Does Medicare really pay 80% Really?

[kaneohe]

........................................
Also because my hospital is listed under CAH that MBSC wrote about would explain the footnote on my Medicare statement that the amount Medicare paid was reduced due to federal, state and local rules.
........................................................

I see that footnote routinely on almost all of my charges even when the bill works exactly the way I expect it:
big initial charge, reduction by factor of 2-3 for Medicare approved charge,
80% paid by Medicare; 20% Max charge to patient.

so it doesn't only apply to strange situations like yours.

 

[braumeister]

The situation is so common (if sometimes inexplicable) that I long ago quit wondering about it. Of course, I have a supplemental policy that pays what Medicare doesn't.

Here's a typical bill I got earlier this year:
Billed amount: $$1,262
Medicare approved: $$267.28
Medicare paid: $205.14 (so nearly 25% less than the approved amount)

My share: $257.47 (20% of Medicare approved)
My insurance approved: $257.47
My insurance paid: $52.33 (just 20% of their approved amount)

So the provider was actually paid just 20% of the billed amount. Still not bad for a half hour of work, but it's very hard to understand how the system works.

 

[ivinsfan]

I see that footnote routinely on almost all of my charges even when the bill works exactly the way I expect it:
big initial charge, reduction by factor of 2-3 for Medicare approved charge,
80% paid by Medicare; 20% Max charge to patient.

so it doesn't only apply to strange situations like yours.

I think the difference here is that the billed amount is the same as the Medicare approved amount. You aren't getting any kind of a Medicare discount off the top. I don't think my DH has ever had that happen in any of his bills.

His cardiac rehab bills were really odd..the facility charge and the Medicare approved amount were the same 279... Medicare paid 99.59 but our copay was only 25.42....this is probably some special rule for repeated rehab visits..

 

[ivinsfan]

The situation is so common (if sometimes inexplicable) that I long ago quit wondering about it. Of course, I have a supplemental policy that pays what Medicare doesn't.

Here's a typical bill I got earlier this year:
Billed amount: $$1,262
Medicare approved: $$267.28
Medicare paid: $205.14 (so nearly 25% less than the approved amount)

My share: $257.47 (20% of Medicare approved)
My insurance approved: $257.47
My insurance paid: $52.33 (just 20% of their approved amount)

So the provider was actually paid just 20% of the billed amount. Still not bad for a half hour of work, but it's very hard to understand how the system works.

Is this right because 20% of the medicare approved amount is around 52 dollars not 257.47

 

[braumeister]

Oops! Right, I was looking at the wrong thing.
Amounts paid are right though.

 

[imoldernu]

Sidenote on Medigap plans. Something we didn't know in the beginning.

If you move from one state to another, you don't have to change your Medigap plan to the new state.

Ou plan... 7 years later is in Florida, while we live in Illinois.

You probably knew that, but ... just in case...

 

[MBSC]

Medicare should let us know in their manual that you will be responsible for 20% of Approve Amount and Medicare will be responsible for 80%...…. maybe.

The cost to the CAH was $724.95. Normally, your 20% coinsurance would be $144.99 ($724.95*0.20). Since the outpatient service was rendered at a CAH, your coinsurance responsibility is higher as explained on page 51 of the 2018 Medicare & You book:

Outpatient hospital services

If you get hospital outpatient services in a critical access hospital, your copayment may be higher and may exceed the Part A hospital stay deductible.

Source: https://www.medicare.gov/pubs/pdf/10050-Medicare-and-You.pdf

I just got off with Medicare Chat and it appears Original Medicare uses the outpatient prospective payment system (OPPS) and the amounts paid are preset ahead of time.

CAHs are exempt from OPPS. If the CT scan was performed at an acute care hospital, the approved amount would have been reduced to the OPPS preset rate (maybe $800 depending on the CPT code) and your 20% coinsurance would be about $160. If it was done at a freestanding imaging center, the approved amount would have been reduced to the Medicare Physician's Fee Schedule (MPFS) preset rate (maybe $500) and your 20% would be $100.

