Tricare Reimbursements

Discussion in 'Military Medicine' started by militarymd, Jul 22, 2006.

  1. militarymd

    militarymd SDN Angel
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    Interesting tidbit that I found while reviewing fincances for my group.

    We took care of a Tricare patient, and the charges were, according to standard units charged per other insurance companies, $715.

    With really good insurance, you will collect almost 100%.

    With Tricare, we got paid a whopping $93.72!!!

    So, after taking into consideration for costs like malpractice, disability insurance, employees, etc...our group lost money.

    We PAID money to take care of someone with Tricare for insurance.

    This is the reason that Tricare does not work.....MANY physicians will not accept Tricare because, you lose money taking care of these patients.
     
  2. orbitsurgMD

    orbitsurgMD Senior Member
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    Worse than Medicaid in many places. Don't plan on getting a lot of choices of providers, and once you find one, don't be surprised when you get told your insurance won't be accepted any longer due to non-payment or chronic underpayment. Sad reality.
     
  3. Monty Python

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    Our group gets ~ $1,250-1500 for anesthetizing a private insurance CABG. Maybe 1/2 that for a Medicare CABG. Lots less for Tricare-to the point our chest cutters are thinking of no longer accepting Tricare. The only reason they still do is that the senior partner is a Walter Reed alum and feels patriotic duty.
     
  4. IgD

    IgD The Lorax
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    What is the billing code you used?
     
  5. militarymd

    militarymd SDN Angel
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    Standard anesthesia billing units as published by the ASA and recognized by every other insurance company (including Medicare) that we bill.
     
  6. militarymd

    militarymd SDN Angel
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    Are you implying that if our billing company had used the proper code, then we would have been paid????

    Because Tricare IS GREAT insurance for our men and women of the armed forces.

    It must be OUR fault if we didn't get paid...right?

    It can't be possible that Tricare actually sucks.
     
  7. IgD

    IgD The Lorax
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    What is the exact billing code you used? I'm trying to validate your claim. We can look up the reimbursement rate.
     
  8. orbitsurgMD

    orbitsurgMD Senior Member
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    I just wonder exactly how you would be able to verify the amount reimbursed to a private claimant for a service claimed. Who exactly is the we you refer to? If by asking this you are indirectly implyingthat Tricare isn't a poorly-reimbursing insurance plan, you will have to do better than that. Look at the comments about Tricare on the veterans boards if you want opinions about that coverage. Compared to what you read there, this is understatement.
     
  9. militarymd

    militarymd SDN Angel
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    I rest my case.
     
  10. Galo

    Galo Senior Member
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    Once again, you need to double the dose of your meds.

    You are going up against practicing physicians and you are not even an attending yet, not even on the outside, and you are questioning simple matters they are offering as proof that tricare is a crap insurance. If you were in front of me I'd squeeze your head like a [email protected]!. Sorry, I am reaching peace now, I'd just say you once again have shown how much of an idiot you are.
     
  11. IgD

    IgD The Lorax
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    X-MMD claimed that Tricare offers 1/7th of the reiumbursement rate that other plans are offering for a procedure. We (this forum) can look up the reimbursement rates to verify the claim. For example, Tricare has a website where you can look up reimbursement rates. If it is true, it should be fixed. Medicine is an evidenced based science. It is important that such claims be validated and based in fact.
     
  12. militarymd

    militarymd SDN Angel
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    Look up anesthesia reimbursement.

    We are reimbursed at a $ per unit.

    Cases we do have start up units plus time units.

    Look up Blue cross reimbursement units...

    Look up Tricare reimbursement units....

    80 to 150 per unit vs < 15 ? per unit...

    Time unit also varies....10 minute, 15, 20....30 ...a variety of them exists based on insurance.

