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(Journal News)   Investigators discover the largest Medicaid overbilling case ever, $15 billion over 20 years, committed by a) evil pharmaceutical companies, b) Ukrainian gangsters, or c) the government of New York state   (lohud.com) divider line 29
    More: Interesting, Medicaid, New York, advance copy, oversight, federal government, Government of New York, New York overbilled  
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1148 clicks; posted to Politics » on 20 Sep 2012 at 12:13 PM (1 year ago)   |  Favorite    |   share:  Share on Twitter share via Email Share on Facebook   more»



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2012-09-20 09:49:21 AM
Has to be "C". Over-billing by pharmaceutical companies is legal.
 
2012-09-20 09:52:58 AM
Something ilegal or corrupt in the state of New York?
You don't say?
 
2012-09-20 12:18:24 PM
So, exactly the kind of thing the democrats wanted to stop to pay for a jobs for veterans bill?

I can see why the republicans are against it, now.
 
2012-09-20 12:20:32 PM
The article made it sound like it's all legal. Dumb, but legal.
 
2012-09-20 12:21:04 PM
Good thing Republicans want to keep Medicare strong by keeping these overpayments going.
 
2012-09-20 12:22:23 PM
If we would just shift Medicaid to block grants, we wouldn't have to hear about this anymore.
 
2012-09-20 12:23:13 PM
D) erp
 
2012-09-20 12:25:15 PM
This means MedicAid should be abolished and all poor people should die off after a couple Flu seasons.
 
2012-09-20 12:26:34 PM

Lost Thought 00: This means MedicAid should be abolished and all poor people should die off after a couple Flu seasons.


The current poor will be replaced by today's middle class, it will be a never ending cycle...
 
2012-09-20 12:26:46 PM
I was going to make a remark about "overbilling" for medicaid just meaning that Medicaid actually just had to pay out once, since it's famed for shorting doctors arbitrarily to the point where the death panel thing almost seems within reasonable bounds and it's generally worse than any private insurer...

But apparently this is an overpayment by two factors of ten, so holy shiat.

//Medicare, by contrast, has a reputation for being _better_ than most private insurers at actually paying for things. So government services kind of run the whole range of quality there.
 
2012-09-20 12:30:56 PM

monoski: Lost Thought 00: This means MedicAid should be abolished and all poor people should die off after a couple Flu seasons.

The current poor will be replaced by today's middle class, it will be a never ending cycle...


Until only the great, white John Galts are left
 
2012-09-20 12:39:27 PM

HotWingConspiracy: The article made it sound like it's all legal. Dumb, but legal.


Yea, I was gonna ask if some of the info in TFA seemed fishy to anyone else besides me.

I worked for an insurance company for almost 10 years and when I read this:

The state bills Washington for what's described as reimbursable costs rather than the actual cost of providing those services.

I remember that 'reimbursable' was always LESS than 'actual'. It would be nice to see some examples of this.

Also this:

Many New Yorkers in those categories who also have high needs are housed in group homes or privately run intermediate care facilities that are much less expensive to operate than the state facilities.

smells like bullshiat.

And of course, there's the part where everything seemed fully legal and approved (in 1986... under Reagan, BTW)
 
2012-09-20 12:41:13 PM

Lost Thought 00: This means MedicAid should be abolished and all poor people should die off after a couple Flu seasons.


Yea, those mentally ill people should just be put on the street... where they can probably easily, and legally, buy guns. What could possibly go wrong?
 
2012-09-20 12:49:02 PM
Why wont the poor just die already ?
 
2012-09-20 12:58:44 PM

HotWingConspiracy: The article made it sound like it's all legal. Dumb, but legal.


Mostly it is legal. Kind of like subprime lending or paying CEOs billions of grupniks when the company is going bankrupt.

CNBC had an excellent special on this just the other night. For one thing, the coding for Medicaid is a nightmare. Everything--every action and inaction--has its own code, and the codes are unrelated to each other. For instance, there is one code for a workmans' comp claim "stuck by sewing needle--first incident" and several pages later, an unrelated number for "stuck by sewing needle--second incident" (or some such). The problem is that what constitutes a code is entirely up to the doctor. There are quacks and fraudsters who, for a fee, will explain to crooked doctors how to define things to the code, so that having the patient walk down the hall to a room can be billed as "aerobic fitness assessment". Yet its all totally legal.