CAHs are not subject to the Inpatient Prospective Payment System (IPPS) or the Hospital Outpatient Prospective Payment System (OPPS).

Reference: https://www.cms.gov/Outreach-and-Ed...LNProducts/downloads/CritAccessHospfctsht.pdf

 

[kaneohe]

I think the difference here is that the billed amount is the same as the Medicare approved amount. You aren't getting any kind of a Medicare discount off the top. I don't think my DH has ever had that happen in any of his bills.

His cardiac rehab bills were really odd..the facility charge and the Medicare approved amount were the same 279... Medicare paid 99.59 but our copay was only 25.42....this is probably some special rule for repeated rehab visits..

Yes, I know OPs situation is unusual. OP keeps pointing out the footnote about Medicare charges may be reduced for Fed laws,etc. I was just pointing out that that footnote seems to be boilerplate since I see it often on my bills even when the bills are typical of what you expect.

 

[Dtail]

yes, thanks for the education. Had never heard of this. Fortunately in my state, they appear to be mostly (only) in rural areas, not where I live.

+1 in FLA

 

[audreyh1]

There are a lot of counties with only one hospital that has to be kept going?

 

[ivinsfan]

Yes, I know OPs situation is unusual. OP keeps pointing out the footnote about Medicare charges may be reduced for Fed laws,etc. I was just pointing out that that footnote seems to be boilerplate since I see it often on my bills even when the bills are typical of what you expect.

Yes many of my DH surgery bills have the footnote and we end up paying a little more then 20% but its usually been reduced from the billed amount.

 

[ivinsfan]

There are a lot of counties with only one hospital that has to be kept going?

That's the way it looks in MN, but a Medicare user has to pay the subsidy not the government. It's kind of a hidden tax..

 

[Major Tom]

I never thought I'd say anything positive about a US government run program, but it's been great. (so far)

As far as I know, SS runs pretty smoothly. I don't hear any seniors grumbling that they didn't get their checks. Also, although it's only one data point, I was on UI (unemployment insurance) for an extended period during the great recession. It went like clockwork. No complaints here.

I happen to think that government can work well for administering these types of programs, but I know that not everyone agrees.

 

[Just_Steve]

Well I went down the rabbit hole reading about CAH's gained some knowledge and actually found it interesting.

 

[audreyh1]

The Critical Access Hospital program was created in response to a string of hospital closures in the 1989s.
https://en.m.wikipedia.org/wiki/Critical_Access_Hospital
https://www.ruralhealthinfo.org/topics/critical-access-hospitals

 

[ivinsfan]

The Critical Access Hospital program was created in response to a string of hospital closures in the 1989s.
https://en.m.wikipedia.org/wiki/Critical_Access_Hospital
https://www.ruralhealthinfo.org/topics/critical-access-hospitals

Rural living can be expensive, this is a good case of that. We have less choices for health care and yet have to pay more for less choice.

 

[pedidiva]

My understanding:

If you have Medicare Part B, it will cover 80 percent of all approved charges for doctor’s office visits, blood tests, X-Rays, CT scans, MRIs and ER visits. It even covers IV medications when given at an office or hospital infusion center or a nursing home. This is after you pay a $147 deductible each year.

Now, I want to be clear about what it means when I say Medicare covers 80 percent of approved charges. Let’s say your doctor orders an MRI of your knee. The hospital where you get that MRI might bill Medicare $4,000. Medicare looks at that $4,000 bill and says “we think that MRI is really worth $580 and not a penny more!” That means that Medicare pays $464 for that MRI, you pay $116, and the remainder is completely disregarded. No health care provider who accepts Medicare is allowed to go after you for any more than what Medicare approves.

FRom: https://www.huffingtonpost.com/david-belk/medicare-supplemental-policies_b_3901861.html

 

[braumeister]

pedidiva, your entire post is a quote from the linked article. When you do that, please be sure to mark it as a quote (and keep it short). Thanks.

