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Just throwing this out there, but what if for every $3 the carrier was able to save through better administration, Medicare keeps $1, the carrier gets $1 as an incentive, and the senior saves $1 in Part B premium?
Just throwing this out there, but what if for every $3 the carrier was able to save through better administration, Medicare keeps $1, the carrier gets $1 as an incentive, and the senior saves $1 in Part B premium?
love your comment
to much paper work for CMS I had so many people to see and not enough time to write up their MAPD'S
45 days out of 12 months is just crazy
There you go again, thinking that using a TPA will save money.
Administration of govt plans is a bid situation where carriers and TPA's vie for the business. (I covered this in another thread with links).
Medicare is bid by region and Medicaid by state. In most cases a carrier wins the bid to provide ASO services on these self funded plans.
PCIP is a self funded govt program administered by a TPA.
MA's are slightly different but are still considered self funded even though there is a transfer of risk to the carrier.
Waste, fraud and abuse . . . a favorite chant of the socialists . . . exists more in Medicare and Medicaid because of the way the plan is designed. Any provider that agrees to accept assignment can play. As long as they submit bills with proper coding the Medicare/Medicaid claim payer is obligated to honor the claim and pay it.
The claim administrator's job is to process and pay claims and that is it. Medicare claims payers are required by law to pay any properly coded claim in 21 days or less. Fraud is only discovered after the fact under this system when someone notices 8000 claims for individuals with the last name Perez come from one clinic over a 90 day period.
Well, except for one thing . . . Obamacrap and MLR.
It is already impacting under 65 major med. Extending this kind of handcuff and micromanagement to Part C & D will only make things worse, not better.
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somarco, you're all over the place on this. Maybe we're using different terminology, to me, when an entity pays a premium to a health insurance carrier and that carrier is responsible for all of the claims for that member it appears that we're looking at a situation where it's fully insured. How is that self funded?
WTF does MLR have to do with MAs working as TPAs? I think you're just being a naysayer without understanding the conversation, but, that's why we have the internet.
WTF does MLR have to do with MAs working as TPAs? I think you're just being a naysayer without understanding the conversation, but, that's why we have the internet.
The govt is not paying a premium to the MA carriers, they are making claim deposits for the agg fund.
This is no different from Coca-Cola hiring Cigna to pay claims on their self funded group and Cigna manages the fund but assumes the risk if claims go sour.
The MA carriers are doing likewise.
If they have money left over, in a manner of speaking, they increase benefits or lower premiums. If they make money they get to keep it (but capped at 5%). If they lose money they eat it.
At that point they decide if they want to play next year (assuming CMS doesn't slap them around and make them to to time out). If they decide to play, they do so at higher premiums, lesser benefits or both.
Admin costs are a negligible part of the equation. Claims drive 80%+ of the cost of health insurance, including Medicare.
Dicking around over saving a percent or two on admin is not going to be noticed at the consumer end.
- 11,996
Do you have a source on this? It has been my understanding that the carrier reimbursement was basically the government paying the premium to the carrier in exchange for the transfer of risk. Maybe we're splitting hairs here, but if you know something about that I don't then I'm all ears.
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No disagreement there, but if carriers were managing the claims and doing reviews the same way they do on their current MA plans, we would notice a major difference. I'm not suggesting that the carriers should just cut the checks on the claims as a way of saving money, I think they should be managing the entire claims process, including provider networks.
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- 7,790
Hey, Bob (somarco), why don't you place the source of your quotes like everybody else does? it is annoying to have scroll through the thread to ascertain to whom you are referring.
Never saw a need to source it.
I cut out the part that I want to address rather than quoting the entire post which makes it easier to follow. The person who made that comment will know who they are.
Most of the time my rebuttal or embellishment is directly below the referenced post.
In this case (and in another thread), MPS is trying to pretent he understands the claims & risk management side of Medicare but he has failed miserably.
Doesn't matter. I am through trying to educate him on this matter.
I cut out the part that I want to address rather than quoting the entire post which makes it easier to follow. The person who made that comment will know who they are.
Most of the time my rebuttal or embellishment is directly below the referenced post.
In this case (and in another thread), MPS is trying to pretent he understands the claims & risk management side of Medicare but he has failed miserably.
Doesn't matter. I am through trying to educate him on this matter.
- 7,790
I see your point, Bob, but you can still have the source shown and edit the quote to display only the portion to which you are referring. It's not relevant when you are replying to the post just prior to your post. but confusing when your post is several post after that one. I'm not trying to bust your chops. I really enjoy reading your erudite posts.
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