular, thoracic, general, and orthopedic). Below is a listing of bills and provisions the physicians have introduced  that includes their prescription for health care reform.


Bills by Physician

John Barrasso    –  S. 244   (State Health Care Choice Act)
Michael Burgess – H.R. 896  (Medical Justice Act)
Bill Cassidy          – H.R. 3315  (Direct M.D. Care Act)
Tom Coburn        – S. 1031        (Medicaid Improvement and State Empowerment Act)
Phil Gingrey        – H.R. 5       (Protecting Access to Healthcare Act)
Paul Gosar           – H.R. 1150  (Competitive Health Insurance Reform Act)
Joe Heck               – H.R. 2472  (Health Care Professionals Protection Act)
Jim McDermott  – H.R. 1256   (Medicare Physician Payment Transparency Act)
Ron Paul              – H.R. 147     (Prescription Drug Affordability Act)
Tom Price            – H.R. 969     (Medical Practice Freedom Act)


Key Provisions


Medical Practice Management Provisions

Cap on non-economic damages to health care practitioners and hospitals (Source 2)
Speedy resolution of health insurance claims (Source 5)
Restoring Anti-Trust Laws to Health Insurance Companies (Source 5)
Prohibit health entities from reporting professional review against health care professionals (Source 6)
People may import pharmaceutical drugs into U.S. if is approved by Secretary of Health and Human Services (Source 8)
Physicians not required to participate in any health insurance plan as a condition of licensure (Source 9)
Tax incentive for maintaining health care coverage (Source 10)
Financial incentive for treatment compliance (Source 10)
Student Loan forgiveness for primary care providers (Source 10)
Federally supported student loans for medical students (Source 10)


Medicare and Medicaid Provisions
Establish pilot program for monthly fee based direct primary care medical home Medicare and Medicaid enrollees (Source 3)
Require analytic contractors to review Medicare Physician Fee Schedule (Source 7)
Refundable tax credit for low-income individuals (Source 10)
Enforcement of Medicare Secondary Payment Provisions (Source 10)


State Health Care Provisions
States can opt out of provisions of Patient Protection and Accountable Care Act   (Source 1)
State incentive fund for medical malpractice reform (Source 4)
Grant to create health care tribunal (Source 10)
Track banned medical providers across state lines (Source 10)













2013 Medicare Physician Fee Schedule Released

July 10, 2012 1 comment

CMS has released the Physician Fee Schedule for 2013 has been released. The fee schedule will be officially published July 20th and will become finalized November 1. Primary Care will sill see a 16% increase in reimbursement and specialities will see a 33% decrease in reimbursement.  Here exactly is how it is broken down by specialty.


Family Practice        7%
Internal Medicine    5%
Geriatricians              4%
Radiation Oncology     -15%
Radiology                       -4%
Anesthesiology            -3%
Cardiology                     -3%
Vascular Surgery        -3%
Pathology                     -2%
Urology                         -2%
Neurosurgery               -1%

No Effect
General Surgery
Plastic Surgery


Keywords: family medicine, family practice medicine, internal medicine, health care, medicare fee schedule, medicare, reimbursement, health plan, medical practice, U.S. Health and Human Services

Student Loan Forgiveness for Primary Care Physicians Announced

July 2, 2012 Leave a comment

Dr. Tom Price, MD of Georgia has a bill in the U.S. House geared directly at replacing the infamous health care reform bill officially known as the affordable care act. This bill is called HR 3000 “Empowering Patients First Act”. Below are key provisions of the bill. You can read the bill for yourself here:

Key Provisions
Loan forgiveness for Primary Care Providers

Federally Supported Student Loans for Medical Students

Refundable Tax Credit for low-income families

Deduction for health care costs

Credit for small employers adopting auto-enrollment

Improve beneficiary choice in S-CHIP

Financial Incentives for Treatment Compliance

Freedom of Choice, Right of Contract with Providers

Reduction in Medicaid DSH


Keywords: physician, health care reform, primary care physician, student loan, health policy

Health Insurance Company Scheme Alert: Downcoding

June 28, 2012 Leave a comment

Physicians are finally beginning to drop insurance carriers due to the downcoding “scam” that insurers are using in order to greatly enhance their profits. Downcoding specifically is when an insurer unilaterally decides after services have been rendered to reduce the amount of reimbursements a physician (even hospital) can receive. According to the American Medical Association, most physicians believe this practice is a scam aimed directly at giving insurers as much profit as possible and this specific issue is what physicians complain to the AMA the most about.