 

[ivinsfan]

My understanding:

If you have Medicare Part B, it will cover 80 percent of all approved charges for doctor’s office visits, blood tests, X-Rays, CT scans, MRIs and ER visits. It even covers IV medications when given at an office or hospital infusion center or a nursing home. This is after you pay a $147 deductible each year.

Now, I want to be clear about what it means when I say Medicare covers 80 percent of approved charges. Let’s say your doctor orders an MRI of your knee. The hospital where you get that MRI might bill Medicare $4,000. Medicare looks at that $4,000 bill and says “we think that MRI is really worth $580 and not a penny more!” That means that Medicare pays $464 for that MRI, you pay $116, and the remainder is completely disregarded. No health care provider who accepts Medicare is allowed to go after you for any more than what Medicare approves.

FRom: https://www.huffingtonpost.com/david-belk/medicare-supplemental-policies_b_3901861.html

Huffington post doesn't know what they are talking about as we have provided many times over on this thread.... Medicare approved charge 580 true....you part of the bill 116 true.. Medicare part of the bill 464 minus what ever state and or federal rules allow it to pay, which might be well under 464...but you still pay the 116, that doesn't change. Point being that sometimes Medicare does not pay a full 80% of the actual Medicare approved amount. You however do pay 20 of that charge...

 

[haha]

Huffington post doesn't know what they are talking about as we have provided many times over on this thread.... Medicare approved charge 580 true....you part of the bill 116 true.. Medicare part of the bill 464 minus what ever state and or federal rules allow it to pay, which might be well under 464...but you still pay the 116, that doesn't change. Point being that sometimes Medicare does not pay a full 80% of the actual Medicare approved amount. You however do pay 20 of that charge...

Would this be most relevant for a patient who does not carry a Medigap policy?

Ha

 

[ivinsfan]

Would this be most relevant for a patient who does not carry a Medigap policy?

Ha

Well even if you have a Medigap policy the 20% co pay has to be settled so I'm not really sure what you are asking. Technically they should be saying is you pay 20% of the Medicare approved charge which is not the same as saying that Medicare pays 80% of the charges.

 

[W2R]

Well even if you have a Medigap policy the 20% co pay has to be settled so I'm not really sure what you are asking. Technically they should be saying is you pay 20% of the Medicare approved charge which is not the same as saying that Medicare pays 80% of the charges.

Wow, that does sound less than ideal when the Medicare approved charge is so much higher than what is actually paid.

Luckily my federal BCBS health insurance converted to some sort of Medicare supplement or Medigap or something (? I'm not sure what they call it!) when I reached Medicare age. It has no co-pay and no deductible, and it pays whatever Medicare doesn't pay. Its premiums do cost a bit. Still, between the two of them I have not paid a cent for anything except for part of any prescription drug costs, during the past 5 years since I went on Medicare.

 

[ivinsfan]

Wow, that does sound less than ideal when the Medicare approved charge is so much higher than what is actually paid.

Luckily my federal BCBS health insurance converted to some sort of Medicare supplement or Medigap or something (? I'm not sure what they call it!) when I reached Medicare age. It has no co-pay and no deductible, and it pays whatever Medicare doesn't pay. Its premiums do cost a bit. Still, between the two of them I have not paid a cent for anything except for part of any prescription drug costs, during the past 5 years since I went on Medicare.

That's the policy my DH is on and I just went on, it was a little more then I wanted to pay, but what supplement isn't....DH had a super complicated cardiac surgery, 4 days in the ICU and 8 days total in the hospital and it didn't cost us one cent out of pocket but it is a little pricey.

 

[pedidiva]

Ok, thanks. Will do.

 

[braumeister]

Ok, thanks. Will do.

Great.
But one more thing. When you respond to a post (as you just did to mine), it's best to quote the post you're replying to (or at least the relevant part of it), as I did here.

For other little details, you might want to take a look at this (the section on reading and posting messages):

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