Federal officials have warned doctors that they may be subject to penalties if they persist in these practices and could be fined or excluded from Medicare.
I bet you didn’t know this (unless you are a doctor caught in the middle). Talk about fair share😷
Some low-income Americans are eligible for both Medicare and Medicaid. When a doctor or hospital treats them they are legally prevented from billing them for deductibles or co-pays. However, there’s more.
Medicaid, run by the states, is supposed to help pay these out-of-pocket costs (and the Medicare premium). However, by law Medicaid can set its own payment limit. To save money states may have Medicaid allowable fees less than Medicare in which case, no program pays the out-of-pocket costs and the doctor is the loser.
For the US, the average Medicaid allowed fee is 0.66 of the allowed Medicare fee. Only three states use a Medicaid reimbursement equal to or above Medicare. At the low-end are New Jersey and Rhode Island at 0.45 and 0.38
Here are a few real life examples: (all doctors are specialists – in NJ)
😷 Physician billed fee: $125 Medicare approved $118.91 (paid $93.23)
😷 Physician billed fee: $100 Medicare approved $96.14 (paid $75.37)
😷 Physician billed fee: $200 Medicare approved $117.72 (paid $92.29)
In virtually all states these doctors could not bill low-income Medicare patients for the 20% co-insurance. Knowing this, is it unreasonable to assume that either doctors shun such patients or more likely have built this loss into the fees they charge other patients?
Add to this the increasing number of non-Medicare patients with high deductible health plans and collecting fees must be a growing challenge for many physicians and other health care facilities.
The U.S. approach to paying for health care can only be described as a poorly designed Rube Goldberg machine.Add to this environment the Republican concept of consumers shopping for the best price in order to manage costs and leverage competition and you have the perfect storm for an ongoing failing system. So, is the problem doctors improperly billing patients as the NYT notes, or the screwed up system itself⁉️