Because of the plethora of codes and dearth of specific definitions, even honest doctors are confused about what to bill Medicaid for and what not to. It also makes auditing a nightmare. For instance, what if the doctor REALLY DID have the patient walk down the hall to assess his breathing, but it was just a routine observation while going to the room? Is that a legal billing or not? Who's to say. By trying to create certainty through specificity, the system merely creates a system whereby crooks can bill for every walk down the hall, while honest doctors don't get payment for actual tests.
 
2012-09-20 01:30:29 PM
As a New Yorker..... God, no, you mean we're becoming more like New Jersey? I thought we cut that off at Staten Island. Oh well what do you expect from the most politically grid locked state in America

upload.wikimedia.org
 
2012-09-20 01:34:22 PM

jedihirsch: As a New Yorker..... God, no, you mean we're becoming more like New Jersey? I thought we cut that off at Staten Island. Oh well what do you expect from the most politically grid locked state in America

[upload.wikimedia.org image 300x150]


It's called 'Jersey Creep', and it'll take over the country. My God, look what it's done to Long Island already!
 
2012-09-20 01:44:42 PM
But yet this shiathole has the highest taxes I've ever had to deal with and I am from Massachusetts
 
2012-09-20 01:48:25 PM
Is it Rick Scott? It's Rick Scott, right?

/Wait, that was Medicare.
 
2012-09-20 01:54:38 PM

Gyrfalcon: Because of the plethora of codes and dearth of specific definitions, even honest doctors are confused about what to bill Medicaid for and what not to. It also makes auditing a nightmare. For instance, what if the doctor REALLY DID have the patient walk down the hall to assess his breathing, but it was just a routine observation while going to the room? Is that a legal billing or not? Who's to say. By trying to create certainty through specificity, the system merely creates a system whereby crooks can bill for every walk down the hall, while honest doctors don't get payment for actual tests.


That's why the Feds are trying to shift toward reimbursing for *outcomes* instead of services.
 
2012-09-20 01:59:44 PM

UberDave: Has to be "C". Over-billing by pharmaceutical companies is legal.


Well played.
 
2012-09-20 02:45:42 PM

Virtuoso80: jedihirsch: As a New Yorker..... God, no, you mean we're becoming more like New Jersey? I thought we cut that off at Staten Island. Oh well what do you expect from the most politically grid locked state in America

[upload.wikimedia.org image 300x150]

It's called 'Jersey Creep', and it'll take over the country. My God, look what it's done to Long Island already!


HEY!

I live on Long Island (Borough of Queens). Don't you dare insult us. The Jersey type crowd don't really go beyond brooklyn, further out here we have Irish, 30 types of asians, every latino group, jews, blacks, but few "Jersey types" so thank go for that
 
2012-09-20 03:48:28 PM
What, they expected strong math skills in a home for developmentally disabled folks?
 
2012-09-20 05:35:07 PM

jedihirsch: Virtuoso80: jedihirsch: As a New Yorker..... God, no, you mean we're becoming more like New Jersey? I thought we cut that off at Staten Island. Oh well what do you expect from the most politically grid locked state in America

[upload.wikimedia.org image 300x150]

It's called 'Jersey Creep', and it'll take over the country. My God, look what it's done to Long Island already!

HEY!

I live on Long Island (Borough of Queens). Don't you dare insult us. The Jersey type crowd don't really go beyond brooklyn, further out here we have Irish, 30 types of asians, every latino group, jews, blacks, but few "Jersey types" so thank go for that


They must have skipped Queens, because we have them here in Nassau County.
 
2012-09-20 06:16:39 PM

Aexia: Gyrfalcon: Because of the plethora of codes and dearth of specific definitions, even honest doctors are confused about what to bill Medicaid for and what not to. It also makes auditing a nightmare. For instance, what if the doctor REALLY DID have the patient walk down the hall to assess his breathing, but it was just a routine observation while going to the room? Is that a legal billing or not? Who's to say. By trying to create certainty through specificity, the system merely creates a system whereby crooks can bill for every walk down the hall, while honest doctors don't get payment for actual tests.

That's why the Feds are trying to shift toward reimbursing for *outcomes* instead of services.


