r/NoStupidQuestions • u/UseMeAndThowMeAway • 1d ago
Why are Healthcare providers in the US allowed to decline people with Medicare/Medicaid?
I had an eye-opening and honestly heartbreaking conversation recently, and I can’t stop thinking about it. I ran into an old friend from high school at a coffee shop, and we started catching up. She told me about her struggle to find a doctor or specialist who would accept her insurance.
She’s disabled and relies on Medicaid for her healthcare. Her condition requires frequent check-ups and treatments, but every local provider she’s contacted has either told her they’re not accepting new patients with Medicaid or doesn’t take it at all. She’s been forced to look for care hours away, which is a logistical nightmare because she can’t drive due to her condition.
She mentioned that even for providers that technically accept Medicaid, they limit how many Medicaid patients they’ll see in a given time, and the waiting lists are ridiculous. She’s been skipping appointments because she physically can’t get to them, which is only making her condition worse.
This situation just seems so wrong. Isn’t the point of Medicaid to make healthcare accessible for people who otherwise couldn’t afford it? I know reimbursement rates are lower, but shouldn’t there be some sort of obligation for providers to accept it?
Even getting on someone else's insurance wouldn't fix this apparently, as Medicare will always be her primary insurance.
It’s heartbreaking that those who need care most are left without options. This system makes no sense.
99
u/minus_minus 1d ago
Medicare and Medicaid are two different beasts. Medicare is gladly accepted by most providers. It is administered by the federal government and funded by a payroll tax that currently has a long running surplus.
Medicaid is as partial funded by states and so they set the amounts they will pay for services, often constrained by how much that state wants to spend in total each year. A lot of the rates set by states are actually below the cost of the care delivered.
https://www.bellpolicy.org/2024/03/18/in-the-know-medicaid-reimbursement-rates/
7
u/mslauren2930 15h ago
Medicare Advantage is where you run into trouble. AARP pushes UHC on people as their Medicare Advantage insurer of choice, and we all know how awesome UHC is.
→ More replies
110
u/rewardiflost Dethrone the dictaphone, hit it in its funny bone 1d ago
Medicare and Medicaid pay less than what the procedure costs the doctor or hospital to provide.
If they filled up their practice with too many patients on those programs, their business would fail.
If they can't stay in business, then they can't help anyone.
Medicare is usually pretty close - about 80%-85% of what HHS finds the actual costs should be. Medicaid can vary a lot from state to state, and even between procedures. Some pay less than 65% of what the actual cost of the care is.
The only ways to increase the reimbursement rates is to increase the amount of tax dollars assigned to the program, or to cut the number of people who get benefits so those left can get more.
54
u/muenchsc 1d ago
And even worse is that reimbursement rates continue to fall. It’s not that any of us want to avoid patients with government insurance. In fact, we wish we could see them and get reimbursed even remotely close to private rates. But the reality is, especially with Medicaid, it’s just too prohibitive. Even amongst the various state Medicaids coverage can vary widely.
8
u/curiousbabybelle 1d ago
Also documentation is pretty strict for Medicare.
5
u/MacduffFifesNo1Thane 18h ago
UB04s are the only form they’ll accept and are pains in the ass to read.
27
u/ultramisc29 1d ago
Which is why medical care shouldn't be run as a for-profit business.
Fuck privatization.
24
u/Thalionalfirin 1d ago
You do realize that Medicare is run by the federal government and Medicaid is largely administered by the state?
-10
u/HazMatterhorn 1d ago
Yes, the point is that having the option of private insurance allows for the uneven reimbursement rates across insurance types. If everyone’s insurance was public, providers wouldn’t have the option to decline people with public insurance (and they wouldn’t need to).
15
u/Bo_Jim 1d ago
If everyone's insurance was public then you'd be stuck with whatever health care the government was willing to give you. If the system was run like in Canada then the health care providers would still be private sector, but they'd have to slash operating costs in order to stay afloat collecting only what they government will give them. If the system was run like in the UK then everyone in healthcare would be an employee of the government. In both cases, it's the government - not the doctors - deciding if a procedure is medically necessary.
If you'd like an example of how well a system like that would work in the US then look at the VA hospital system.
→ More replies2
u/ManyNeedleworker3693 1d ago
"it's the government - not the doctors - deciding if a procedure is medically necessary."
First, that's not true. But I would rather a branch of the government that was held to results around positive outcomes made those decisions than an insurance company with no motive but profit. The "nightmare scenario" picture you're painting is still better than what we have.
