Impeding changes to our Health Care system

[TheMercenary]

Once we can establish what the cost of a general eye exam is, which may or may not include refactory testing, which changes the cost, then we can determine what percent Medicare pays. I have the CPT codes and Medicare rates for NJ. So do you have an EOB with the phyicians charged fee on it?

[Spexxvet]

Originally Posted by TheMercenary

I am thinking that you would have a hard time proving that. My for profit insurance company pays 100% for a complete eye exam each year for each person in my family.
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How much does your insurance company pay the doctor, though? That's the question. I'll bet it's not doctor's the "regular retail" rate, nor is it as much as Medicare pays.

Originally Posted by TheMercenary

Once we can establish what the cost of a general eye exam is, which may or may not include refactory testing, which changes the cost, then we can determine what percent Medicare pays. I have the CPT codes and Medicare rates for NJ. So do you have an EOB with the phyicians charged fee on it?

92014. Medicare allowable is $111.83, of which they pay 80%, or $89.46. Medicare never pays for a refraction. Are you sure this is your business?

[TheMercenary]

Originally Posted by Spexxvet

How much does your insurance company pay the doctor, though? That's the question. I'll bet it's not doctor's the "regular retail" rate, nor is it as much as Medicare pays.

You do understand that most private insurance pays much more than Medicare rates don't you? Private insurance has contractual relationships with each provider or group or hospital.

92014. Medicare allowable is $111.83, of which they pay 80%, or $89.46.

Each state is different for reimbursement amounts.

[Spexxvet]

Originally Posted by TheMercenary

You do understand that most private insurance pays much more than Medicare rates don't you?

I don't know anything of the sort. I know that Medicare pays the highest for an annual eye exam. I also know that most for-profit insurance companies use Medicare guidelines for their cataract surgery reimbursement. Where do you get your information that for-profit insurance pays the provider more than Medicare?

Originally Posted by TheMercenary

...Each state is different for reimbursement amounts.

Yes, that's why I bagan with:

Originally Posted by Spexxvet

In New Jersey, Medicare pays 80% of $110ish ($88ish) for a complete eye exam by an ophthalmologist. Most for-profit insurance companies pay $40 - $50 for the same service. And here's the kicker: some patients pay a $40 copay, and their insurance company contributes zilch, nada, nil, zip, zero. But we're all better off with health insurance companies running things...

[TheMercenary]

Originally Posted by Spexxvet

I don't know anything of the sort. I know that Medicare pays the highest for an annual eye exam. I also know that most for-profit insurance companies use Medicare guidelines for their cataract surgery reimbursement. Where do you get your information that for-profit insurance pays the provider more than Medicare?

I get my information not from cataract surgery but from other procedures, GYN surgery specifically, but I was thinking of reimbursement in the larger sense. For example in bariatric surgery Medicare pays 28% less than private insurance. http://www.springerlink.com/content/m52w62k100j21n71/
. For choclear implants Medicare paid 57%, and Medicaid 46% of what private insurance paid for the surgeon. For the hospital Medicare paid 80% of what private insurance pays for outpatient services and less for inpatient services. http://www.rand.org/pubs/research_br...-1/index1.html . For anesthesia services the difference is huge. For GYN procedure is in our outpatient surgery center the differences are huge. Bottom line is that Medicare pays significantly less than what private insurance pay for reimbursement. Cataract surgery may be the exception, not the rule when it comes to differences between private insurance reimbursement and Medicare.