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- Oct 14, '12 by TweetyQuote from JolieUnderstood and nothing to disagree with.To a large extent, yes. All businesses are subject to loss. Some unintentional (such as mis-communications, honest mistakes), some which can be prevented (poor quality work, theft.)
When we first opened, we were approached by a number of people wanting to sell us loss prevention plans for many aspects of our business. Some focused on employees, some focused on inventory, some on customers, some on security of the building. We chose to take an internal approach and educate ourselves, our managers and our staff on normal operations and what to watch for that might indicate theft or fraud. We have had some losses, including an employee who was stealing from customers, as well as a few that were stealing from us. We've also had some customers attempt to defraud us. We've learned what to watch for, and how to prevent loss, but will probably never be 100% secure, as few businesses are. We have also been very public about the known cases, to make people aware that we will not be an easy mark.
I think the primary difference between private business and government is personal investment and motivation. Since I don't get paid unless we make a profit, you can bet that I'm a hawk. While most high level managers receive both a salary and bonus, the motivation for manager who does not own the business to detect and stop loss is still great, but not as high as an owner. And sadly, since many government employees are not held accountable for loss, there may be very little motivation for them to detect, report or act on fraud. This is a major drawback of publically funded healthcare and is evident when we read stories about the same provider billing hundreds and thousands of times for the very same services in an unrealistic time frame from some little storefront.
However, a lot of the healthcare fraud is not occurring at the government level, it's occurring in private facilities like HCA did in 90's. It's occurring by computer hackers, and what not, so there aren't any government employees motivated or not to report it. Someone approving payment to a "doctor" might not know this doctor is not a doctor and the "patient" died years before. Like I said, it is reported and discovered the resources to combat it are limited.
I will add to my list of reasons for high healthcare costs government regulation and the Joint Commission. Still other countries have safe outcomes and lowered cost than us.Last edit by Tweety on Oct 14, '12
- Oct 14, '12 by NRSKarenRNPeople "loosing" Medicare Advantage (MA) plans are really just changing policies back to traditional Medicare or choosing another MA plan due to several reasons:
a. End Stage Renal disease coverage kicks in after 30month on dialysis -most go back to traditional Medicare. Since MA plans got their additional 10% extra payment cut, all the dialysis companys that had set up MA renal benefit plans "no longer have contracts with Medicare".
b. Eligibility for dual coverage: Medicare and Medicaid. Some will then change to another MA plan that is specific for dual recepients.
c. Moved outside MA service territory: MA plans have a restricted US market, they covercertin couties/parishes within each state. So if you have a home in FL, have a stroke and move to PA to live with son, not covered as outside service area. My homecare agency eats the cost of caring for these persons. Traditional Medicare allows you to be treated in every US state without network as long as facility/provider participates; ~95% all hospitals do participate in Medicare.
d. Lack of in-network providers in new territory that MA plan just expanded too-- so patient that has been seeing same oncologist for past two years, now has huge bill because provider is not in-network with new MA plan; patient was unaware docotrs not in network, chose as cheepest plan --so they switch again to another plan.
e. Limited income and never paid via payroll deduction so only eligible for Medicare part B, lost medicaid coverage so kicked out of MA program.
f. MA plan requires PCP approval for services like homecare: PCP refuses to order homecare despite client having need ordered by another specilist like GU/Ortho surgeon cause they want you to use PCP's own homecare agency. Or homecare is limited # visits benefit Client withdrews to get agency services of his choice unlimited under traditional Medicare plan.Last edit by NRSKarenRN on Oct 15, '12
- Oct 14, '12 by herring_RNHere are some so far this month: https://oig.hhs.gov/fraud/enforcemen...inal/index.asp
- Oct 15, '12 by NRSKarenRNIn 2009. after President Obama was elected, a HEAT task force was put together to combat Medicare fraud. Over 1 BILLION/year has been recouped. With passage of ACA/Obama care more monies were put into the effort.