    IGD...I can't believe I'm explaining this to you....you are a [email protected]#$[email protected]# [email protected]#[email protected]#$
     
  13. IgD

    IgD The Lorax
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    When asked for specific facts, the critics respond with personal insults. Providing a simple billing code would take a minimal amount of effort. If the information was provided and it was true this would bolster their position. Does this mean that there is no factual basis behind the claim?
     
  14. IgD

    IgD The Lorax
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    Here is the Tricare Anesthesia reimbursement rate look-up tool. Enter locale, procedure code and procedure time and it should kick back a dollar amount.

    http://www.tricare.osd.mil/anesthesia/default.aspx

    I'm very curious as to what procedure Tricare would pay $90 but private insurance would pay $700. It if is true it needs to be fixed.
     
  15. militarymd

    militarymd SDN Angel
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    Only someone who clearly has no clue about practicing medicine outside of the military (if that's what you actually do) would doubt the truth to my claims.

    In my practice, I don't WASTE my time coding and billing the patients. I do clinical work.....We pay a company to take care of stuff that military docs have to do on their own...like coding.

    We get financial reports showing what is billed and what is paid by the insurance company and what co-pays the patients have to pay.

    Billing companies do this for a living. They make their pay as a percentage of what is collected (7% in our case). It is in the companies BEST interest to collect as much as possible.

    I don't know the exact code...hell, I don't even know the patients name, or procedure....all I know is that tricare reimbursement essentially makes us PAY to take care of tricare patients.

    IGD, you don't have to believe it....you don't have to verify it....It doesn't matter what you think.....You'll find out, when you rely on Tricare for you care.
     
  16. militarymd

    militarymd SDN Angel
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    I agree with you on this.

    Our group takes care of EVERYONE who walks through our doors...including the so called "self pay".

    However, there are groups and places where tricare recipients can't get care....and it needs to be fixed.......

    and as always...what's the answer.....$
     
  17. Monty Python

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    Sorry, but I have no input with billing. We have an outside service do it.

    My comments are quotes from the senior partners. What sucks is that a difficult Medicare CABG (averaging ~ $750) actually costs the group money if it takes over eight hours (multi-valve, multi-vessel, bleeding won't stop, can't wean from bypass etc) and we have a locums (@ $100/hr) on the anesthesia stool.

    I've overheard many surgeons say they're LOSING money each and every time a surgical patient seeks their services. The typical reimbursement for a gall bladder, hernia, hemorrhoid, hysterectomy etc is less than the surgeon's overhead, much less making any take-home income from his/her services. Ridiculous.
     
  18. orbitsurgMD

    orbitsurgMD Senior Member
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    Ridiculous, but true. There are a few procedures that I do that are almost always money-losers.
     
  19. IgD

    IgD The Lorax
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    I think you guys should follow through with this and post specific billing codes with the Tricare vs. private pay reimbursement rate. All you have right now is anecdoctal evidence. If you can post hard facts it bolsters your argument.
     
  20. militarymd

    militarymd SDN Angel
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    Why would I want to waste my time doing that?

    I pay my billing service 7% of what they can collect to do that.

    I don't care what codes are used as long as I get paid.

    The hard facts are this....I don't want to or have to waste my time looking up billing codes when I'm working. Administrating is for administrators....

    Tricare needs to get its act together.....NOT the doctors.

    I'm not arguing anything.....I'm telling you how much money I lost taking care of Tricare patients.....

    You don't have to believe it. I'm not going to spend time doing what you do to convince you....

    However, if things keep up.......people may STOP accepting Tricare....or only the "hungry" doctors will take it...read..can't get any other patients...will take Tricare.

    I would rather spend my free time on my hobbies.
     
  21. orbitsurgMD

    orbitsurgMD Senior Member
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    IgD, in finance and law, anecdotal evidence is sufficient. We don't need double-blind controlled studies to verify anything. One act of fraud by downcoding is still an act of fraud. You don't have to be a consistent serial offender to be an offender. So don't try to muddy the waters here by demanding "evidence" of widespread abuse. One instance is sufficient, unless you think Tricare deserves the attention of the DOJ as a RICO violator.