5
u/Ruthless4u 21h ago
It is, whether you want to see it or not.
As anecdotal as it is I’ve had several family and friends denied care by the VA for service related issues or put on wait list that are months long.
Go to support groups for children that have medical issues due to a HIE event at birth, all this free government healthcare in other countries still denies care for these children. You see parents in these groups begging for help with the system.
1
u/Plenty-Serve-6152 20h ago
That’s true, but a doctor at the insurance company is signing off if the procedure is necessary. You can check the rejection form, they’ll usually mention an identifier for a physician or pharmacist that reviewed it and decided to cover it or not.
3
u/Different-Humor-7452 22h ago
Well said. I know of many people who have gotten excellent care from the VA clinics. They take responsibility for providing care for a great many people who can't get care with a private provider, or can't get quality care.
1
u/curiousbabybelle 1d ago
Or if it goes public it could end up being a two tiered system where regular patients end up seeing nurse practitioners or foreign doctors on j1 visas and people who pay cash will see MDs. Doctors will probably just become supervisors and not even see patients based on current trends. I know for mental health a lot of the really great psychiatrists won’t even take health insurance and just take cash patients because insurances are trying to pay them low or not even pay what is agreed upon. The government can’t force doctors to work if they don’t want to and if it becomes too expensive to see patients due to liability and lawsuits expenses etc many of them will probably just end up doing research or in supervising positions etc.
2
u/Massive-Device-1200 1d ago
So slave labor. Because they are forced to give care for essentially free. Medicaid is a joke. It’s not insurance when all they payout is 10 dollars.
You remove competition and the market gets screwed. There should be no insurance. Docs should charge what they want and people will decide to pay. What the hospitals and surgeons will realize is people can’t afford the insane prices that are charged and prices will come down.
Having the government decide compensation is akin to the education system. Year by year there will be less payouts and worse ratios.
But congress will without fail increase there yearly pay and benefits. But look to cut teachers and government doctors salaries.
As I get older it’s all a scam. Public education, healthcare. Shut it all down and let it be private with government oversight. Need better controls and barriers on monopoly.
I ll take my downvotes.
8
u/ManyNeedleworker3693 1d ago
"people will decide what to pay"
It's not a free market when your alternative is being sick or dead. You can't rely on free market capitalism in every market.
4
u/flumberbuss 1d ago
Medicare and Medicaid pay what other nations pay. Medicare actually pays more than average. When you want universal single payer healthcare in the US, it is this “slave labor” you are asking for.
9
u/courtd93 1d ago
Medicaid pays vastly different things state to state. I know of two states with over $80 difference in what they pay out for a therapy session. Medicaid absolutely is not measured as what other nations pay.
Medicare pays fine. The paperwork nightmare that can come with them is the main deterrent
5
u/curiousbabybelle 1d ago
Medicare does actually pay a fair amount. I think doctors just don’t really like all the documentation that goes with it.
→ More replies1
u/Funny-Difficulty-750 1d ago
Too bad real competition won't happen until we get rid of the disgusting corrupt and monopolistic practice of requiring certificate of needs.
2
u/Massive-Device-1200 17h ago
What’s a certificate of need
1
u/Funny-Difficulty-750 9h ago
Basically a requirement that anyone who seeks to open a hospital must supply a "need" for the hospital, which has to be approved by regulators, and almost always results in existing providers having a monopoly on hospitals in a region while blocking any competition from opening. There are cases where existing providers will literally sue to prevent new hospitals from opening because they say there is no "need" for the hospital to open, even when regulators also approve the hospital opening.
1
u/Pristine_Frame_2066 1d ago
I am fine with people having extra private insurance, great! But baseline everyone should have ability to get care. You should be able to walk into any clinic and be seen and triaged. You should be able to go to any pharmacy and get your prescription.
That is what it is like in pretty much any country except war zones and he USA.
And yeah, you wait for elective surgery and specialists in the USA private health system too. Unless you have an emergency, and unless it is a general common surgery, you are waiting for an opening. Medicare, Medicaid, private pay. And you pay through the nose to get lower share of cost and copays 🤷♀️.
There is a really weird cognitive dissonance when it comes to healthcare. I pay 2700/month for an HMO. I pay 6k+/year for three drivers. I pay separately for vision (120/month) and dental (250/month). I pay homeowners insurance. I pay Medicaid and medicare taxes. I pay 4% local service taxes in bay area for free clinics.