That would work a hell of a lot better...
 
2012-09-20 08:03:07 PM

Gyrfalcon: CNBC had an excellent special on this just the other night. For one thing, the coding for Medicaid is a nightmare. Everything--every action and inaction--has its own code, and the codes are unrelated to each other. For instance, there is one code for a workmans' comp claim "stuck by sewing needle--first incident" and several pages later, an unrelated number for "stuck by sewing needle--second incident" (or some such). The problem is that what constitutes a code is entirely up to the doctor. There are quacks and fraudsters who, for a fee, will explain to crooked doctors how to define things to the code, so that having the patient walk down the hall to a room can be billed as "aerobic fitness assessment". Yet its all totally legal.

Because of the plethora of codes and dearth of specific definitions, even honest doctors are confused about what to bill Medicaid for and what not to. It also makes auditing a nightmare. For instance, what if the doctor REALLY DID have the patient walk down the hall to assess his breathing, but it was just a routine observation while going to the room? Is that a legal billing or not? Who's to say. By trying to create certainty through specificity, the system merely creates a system whereby crooks can bill for every walk down the hall, while honest doctors don't get payment for actual tests.


Well, doctors don't (or shouldn't) code their own encounters - they hire coders to manage these. And it's not just CMS that requires HCPCS/CPT codes, private insurance uses it, too. That said, moving away from fee-for-service is one of the biggest and most necessary steps that our nation needs to take. The PPACA has some potential there; we'll see if the ACO model takes off.

Even without billing, though, there are also benefits in having a common "language" among various medical records - for all of the zaniness that is SNOMED, for example, it enables two different electronic health records to share data about a patient's problems in a standard way. One of the largest hurdles in interoperability of medical software is the lack of standards for encoding and transmitting various pieces of data.

In fact, if anything, CPT is often not specific enough. For example, 73701 is a CT of the lower extremity with contrast. But is it right or left? Is it a leg CT, an ankle CT, a foot CT - which might have important distinctions in the various systems? It's not always granular enough to use this to exchange information about a procedure between different systems. Worse, the damn thing changes too often.
 
2012-09-20 09:03:00 PM

Virtuoso80: jedihirsch: Virtuoso80: jedihirsch: As a New Yorker..... God, no, you mean we're becoming more like New Jersey? I thought we cut that off at Staten Island. Oh well what do you expect from the most politically grid locked state in America

[upload.wikimedia.org image 300x150]

It's called 'Jersey Creep', and it'll take over the country. My God, look what it's done to Long Island already!

HEY!

I live on Long Island (Borough of Queens). Don't you dare insult us. The Jersey type crowd don't really go beyond brooklyn, further out here we have Irish, 30 types of asians, every latino group, jews, blacks, but few "Jersey types" so thank go for that

They must have skipped Queens, because we have them here in Nassau County.


Worse. We have Forest Hills and Regostan...I mean Rego Park. Every A$$hole from Russia, Ukraine, Georgia, Uzbekistan, Tajikistan, Turkmenistan, etc lives there (all the smart and professional ones seem to live in Manhattan Beach and Brighton Beach in Brooklyn) and god help you if you're on the Road with them at the same time. So lets see who got it worse
 
2012-09-21 12:19:51 AM

Aexia: Gyrfalcon: Because of the plethora of codes and dearth of specific definitions, even honest doctors are confused about what to bill Medicaid for and what not to. It also makes auditing a nightmare. For instance, what if the doctor REALLY DID have the patient walk down the hall to assess his breathing, but it was just a routine observation while going to the room? Is that a legal billing or not? Who's to say. By trying to create certainty through specificity, the system merely creates a system whereby crooks can bill for every walk down the hall, while honest doctors don't get payment for actual tests.

That's why the Feds are trying to shift toward reimbursing for *outcomes* instead of services.


I don't see how that's going to work any better than basing teachers' pay on standardized test results. Doctors can't make patients take pills, jog, or stop eating fast food.

Outcome-based payments, would however, reduce end-of-life care costs to zero. So they've got that going for them.
 
HBK
2012-09-21 05:35:23 PM

davideggy: Good thing Republicans want to keep Medicare strong by keeping these overpayments going.


The fact that you don't know the difference between Medicare and Medicaid makes you look like an idiot.
 
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