CPT Codes Most Downcoded by Insurance Company:
Code:                                                    Medicare Rate:                                         Usual Downcoding Amount
99205 (new pt office visit)               $213.60
99204 (level 4 new office visit)       $170.47                                                      $43.13
99203 (leve 3 new office visit)         $110.92                                                       $59.55
99202 (level 2 new office visit)        $76.88                                                        $34.04
99201  (level 1 new office visit)        $44.77                                                         $32.11
99215  (level 5 established patient)  $149.60
99214  (level 4 established patient)  $111.39                                                      $38.21
99213  (level 3 established patient)   $74.46                                                      $36.93
99212  (level 2 established patient)   $44.77                                                      $29.69
99211 (level 1 established patient)     $22.39
9234 (outpatient observation)            $142.68
99233 (level 3 hospital progress note)   $108.67                                                $34.01
99232 (level 2 hospital progress note)   $75.78                                                  $32.89
99231 (level 1 hospital follow up)            $42.12                                                  $33.66

Average % difference between usual downcoding amount and normal Medicare rate is 49%.
( Source 2)
—————————————————————————————————————————————— Aetna

– Paid $6,270,000 settlement for downcoding dentist claims  (Source 3)
Blue Cross Blue Shield
– downcoded Anesthesiologist claims (Source 4)
-downcoded Urologist claims in Kansas (Source 4)
Physician exposes massive  “scam” run by Humana (Source 1)
– Humana underpaid by $108.47 on code 99215 when should have paid $149.60
-Humana underpaid by  $27.13 on code 99213 when should have paid $74.46




Keywords: medical coding, medical billing, health care insurance, health plan, united healthcare, humana, blue cross blue shield

Accountable Care Organizations Caught Defrauding Medicare by $2.20 BIllion!

June 25, 2012 Leave a comment

Accountable Care Organizations (ACOs) have been established and are operational. Blue Cross Blue Shield, Cigna, Humana, and United Healthcare specifically already have theirs set up. Unfortunately, these same companies have been caught by the U.S. federal government defrauding Medicare on purpose by a whopping $2,208,408,879 billion.
—————————————————————————————————————————————– Blue Cross Blue Shield
Actual Fraud Amount:  $522,180,879  (Source 1,2,3,4,17
Settlements:                    $302,100,000  (Source: 5,6,7,8, 9, 17, 18)


Actual Fraud Amount:  $74,500,000
Settlements:                          $58,000,000  (Source 16)

Actual Fraud Amount:   $311,800,000
Settlements:                     $155,500,000  (Source: 10,11,12,13)

United Healthcare
Actual Fraud Amount:    $1,300,000,000  (Source 14)
Settlements:                       $97,500,000       (Source 15, 16)

Health Insurance Companies Should Pay $4.3 Billion for Defrauding Medicare/Medicaid

June 19, 2012 1 comment
The total amount that health insurance companies should pay for defrauding Medicare and Medicaid is $4,319,180,879 billion. The insurers have settled with the government for only $1,502,300,000 billion (34% of total fraud amount). The government settled at an average rate of 45% of the total amount defrauded. Total amount that was pocketed by the insurers (unrecovered) is $2,816,880,879 billion.  This is all found via public records. The amount of money in some recent cases that has been unreported (sealed by Judge) is probably a high amount as well and probably would greatly inflate the total amount I was able to find.
Actual amount of Fraud:      $524,700,000
Settlements:                           $225,000,000    (Source 1)
% Settled for                           42%
 Blue Cross Blue Shield
Actual Amount of Fraud        $522,180,879     (Source 2, 3, 4, 5, 23)
Settlements:                            $302,100,000        (Source 6,7, 8, 9, 10, 23, 26)
% Settled for                            57%
Actual Amount of Fraud:        $110,000,000 million
Settlements:                           $54,200,000 million     (Source 26, 27,28)
 % Settled for                         49%
Actual Amount of Fraud       $74,500,000
Settlements:                           $58,000,000   (Source 19)
% Settled for                           77%
Actual Amount of Fraud       $311,800,000
Settlements:                           $155,500,000    (Source 13, 14, 15, 16)
% Settled for                           50%
Actual Amount of Fraud:       $430,000,000 million
Settlements:                            $155,000,000 million  (Source 24, 25)
% Settled for                            36%
 UnitedHealthcare /Pacificare
Actual Amount of Fraud       $1,300,000,000 billion (Source 17)
Settlements:                                  $97,500,000 million (Source 18, 19)
% Settled for                          7%
Actual Amount of Fraud:         $1,046,000,000 billion (Source 20)
Settlements:                              $455,000,000 million  (Source 21, 22)
% Settled for                              43%
Total Fraud                                                               $ 4,319,180,879
Settlements                                                               $1,502,300,000
Average % of total fraud amount Settled for:  45%
Insurers Pocketed:                                                  $2,816,880,879


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