Not sure when it is better or cheaper than what they have in Sweden or Japan or fricking Bosnia. The only way free public healthcare could be worse than what we have now in mainly private pay is if it were underfunded and understaffed. Instead you get to pay a premium to have underfunded and understaffed.
Good job, Americans. Best healthcare no one can actually afford.
2
u/Sammystorm1 15h ago
You can walk into any hospital and get care regardless of your ability to pay. Look up EMTALA
→ More replies6
u/sieurblabla 1d ago
Medical procedures in the US cost much more than in other parts of the world. So I'm wondering if they are operating at a loss or only with lower margins.
10
u/courtd93 1d ago
It depends. I’m a licensed therapist so I’m speaking from the mental health side, but Medicaid funding is determined by the states. There are some states that reimburse at similar amount to commercial insurance. In my state, it’s about 1/4 of a commercial reimbursement. I run my own practice and do all of my own admin. If I took all Medicaid clients, I would end up making less than 40k a year before any of my business expenses, so I’d be down somewhere in the 28-30k a year, with a masters degree and a license. So, if you want to consider that technically not a loss you could, but I’d be on the street fairly quickly. The psychiatrists I used to work with would be in a pretty similarly problematic space though there number is slightly higher with more business expenses (a med secretary, much more expensive malpractice insurance, higher student loan debt, more physical equipment, etc) so the concept becomes pretty proportionate.
6
u/redux44 1d ago
Other countries have the benefit that the government is the main payer and can effectively force healthcare providers to accept the costs.
One reason why physician groups like the AMA oppose single payer policies and also why doctors are paid much more in the US versus other countries.
8
u/sieurblabla 1d ago
I agree with you. But, in other countries, doctors are also very well paid. It is usually among the highest-paying jobs in many countries, even in European countries with universal healthcare.
Can the U.S. find a middle ground between the population having access to healthcare and doctors remaining among the top-paid professions?
2
u/Prasiatko 17h ago
There very well paid but still 1/2 to 1/4 what they'd earn in the USA. Especially nurses are paid way more.
2
u/soleceismical 17h ago
Physicians in the US have six figure student debt and American patients love to sue. If people don't get paid enough to make it worth their while, people will leave medicine and others will decide not to pursue that career, and then medical care will be especially hard to access. We already have physician shortages in many fields.
2
u/Emergency_Buy_9210 14h ago
Adopting a European style education system would take care of the medical school problem.
-3
u/PriscillaPalava 1d ago
Hol up let me fix one little thing for you. Let’s change:
Medicare and Medicaid pay less than what the procedure costs the doctor or hospital to provide.
To:
Medicare and Medicaid pay less than what the doctors and hospitals charge for procedures.
Small but important difference! Fuck our healthcare system and their money-grubbing bullshit.
14
u/rewardiflost Dethrone the dictaphone, hit it in its funny bone 1d ago
The agencies making those payments themselves say differently, but you are entitled to your opinions.
→ More replies5
4
u/hunterkll 23h ago
It's both - there's a comment above that provides a good perspective on it from a therapist, on what the rates are.
The whole state-set thing means it's different by state, but at them making 40k/yr on all medicaid clients, (And yes, similar numbers exist in many states, I have family who has worked both as providers and in billing), they're better off working at mcdonalds than being a healthcare provider of many types.
Obviously some reimburse higher, but not always, and it's hit or miss since it's all state-level policies for medicaid.
There needs to be a voter-push to get a happier medium in states like that (at least medicaid related, medicare is federal) that don't pay insane rates, but make it still worthwhile to work those far more demanding and impactful jobs, instead of making retail or private non-medicare/medicaid practice actually more lucrative and only taking on those customers as effectively charity knowing it's axing your salary. That's why a lot of providers who DO take those patients only have a limited capacity to do so/that they'll accept, and it varies by field because of those above issues.
Private insurance doesn't pay the rates you see on the bill either - they'd be insane to. That's why hospitals also crumble if you willingly negotiate with them to reduce costs on your bill to get you to pay as well, you still probably pay more than private insurance will, but nobody ever pays sticker price.
It's kind of disgusting - like a car dealership.