    And who are you to know anything about this anyway? You have consistently refused to post any of your credentials giving the oblique and laughable excuse that you don't want to reveal your identity or whereabouts. If you had any civilian experience, you wouldn't be so obtuse.
    My assumption is that you have only military practice experience and little else, unless you have been putting up a front and are really not a physician at all, which I suppose is possible too.
     
  22. Galo

    Galo Senior Member
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    I'm getting back on the verge of wanting to pop his head like a pimple, Oh OH, no, there it is, peace once again.

    If I was on active duty with you idg, I'm sure we would tangle, I cant imagine a sane person, even a military loving one, that would not find you unimaginably intolerable. You are insane, and therefore might do well in the military. Just do not ever come out, in the civilian world, you will be eaten alive. If you are a physician, you will not last. Stop trolling these posts, and go and learn how to deal with human beings.

    And now peace again.
     
  23. FliteSurgn

    FliteSurgn This space for rent.
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    Ok, here are a few representative codes and their respective reimbursement rates for general surgery. (Isn't it funny how IgD always wants more data, but he's the one who never posts any data about himself?)

    CPT 45385 (colonoscopy with snare biopsy): BCBS $771.56, Aetna $863.15, Medicare $270.86, Tricare $275.73

    CPT 47563 (lap chole with cholangiogram): BCBS $1016.56, Aetna $1809.67, Medicare $571.63, Tricare $556.75

    CPT 49505 (inguinal hernia): BCBS $712.49, Aetna $808.49, Medicare $510.77, Tricare $429.71
     
  24. IgD

    IgD The Lorax
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    Let me summarize a few of the key points above. Several of the key critics claim they are above billing codes and admin. Now you are claiming anecdotal evidence is sufficient. The positions are indefensible.
     
  25. IgD

    IgD The Lorax
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    Congratulations. You just posed the first fact based critique of military medicine I've read on here. Was it really so hard?
     
  26. FliteSurgn

    FliteSurgn This space for rent.
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    What are you talking about? I've seen (and provided) many fact-based critiques of military medicine on this board. Here's a few facts.

    Fact: The military is having an increasingly harder time filling their HPSP coffers with unsuspecting medical students.
    Fact: Surgical skills are allowed to atrophy.
    Fact: Primary care in the AF is withering on the vine.
    Fact: There are many of us who have experienced life on both sides of the proverbial fence and we all agree that the grass is greener on the civilian side.
    Fact: It's not about the money. They could offer to pay me $500k/yr and I would not stay in one minute longer based on the ridiculous way things are run.

    Wake up and smell the coffee. Would that be so hard?
     
  27. orbitsurgMD

    orbitsurgMD Senior Member
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    IgD, this is not a drug study. Get a clue. What you so dismissively refer to as "anecdotal" evidence in matters of finance and law--which is where issues of insurance reimbursement and claims denial may be considered-- is evidence nonetheless, if even a single episode. Claiming a pattern of abuse requires an evidence of that. But even if there isn't a pattern you can discern doesn't obviate the facts as they exist.

    Most private practice physicians do not do coding beyond selecting appropriate CPT codes for services they render on internal practice billing forms. Claims submission is done either by practice staff or outside services under contract. Many contracts are paid as a percentage of claims recovered: the more recovered, the more the contractor gets paid. Ergo the incentive referred to in posts above. Doctors in practice see their patients and do procedures, they don't spend their days on a computer filing claims and posting payments. Most billing departments and services provide periodic reports. Thorough ones also review payor performance and do trend analysis, looking for indicators of third-party payor performance, late payments, downcoding, claims denials and other aberrations from expected standards.This is done with the idea of determining the value of continuing with payors like Tricare whch is unfortunately widely known as a poor payor.

