Healthcare Coding Expert:
Fraud is not standard practice. The unfortunate reality is that healthcare delivery in the U.S. is currently guided by a third party, not the patient and not the provider. Insurance is often the perpetrator of discord and can be considered the portion of the health care business equation that puts "business" before the treatment of you/us the patient.
Fee schedules or reimbursement meaning ICD-9 to CPT's combos are awfully mis-understood by some folks on previous posts; My contract pays X amount per procedure. This can be RVU based and/or fee schedule or contract executed based. Simply put, I bill $100 for a 99213 (office visit) and Medicare pays me 76.19 in LA county and a tad more in OC. A commercial carrier like Aetna/BC/Cigna/UHC may have a contract with me from 80% to 125% of that allowable. IT DOES NOT MATTER WHAT PRICE I PUT ON THE PROCEDURE...I get paid a contracted rate for services provided to in network/contracted lives. OON (out of network) may pay more but many insurance policies or "product lines" do not have OON benefits, check your own. All of these commercial policies are generally ERISA based and laws governing them are quite different then the mainstream patient population, the Managed Care lives. Fact, most procedures cannot be fraudulent as what we code is what was done...period... the best EMR is the images we take and of course cameras during arduous surgeries/OV's are a viable future thought for EMR gurus out there. Observation on simple procedures/visits that we just can't make up: Hip/Knee Replacements, Nuc Medicine, CT (as mentioned above, which by the way remove a zero and this is what most HMO/IPA's pay for said procedure $300),MRI, Vasectomy, Delivery, and of course the ever argued about family practice Office Visit where the doctor after costs takes home a big $20 for putting his/her license, staff and practice on the line in hopes of keeping a non compliant patient alive. S/he can't make up how much time was spent or how much thought and materials were used, this is now very traceable much to the chagrin of payors.
You see an MD can't fuck up once a day like an attorney or an exec from any insurance company (probably attorney) but they must keep their doors open and one item that actually has helped them collect money on services they performed is an audit system or scrubbing software that let's them put a team of scrubs out & play on the same field as the industry that's holding your health in their hands, insurance...which by the way are are the ones that really need to be audited for fraudulent clandestine shit. In the end if you need your ticker checked out in that time of need or you have a baby with a fever of 105, try calling BC/BS see how fast they help, otherwise come to my office we'll see you because we are actually concerned with you and your health. By the way it's HIPAA not HIPPA and the ACA and ACO's are upcoming notables for those in the know so be prepared.
Agreed, buy it now and buy it cheap, I lived on Tesla Avenue in L.A. back in the 60's prior to reading anything about Mr Tesla's rather fascinating and energetic work. I currently work a block from Tesla Motors on Santa Monica Blvd in West LA, where 1.5 Mil is about 3 bentleys and a couple sporty italian rides worth of chinga. Since I can't find a house for less than a eight hundred thousand that Million and a half or so is considerably cheap for most adults, it is a shame a few people from Google who apparently have some net worth still intact could not see the long term rewards that would come from a simple write off and later profit line after investing in a new venture...imho...get it while he still lives...
Your words seem knowledgeable, if a company like BMW or Mercedes were teamed up with pharma or other very high defense like budgets then started running with the ball, would we already be accomplishing some of the dot connecting from earth, moon, mars and other probably rich ROI ventures into the new worlds?
Slashdot Mirror
Healthcare Coding Expert: Fraud is not standard practice. The unfortunate reality is that healthcare delivery in the U.S. is currently guided by a third party, not the patient and not the provider. Insurance is often the perpetrator of discord and can be considered the portion of the health care business equation that puts "business" before the treatment of you/us the patient. Fee schedules or reimbursement meaning ICD-9 to CPT's combos are awfully mis-understood by some folks on previous posts; My contract pays X amount per procedure. This can be RVU based and/or fee schedule or contract executed based. Simply put, I bill $100 for a 99213 (office visit) and Medicare pays me 76.19 in LA county and a tad more in OC. A commercial carrier like Aetna/BC/Cigna/UHC may have a contract with me from 80% to 125% of that allowable. IT DOES NOT MATTER WHAT PRICE I PUT ON THE PROCEDURE...I get paid a contracted rate for services provided to in network/contracted lives. OON (out of network) may pay more but many insurance policies or "product lines" do not have OON benefits, check your own. All of these commercial policies are generally ERISA based and laws governing them are quite different then the mainstream patient population, the Managed Care lives. Fact, most procedures cannot be fraudulent as what we code is what was done...period... the best EMR is the images we take and of course cameras during arduous surgeries/OV's are a viable future thought for EMR gurus out there. Observation on simple procedures/visits that we just can't make up: Hip/Knee Replacements, Nuc Medicine, CT (as mentioned above, which by the way remove a zero and this is what most HMO/IPA's pay for said procedure $300),MRI, Vasectomy, Delivery, and of course the ever argued about family practice Office Visit where the doctor after costs takes home a big $20 for putting his/her license, staff and practice on the line in hopes of keeping a non compliant patient alive. S/he can't make up how much time was spent or how much thought and materials were used, this is now very traceable much to the chagrin of payors. You see an MD can't fuck up once a day like an attorney or an exec from any insurance company (probably attorney) but they must keep their doors open and one item that actually has helped them collect money on services they performed is an audit system or scrubbing software that let's them put a team of scrubs out & play on the same field as the industry that's holding your health in their hands, insurance...which by the way are are the ones that really need to be audited for fraudulent clandestine shit. In the end if you need your ticker checked out in that time of need or you have a baby with a fever of 105, try calling BC/BS see how fast they help, otherwise come to my office we'll see you because we are actually concerned with you and your health. By the way it's HIPAA not HIPPA and the ACA and ACO's are upcoming notables for those in the know so be prepared.
Agreed, buy it now and buy it cheap, I lived on Tesla Avenue in L.A. back in the 60's prior to reading anything about Mr Tesla's rather fascinating and energetic work. I currently work a block from Tesla Motors on Santa Monica Blvd in West LA, where 1.5 Mil is about 3 bentleys and a couple sporty italian rides worth of chinga. Since I can't find a house for less than a eight hundred thousand that Million and a half or so is considerably cheap for most adults, it is a shame a few people from Google who apparently have some net worth still intact could not see the long term rewards that would come from a simple write off and later profit line after investing in a new venture...imho...get it while he still lives...
Your words seem knowledgeable, if a company like BMW or Mercedes were teamed up with pharma or other very high defense like budgets then started running with the ball, would we already be accomplishing some of the dot connecting from earth, moon, mars and other probably rich ROI ventures into the new worlds?