There's not like a standard rate or anything though, and providers of various skill/expertise should be compensated differently, but as it stands, cost of things like materials, room and board, medication, other facility charges that are incurred/needed, etc shouldn't be anything other than some kind of standardized pricing at a minimum
→ More replies0
u/trevor32192 1d ago
No the problem is we have massive healthcare groups that now require massive profit on top of everything else. Millions of dollars to ceos coos, cfos, stock price, MBAs ruining everything they touch as usual. Even the "non profit" healthcare groups have these bloated salaries.
44
u/amdaly10 1d ago
Its partially reimbursement and partially that the patients aren't reliable.
For a given surgery BCBS will pay $950, medicare will pay $750 and medicaid $350. So the doctor would need to preform three times as many medicaid surgeries to make the same amount as commercial insurance will pay.
Second is that (in my experience in my office I worked in) roughly half of the medicaid patients no-call-no-show. So an appointment slot that could be earning money ends up making no money and delaying care for others.
Our office would take medicaid, but only with a referral since we were a specialty.
23
u/IOI-65536 1d ago
That's actually underselling the problem because "make" is ambiguous here. The doctor would need to perform three times as many medicaid surgeries to have the same gross income. Literally no one knows the breakdown of medical costs in the US (which is its own insanity) but I highly doubt the margin is there to not lose money on medicaid once you consider the costs the doctor is incurring so in reality the doctor is likely losing money on every medicaid procedure or the doctor is only covering variable costs with medicaid patients and needs to limit it to some number in order to have private payers cover the fixed costs.
16
→ More replies1
u/Sammystorm1 15h ago
It’s all about volume for Medicaid. I researched lap choles specifically back in 2018. The break even point was 33 a month. Due to static costs. The break even point is probably worse now
20
u/Gullible_Increase146 1d ago
The problem is Medicaid not paying out enough. If you own a business and the government says, "hey, if you work for me, you can spend more than I pay you!" would you take them up on that? If the government wants somebody to work for them, they need to pay them appropriately. The government saying, "fuck you, you work for me now. You don't have a choice," is a bad thing to do to lawful citizens
1
u/Straight_Violinist0 2h ago
Plus the additional administrative tasks and paperwork needed to “justify” Medicaid work. Time consuming and lower reimbursement rates leads to burnout and resentment.
15
u/PositionNecessary292 1d ago
Because nobody can be compelled to provide their labor for a price they aren’t willing to accept. And Medicaid reimbursement is notoriously low compared with insurance. On top of that when you agree to accept Medicaid you also agree that you can not balance bill a patient if Medicaid under pays or refuses to pay.
13
u/Hirsuitism 1d ago
Keep in mind that the reimbursement isn't only for the physician, it is what pays rent, pays for the front desk staff, the medical assistant, nursing, admin staff, utilities, electronic medical record cords, record keeping and compliance costs. When Medicaid reimbursement is absolute trash, then there's no way that it can help keep all the above individuals employed. I think one estimate is that there are 14-20 other individuals in healthcare for every physician.
30
u/sasquatchfuntimes 1d ago
I used to work for a pediatrician who had to close her office due to low reimbursement, ESPECIALLY Medicaid. After her overhead and staff costs, as well as practice insurance, she made little to no money. Nobody should have to work for free. It was a shame too. She was awesome.
4
u/curiousbabybelle 1d ago
Yes I’ve heard a lot about this in primary care. It’s very expensive to run a medical practice that people don’t realize. Also, the liability is a lot. Do you know what happened to her?
4
u/sasquatchfuntimes 1d ago
Her husband was a software developer and made a lot of money. She also had a Masters Degree in Nutrition, which was really her passion. I think she focused more on that and her kids. It’s a shame because she was sooooo conscientious. She wanted to give each kiddo undivided attention and some of her physicals lasted an hour. You can’t run a practice like that. Most primary care doctors work in a group and see patients in 15-20 minute blocks.
2
u/curiousbabybelle 1d ago
Yea that would be really tough. So sad she isn’t practicing any longer. 😭we need more good doctors.
23
u/GameDevFriend 1d ago
It doesn't matter how much money you throw at a doctor he can only handle so many patients at once. It's a sad reality that there's not enough providers to cover everyone and people who should be a priority don't get prioritized. That's a trend with governments and corporations alike. Once any system gets too big the details are lost.
There's a problem with supply and demand. Everyone wants health care and insurance and the government is covering the cost meaning more people are looking for health care but the government also limits the amount of doctors registered in the US. This means demand is high but supply is capped off. It's part of the reason why health insurance is so expensive.