    The nature of billing practices and the validity of evidence have nothing to do with one another. Your post itself is a non sequitur.

    I now not only doubt your credentials, I am also wondering about your intelligence.
     
  28. IgD

    IgD The Lorax
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    Guys, I'm kind of caught off guard by your responses. Basically you are saying doctors are above admin and billing. This is irresponsible and the reason why HMOs exist in the first place. It's not okay just to turn a blind eye to the process. How would you know if you are being robbed by your billing company?

    While I agree that it is a waste of resources for doctors to be involved in the nuts and bolts of billing it is important for the physician to intimately understand the process! Each physician is going to have a small set of frequently used billing codes they should be very familiar with. For example, if you do a procedure you should have a rough idea how much the reimbursement is.
     
  29. IgD

    IgD The Lorax
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    The truth is Navy and Army HPSP scholarship numbers have decreased. Air Force HPSP scholarships are at 115%.

    This is not a fact but a subjective remark. Military medicine is about readiness. This means deploying a general surgeon for the purpose of treating possible surgical cases. If there are no surgical cases the mission is a success but the surgeon gets bored. Recently I had the opportunity to ask a Navy surgeon about this. He stated he could do any general surgical procedure in his sleep and that skills atrophy was not an issue.

    Again this is a subjective opinion and not a fact. Military medicine is basically a socialized medical system. Compared with England, Canada and other countries military primary care has the highest standard of care.

    I respect your opinion but not everyone agrees with you. There are a number of physicians in military medicine who joined because of frustrations on the civilian side. Just recently I spoke with an OBGYN who did just this.
     
  30. USAFdoc

    USAFdoc exUSAFdoc
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    you would have better luck getting Hezbollah to kiss the Israeli flag than to cure IgD of his military medicine "blindness". Anyone still pursuing the idea of turning him away from the "darkside" best be ready for a lesson in frustration and futility. There are numerous posts already illuminating just how off the mark he is. Just let him go.
     
  31. IgD

    IgD The Lorax
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    There should be a way for us all to peacefully co-exist. I don't agree with what you guys are saying most of the time but I do respect your opinions.
     
  32. Galo

    Galo Senior Member
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    You do not respect anything we say whether we can provide evidence or not. You always have to have the opposite opinion even if you cannot possible experience it for yourself. The facts flitesurgn gave are right on the mark, but you found your own surgeon to refute part of them. Truly, you are impossible to deal with, and hopefully students who read this forum can quickly deduce that you are a large part of what makes the military so incredibly frustrating to people who aspire for excellence. Despite all our attempts to walk you down the path of evidence based experience, national published investigative reporting, even military based critiques of the system, you still want to refute us, and typically by adding some lame insult to our personalities, or ourselves. You really do typify the worst of the worst in the military, someone who will undoubtedly make rank, but has not a clue what his job is.
     
  33. former military

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    I am urology... in 2003 I was appointed to be part of a FAST team... this is an AF trauma team consisting of a general surgeon, anesthesia person, orthopod, and nurse... I was going to take the place of a general surgeon.... The general surgeons at my hospital (and there were more than 8-10) of them were sick of deploying... technically urology or gynecology can "augment" general surgeons- assisting in the OR and giving exposure... they wanted me to be the sew up the portal vein trauma guy.... does that seem standard of care? i don't know many urologists doing trauma ex laps as primary surgeons in us trauma centers.... they are not even credentialed to do this.... general surgeons and anesthesia are especially sick of deploying 4-6 mos a year with know end in sight... the only reason I wasn't the helicopter trauma surgeon was (unbeknownst to the general surgeons who tried to induct me) there is a specific rule prohibiting Uros and Gyns from being on a FAST team....

    and for IgD.... I am sure you would want your surgeon to be coming of a 6-12 month sabattical where they did no significant operations? I think I would like my surgeon to have done the case a couple times in the last few months.
     