You can see actions by state here:
HEAT Task Force News | StopMedicareFraud.gov
Illinois – March 13, 2012 - Health and Human Services (HHS) Secretary Kathleen Sebelius and Attorney General Eric Holder discussed how the Affordable Care Act and the Obama administration’s Health Care Fraud Prevention and Enforcement Action Team (HEAT) are helping fight Medicare fraud.- Read More
Today, the Obama administration also announced more progress from its anti-fraud efforts, beyond the nearly $4.1 billion recovered last year:
- In the early phase of revalidating the enrollment of providers in Medicare, 234 providers were removed from the program because they were deceased, debarred or excluded by other federal agencies, or were found to be in false storefronts or otherwise invalid business locations;
- In 2011, HHS revoked 4,850 Medicaid providers and suppliers and deactivated 56,733 Medicare providers and suppliers (PECOS) as it took steps to close vulnerabilities in Medicare;
- In 2011, HHS saved $208 million through pre-payment edits that stop implausible claims before they are paid;
- Prosecutions are up: the number of individuals charged with fraud increased from 797 in fiscal year 2008 to 1,430 in fiscal 2011 – nearly a 75 percent increase;
- In the first few weeks of enhanced site visits required under the ACA screening requirements, HHS found 15 providers and suppliers whose business locations were non-operational and terminated their billing privileges;
- Through outreach and engagement efforts more than 49,000 complaints of fraud from seniors and people with disabilities reported to 1-800-MEDICARE were referred for further evaluation;
- A recent re-design of the quarterly Medicare Summary Notices received by Medicare beneficiaries makes it easier to spot and report fraud.
- Oct 15, '12 by tewdlesQuote from JolieI don't see where in my post I assigned primary responsibility for the "explosion" in health care costs.If the explosion in healthcare costs is attributable primarily to administrative greed of private insurers, how do you explain the unaffordability of Medicare and Medicaid, which we are told are extremely cost-efficient in their overhead?
Are you asking about the explosion in the cost of delivering care or the cost in obtaining health insurance?
I was not trying to assign a meaning to your post, and didn't intend for another poster to take my comments as such. You mentioned the new mandate for insurance companies to partially refund premiums if they fail to keep overhead under a certain percentage.
"Hopefully we will see these rate increases flatten now that the insurance companies are mandated to cap their "administrative" costs. Only the very out of touch politician cannot see that the average American cannot continue to afford health care that is completely vested in the capitalist market." (Quote from tewdles)
I was trying to clarify, since your comment seemed to indicate that you believe that limiting administrative costs would dampen rate hikes.
I don't believe that will happen to any great extent. I realize that everything (overhead, advertising, legal costs, administrative costs, actual cost of care, etc) contributes to insurance rates. I don't mean to imply that cutting back on any of those things is useless, just that that the actual cost of care is by far the greatest factor in the cost of insurance.
That was the reason for my comparison to Medicare and Medicaid. Despite supposedly low overhead, their costs are exploding as well.
Not until the cost of healthcare stabilizes will there be any hope of reducing insurance rates. I realize that I have little good to say about Obamacare, but one of my biggest frustrations with it is that it does little, if anything to address the actual cost of care.
Extending care to additional people is a noble goal, but it will serve to increase costs, based on supply and demand. Adding comprehensive benefits is a noble goal, but it will also increase costs.
The effective means of reducing costs involve price bidding, competition, opening new markets, all of which are capitalistic concepts that work quite well in keeping our groceries, cell phones and auto insurance affordable and customized to our individual needs.
- Oct 16, '12 by tewdlesI believe that we are already seeing the effects of a health care system that lives in the capitalist world.
- Barely. Health insurance is so regulated and carries so many mandates that it is far from a free-enterprise, capitalist product.
The fact that it isusually puchased by a third party doesn't fit the capitalist model, either.
Unless you pay your own premiums, are free to purchase from any insurer nationwide, are able to craft an individual policy to fit your needs, wants and budget, and negotiate or shop for (non-emergent) care, you are no-where near a capitalist, free enterprise system. Currently, federal law prevents much of the above. Obamacare won't improve that a bit.
- Oct 16, '12 by tewdlesWhat capitalist products in the US are un-regulated?
Are you implying then that the increases in the cost of health care are unrelated to pursuit of profit or unrelated to capitalist practices?
- I don't believe that those are major factors in the astronomical rise in health insurance premiums.