I believe this is by design. The government gets huge lobbies from the health insurance companies, the governments use taxpayer dollars to keep failing insurance companies a float with subsidies and patients with no other options, insurance companies can now deny more claims since people have no other options and pocket that money, they use it to lobby government officials harder.
4
u/bentreflection 1d ago
The government limits the amount of doctors? Can you go into more detail about this? I have not heard anything about this before.
23
u/PositionNecessary292 1d ago edited 1d ago
The government helps to fund medical residencies for hospitals and they determine how many residencies of the various specialties they will fund each year
19
u/Ruminant 1d ago
The federal government caps the number of Medicare-funded residency "slots" for medical school graduates. This effectively sets a maximum limit for the number of doctors in training at one time, and therefore limits how many new doctors the medical system can "produce" each year.
For example: https://www.niskanencenter.org/federal-policy-misallocates-american-doctors/
8
u/SaintNutella 23h ago
To add to this, generally these residencies take place in areas that already have a lot of healthcare providers and most tend to stay with the hospital or in its system (or at least region/city) once that residency is completed. This contributes to how disproportionately distributed providers are.
It's not only that there's a shortage, it's also that some regions may have an abundance and others have a total lack. In NC, for example, Wake, Mecklenburg, and Durham/Orange counties, which host Raleigh/NC State/Cary, Charlotte, and UNC/Duke, respectively, generally have way less of shortage compared to any of the rural counties.
4
u/ComradeGibbon 1d ago
The AMA convinced the feds to reduce the number of lots in the late 90's so there wouldn't be 'too many' doctors.
1
u/Lauren_RNBSN 17h ago
And now they whine about the influx of mid levels. Increase residencies, increase accessibility to medical education, and we wouldn’t be in this predicament we are in.
10
u/Hirsuitism 1d ago
The govt didn't change their number of residency spots for around 2 decades. 2 decades during which the boomers aged out of the work force, got sick as hell, and the strain on our system worsened.
28
u/rabbithasacat 1d ago
I know reimbursement rates are lower, but shouldn’t there be some sort of obligation for providers to accept it?
Medicaid rates aren't "lower," they're ridiculously, unrealistically low, by design. Providers can't be obligated to accept it for the simple reason that they are private providers, not government employees. They therefore have the freedom to make their own business decisions - and the burden of success lies solely on them, with no help from government.
You can't oblige people to accept reimbursement rates that are so low, and the requirements so burdensome, that accepting Medicaid would cause their practice to fail. You're blaming healthcare providers for a stark reality that is not their fault. You should be blaming the lawmakers and insurance companies who collude to ensure that Medicaid reimbursement is so catastrophically low that few providers can afford to participate in it. They are deliberately starving Medicaid out.
I can speak with a little experience on a similar situation. My husband, a healthcare provider, was enrolled in another program designed to expand available care for veterans, by expanding VA coverage to authorized private providers. He was an early adoptee, during the Obama administration, and at first it was quite good. There were paperwork demands, but they were consistent, so that it was possible to learn the system. Reimbursement was straightforward if you played by the rules - meaning, you didn't have to employ an army of costly insurance specialists to fight denials and delays or rule changes, as the system was designed to help patients, not cheat them. It was a bit cumbersome, but it worked - and my husband loved being able to treat patients as needed without their having to worry about being able to afford it. He could just focus on the patients themselves.
And then, during the Trump administration, previous iterations of VA community care gave way to a new system managed by Optum, which is part of United Healthcare. The first thing Optum did was complexify the paperwork involved and make the process hard to deal with. The second thing they did was drastically cut the reimbursement rate--to a fraction of what it was. My husband tried to stay with it for a while out of loyalty to his patients, but ultimately he had to face the math: every time he saw a VA patient, he didn't just make less than he had before, he actually lost money. We are not rich, and in the end, he reluctantly withdrew from the program because he literally couldn't afford to stay in it. Many providers (and pretty much all the ones who were any good) withdrew because they couldn't afford to stay in it.
And that was Optum's intent when they changed the program. Optum/United Healthcare want to get paid for "managing care," but they do not want to actually pay for care. They want to get paid to cut off access to it, and right now they're achieving that goal like champions.
These leeches, and the spineless politicians who cater to them, are the ones you should be angry at, not the providers. Both they and the patients are casualties of a system deliberately designed to defraud them. Your friend doesn't deserve the heartbreaking situation she's in, but it's not her doctor's fault, it's that of her representatives in Congress and the Senate.