  34. IgD

    IgD The Lorax
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    Galo, you are a true model to all. After receiving an administrative separation for unprofessional conduct from military medicine, you came on this board and turned it around. You have become one of the foremost experts in military medicine. While the government struggles to balance the costs of war fighting against increasing billions and billions of dollars spent on post-retirement and active duty personnel medical care, you have solved the problem. I commend you Galo!
     
  35. IgD

    IgD The Lorax
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    How can you avoid deploying a surgeon that is not utilized? Doesn't the military need to assume there will be surgical casualties?
     
  36. FliteSurgn

    FliteSurgn This space for rent.
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    In my case, the sabbatical was my entire obligation period. I spent the last 2 years doing 4 colonoscopies per week and an occasional "operation." I can count on 2 hands how many laparotomies I did in the last 2 years and still have fingers left over. Is that how you prepare a surgeon for major combat-related casualties?

    Fortunately, I'm only 2 years removed from working at a Level I trauma center and I feel I could do it if I had to ( not in my sleep like your esteemed colleague...I mean recruit), but imagine the lack of skills for some of my partners that have been withering like this for 10+ years. It's sad!

    BTW, was talking to one Navy surgeon and one OB/GYN that you recruited from civilian to military practice your idea of a "study" on these issues?
     
  37. Galo

    Galo Senior Member
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    Unlike you, I have at least offered tantable suggestions for keeping surgeons skills along with others from deteriorating, I even did some of those things myself, like become part of a teaching institution, moonlight, do humanitarian, etc. I am not sure you are even a doctor. You are a constant disruptor of healthy critiques of a system you consistently seem to not understand. You also continue to make personal insults, (not that I haven't insulted you), as a way to make your points seem logical. I have never claimed to solve the problem. I think at the current rate, and with people like you on active duty, its not solvable. I am proud to have served and taken care of the most deserving patients in this country. My HONORABLE discharge was a result of jaywalking, walking out of a meeting, and speaking my mind about fraud waste and abuse. Getting out was one of the happiest day of my life.

    Say something tangible about yourself, some suggestions, something to change people's opinion of you, because, most in the forum think you are some type of pathologic psycho, and you really have not given them much else to go on.
     
  38. IgD

    IgD The Lorax
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    I'm going to have to throw the B.S. flag on this one. Physicians don't get ad sep'd for walking out of a meeting, etc. What is missing from this picture?

    The truth is as long as I say anything remotely pro-military medicine you'll continue to engage in name calling. I respect the fact you were frustrated with the military. We will have to find a way to get along.
     
  39. Galo

    Galo Senior Member
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  40. i want out

    i want out Member
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    Anybody will get adsep'd for speaking their mind especially if they are vocal about the problems that are fairly evident in military medicine.

    i want out
     
  41. Galo

    Galo Senior Member
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    I was the epitome of the squeky wheel. I must have filed over 10 IG complaints, and was very verbal about communicating my complaints to the press as well as my state representative. The drop that spilled the bucket is when they wanted to withhold my bonus because I failed to work as a pgy-2 for a month to fill some di**heads spread sheet. I told them I would stop working effective immediately, and my paperwork magically appeared.
     
  42. former military

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    The same few surgeons keep going... the older ones protect themselves with residency coordinator status or profiles... they are sick of it.... they do an honorable job but after their 3rd or 4th deployment they get pretty bitter... especially when they are at an underutilized "show" medical center that doesn't see trauma and treats blisters, ball pain, and plantar's fasciitis. I wonder they stay married.
     
  43. GMO_52

    GMO_52 Senior Member
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    OK, I've got one for you. Saw a pt in the ED a few weeks ago for a Crohn's flare who had been steroid dependent in the past, now well controlled on Remicaide. Her husband had PCS'd to the local area and she had been referred to a civilian GI. He refused to provide the patient with Remicaide because of how much money he lost billing tricare and now she had a flare.
     
