6 ms·

> nearly half of medical spending > something like 2 FTEs focusing just on the reimbursements from Medicare and Medicaid 2FTE’s vs what? The question isn’t i

by Retric 7mo ago

> nearly half of medical spending > something like 2 FTEs focusing just on the reimbursements from Medicare and Medicaid 2FTE’s vs what? The question isn’t is this free, the question is how large is the total staff including price negotiations, doctors, and IT time spent handling billing issues, and is Medicare more or less than 50% of the total. I am ware of one hospital and 2 medical clinics where the difference is very much in favor of Medicare.

CWuestefeld 7mo ago
2FTE’s vs what? versus nothing. Hospitals don't have to maintain a whole team for UnitedHealth, or for Anthem, etc. This is my point. Medicare cooks the books to look more efficient by offloading their administrative costs onto providers. Other payers can't do that because, even if huge, they don't operate at the same scale. Think about it: we often hear on the news about disputes about contracts when a local hospital's agreement with some insurance company comes up for renewal. They play hardball, getting local news to run stories on how many people will be affected if they can't come to terms. But you'll never hear this in the context of Medicare/caid. Hospitals have leverage to negotiate with commercial payers, but not with the government.
- nradov 7mo ago
  Depending on the size of the health system it may not be a team of multiple FTEs but they absolutely do expend significant resources on managing differences between commercial payers. They all have different rules about covered services, step therapy, prior authorization, hospital admission, etc. Sometimes those differ significantly even between health plans offered by a single carrier.
- apical_dendrite 7mo ago
  This isn't really true anymore (if it was ever true). Providers are spending a huge amount of time dealing with prior authorizations and appeals for private insurance. I work in this area and you're right that Medicare can require a huge amount of paperwork from providers. And a hospital will have far more than 2 FTEs for this (it's called Revenue Cycle Management).
- sixothree 7mo ago
  Many providers report that dealing with Medicare has clear rules they can follow while dealing with private payers causes a huge burden.
gamblor956 7mo ago
2 FTEs vs a department. Most hospitals have entire departments to handle insurer coding and some even have departments just to handle insurer disputes.
- CWuestefeld 7mo ago
  to handle insurer coding Coding is a different layer. Everything needs coding, whether for gov't or commercial payers. So the folks doing this coding can't be separated out for commercial. In fact, it's kind of the opposite: CPT codes (for procedures) - these are defined by AMA, but mandated by CMS (i.e., Medicare/caid). Because the gov't mandated them, the commercial payers adopted them too. HCPCS codes (equipment and supplies) - defined by CMS. ICD-10-PCS codes (hospital inpatient stuff) - defined by CMS.
  - gamblor956 7mo ago
    And yet my point still stands. Hospitals employ more people to handle private insurer coding than they do to handle Medicaid.
- CWuestefeld 7mo ago
  I think maybe I did a bad job of explaining. Of course providers have teams to deal with getting approvals from, submitting to, and disputing with, all the various Payers. At this level, we can consider all the Payers roughly equivalent. But for Medicare/caid, there's an ADDITIONAL layer of work that CMS requires Providers to perform. The Providers need to ensure they're compliant with all kinds of standards, and jump through hoops to document and prove to CMS that they're compliant. These standards aren't limited to the specific care - procedures, meds, etc. - being expended on a particular patient. They encompass the entirety of the Provider's operations. For example CMS makes Providers provide documentation about their average pay rates, stuff that's not related to the care of any given patient. The existence of that additional layer of reporting and compliance is the work that they're offloading onto the Providers, and thus increasing costs of providing care without it being legible if you were to audit CMS's own expenses.
  - 7mo ago

by Retric 7mo ago

CWuestefeld 7mo ago

2FTE’s vs what? versus nothing. Hospitals don't have to maintain a whole team for UnitedHealth, or for Anthem, etc. This is my point. Medicare cooks the books to look more efficient by offloading their administrative costs onto providers. Other payers can't do that because, even if huge, they don't operate at the same scale. Think about it: we often hear on the news about disputes about contracts when a local hospital's agreement with some insurance company comes up for renewal. They play hardball, getting local news to run stories on how many people will be affected if they can't come to terms. But you'll never hear this in the context of Medicare/caid. Hospitals have leverage to negotiate with commercial payers, but not with the government.

nradov 7mo ago
Depending on the size of the health system it may not be a team of multiple FTEs but they absolutely do expend significant resources on managing differences between commercial payers. They all have different rules about covered services, step therapy, prior authorization, hospital admission, etc. Sometimes those differ significantly even between health plans offered by a single carrier.
apical_dendrite 7mo ago
This isn't really true anymore (if it was ever true). Providers are spending a huge amount of time dealing with prior authorizations and appeals for private insurance. I work in this area and you're right that Medicare can require a huge amount of paperwork from providers. And a hospital will have far more than 2 FTEs for this (it's called Revenue Cycle Management).
sixothree 7mo ago
Many providers report that dealing with Medicare has clear rules they can follow while dealing with private payers causes a huge burden.

gamblor956 7mo ago

2 FTEs vs a department. Most hospitals have entire departments to handle insurer coding and some even have departments just to handle insurer disputes.

CWuestefeld 7mo ago
to handle insurer coding Coding is a different layer. Everything needs coding, whether for gov't or commercial payers. So the folks doing this coding can't be separated out for commercial. In fact, it's kind of the opposite: CPT codes (for procedures) - these are defined by AMA, but mandated by CMS (i.e., Medicare/caid). Because the gov't mandated them, the commercial payers adopted them too. HCPCS codes (equipment and supplies) - defined by CMS. ICD-10-PCS codes (hospital inpatient stuff) - defined by CMS.
- gamblor956 7mo ago
  And yet my point still stands. Hospitals employ more people to handle private insurer coding than they do to handle Medicaid.
CWuestefeld 7mo ago
I think maybe I did a bad job of explaining. Of course providers have teams to deal with getting approvals from, submitting to, and disputing with, all the various Payers. At this level, we can consider all the Payers roughly equivalent. But for Medicare/caid, there's an ADDITIONAL layer of work that CMS requires Providers to perform. The Providers need to ensure they're compliant with all kinds of standards, and jump through hoops to document and prove to CMS that they're compliant. These standards aren't limited to the specific care - procedures, meds, etc. - being expended on a particular patient. They encompass the entirety of the Provider's operations. For example CMS makes Providers provide documentation about their average pay rates, stuff that's not related to the care of any given patient. The existence of that additional layer of reporting and compliance is the work that they're offloading onto the Providers, and thus increasing costs of providing care without it being legible if you were to audit CMS's own expenses.
- 7mo ago