  44. militarymd

    militarymd SDN Angel
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    So, you have a frustrated practitioner who is lashing out at the patient because of a TERRIBLE insurance that is Tricare.

    So who suffers.....the Patient....why....because Tricare can't get its act together.

    The GI doc is a schmuck, but at least he saw the patient....many will not even see them.
     
  45. orbitsurgMD

    orbitsurgMD Senior Member
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    The patient is a dependent active duty? She is supposedly covered as a dependent by the military, is she not? She has been sent out from military care and been provided an inadequate form of insurance, Tricare.
    A practitioner who did see the patient declined to provide the patient with the medication because of a history of having been denied adequate reimbursement by the patient's insurer. Remicade is costly, so unreimbursed treatment might represent a significant loss to a practice.

    So the doctor is a "schmuck" in your estimation. The U.S. government is the one who has dishonorably reneged on its obligation to properly insure its beneficiaries and to fairly and honorably honor its claims, but you think the doctor is to blame, here?
     
  46. militarymd

    militarymd SDN Angel
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    maybe just a little....I think we should always do the "right" thing....then let the money sort itself afterwards....

    If we can't do the "right" thing, then we probably shouldn't be seeing that particular patient.
     
  47. Homunculus

    Homunculus SDN Caveman Administrator
    Moderator Physician 10+ Year Member

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    my wife was recently referred out to a civilian provider for a surgical procedure that surgeons normally charge around 5k for. TRICARE reimbursed him 1500. another thing i wasn't aware of is that this doc (who happens to be one of the few available) has a quota of procedures TRICARE will reimburse for in a year-- so a surgery she was approved for last fall he couldn't perform until this year because of TRICARE cosxt-containment measures. at least this is what he told us-- and he really doesn't have a reason to lie-- he fills his quota yearly. thank god people like him exist.

    to reimburse less than medicare is disgraceful and pathetic.

    --your friendly neighborhood you're in trouble when medicare is better caveman
     
  48. VolatileNavyDoc

    VolatileNavyDoc Junior Member
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    I'll admit that I'm not very well versed in the ways of billing and medicine, although I am technically a licensed physician. With that being said, I am ACTIVE DUTY and recently had an orthopedic procedure for which the surgeon (reasonably) charged $2900. How much of this was Tricare (Remote) willing to pay for the complete repair of a broken bonefide deployable green side Navy GMO????? $950. I'm embarrassed to tell what they paid the anesthesiologist.

    Luckily, the surgeon is a good guy whose son is a marine, so he always takes good care of us. Also, I am a doctor, and this seems to carry a lot of weight with other practitioners, especially in a small town. But, after his malpractice insurance, 2.5 hours in the OR, paying his office staff, etc. he probably made about $300. I could be way off there, but it seems reasonable that he didn't make off with too much cash after all was said and done.

    I have other stories about my family's care as well. I think we get good care in part because I am a physician. We seem to take care of our own to a large extent. This does not in any way excuse Tricare for making it difficult and expensive for civilian physicians to take care of our AD members or dependents. We have some really good physicians here who are willing to sacrifice some of their livelihood to take care of military dependents. But it is NOT their patriotic duty to be short changed by the government for giving quality care to our military members and their families.
     
  49. IgD

    IgD The Lorax
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    The sad thing is if the reimbursement rates were raised to the equivalent of private pay insurance, the military's medical budget would probably triple. Even at it is I heard a very senior line type comment if medical costs keep increasing we will have a medical corps but no military.
     
  50. militarymd

    militarymd SDN Angel
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    That is just not correct.

    Take a look around a military hospital...then take a look around a civilian one....There are MAJOR differences in where the costs are going....

    Those high dollar COWmanders who do nothing but wield clipboards.

    Those nice offices that E-4's command that my current private practice of 8 BC anesthesiologists would envy.

    etc. etc...

    it wouldn't triple the cost...you just need to "realign" the costs.
     

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