5
u/curiousbabybelle 1d ago
Yes and these ceos are making 15 to 25 million a year. It’s so insane while denying medications, procedures etc for patients. It’s really heartbreaking knowing someone needs something and Uhc just denies it.
Since you’re going through some things with Uhc I was wondering do you mind if I dm you with some questions?
1
u/rabbithasacat 16h ago
You're welcome to dm if you'd like to, but I probably won't have much in the way of answers for you - I'm not actually currently going through things with UHC. I was just relating my past experience with Optum; we've been out of the VA program for years now because of them :-(
11
u/pineboxwaiting 1d ago
It’s simple: Medicare doesn’t reimburse the doctors’ offices enough for them to cover their costs, much less make a profit.
12
u/JTBlakeinNYC 1d ago
Unfortunately, Medicaid reimbursement rates are so low that it doesn’t cover the cost of providing the services. A doctor’s fee doesn’t just cover their salary; it covers the rent on their office space, utilities, medical equipment and supplies, the salaries of everyone working there (note: this isn’t just nurses; solo practitioners generally have to have a minimum of four full time billing associates whose sole job is trying to get health insurance companies to pay for the medical care they have already provided); malpractice insurance, licensing fees, and more. One of the reasons so many small medical practices end up closing or being bought out by hospitals is because they don’t have the leverage to negotiate the same rates as hospitals and thus have a negligible profit margin even when accepting only private insurance. Medicaid reimbursement rates are so low taking on more than a few Medicaid patients can literally bankrupt a small medical practice within the span of a few months—it often costs more to pay an employee to file the initial claim for reimbursement and contest the inevitable denials and refile for reimbursement than the amount that Medicaid ultimately pays for the service.
7
u/fishyperson100 1d ago
Other people have given the answer, but I just wanted to share a little bit of a perspective on the healthcare side. I used to work at a PT/OT office, and we would lose money every appointment for a patient that was on Medicaid, so we only took post surgical/traumatic patients on a case by case basis.
We also weren’t allowed to charge them no show fees, which some of them were prone to (not all but a large percentage).
7
1d ago
[deleted]
7
u/Gullible_Increase146 1d ago
Your rant was about the government system screwing over doctors so they only want to deal with private insurance and then you concluded private insurance is the problem instead of the government screwing over providers? Weird
5
u/Scary_Cupcake8808 1d ago
This isn’t true. Medicare pays timely. Maybe you mean Medicaid? If she has Medicare primary then she shouldn’t have an issue finding a provider to accept her but OP’s story was about Medicaid and then only switched to saying she was actually Medicare primary at the very end
Two very different insurance carriers. One being run federally and one being run by the state.
2
u/Powerful_Jah_2014 1d ago
Perhaps she has medicare advantage. Many practices are opting out of serving people who had medicare advantage.
→ More replies1
u/Vroomped 1d ago
on your rant, absolutely.
The provider: I have the machine, I have eyes and experience, I am done talking to and teaching the patient about themselves...gimme hand motions out into the void and slowly turns the lights off month by month
11
u/nikkidarling83 1d ago
The US healthcare system is terrible, yes, but providers aren’t and shouldn’t be mandated to accept Medicaid or Medicare because then it would be the same as mandating someone work for specific rates, regardless of whether they want to. Doctors don’t have to accept all insurances either.
→ More replies
5
u/Adventurous_Law9767 1d ago
Sometimes it's not that they don't want to accept it, it's that they can't. If they defaulted on their student loans they can't accept medicaid or Medicare we payment because the government would just not pay it.
Source: I worked as a federal debt collector and you'd be surprised how many doctors owe hundreds of thousands of defaulted loans in collections. We can't garnish them because they run their own practice, and we can't offset their tax returns because they make to much to claim a tax refund.
Only penalities they face are dogshit credit and they can't accept medicaid or Medicare. They lump themselves in with "Medicare Medicaid pays sub par." No. A large percentage of these people aren't able to receive the payments at all, and I know this because I'm the guy that clicked the button that says they can't
4
u/HotSteak 1d ago
It's been about 2 decades since I've worked on the financial side but back then Medicare paid about 70% of what private insurance did on average, and medicaid paid 30%. 30% is not enough to cover your hard costs let alone pay your employees.
9
u/PossibilityOk782 1d ago
Because they are not slaves and cannot be compelled to provide labor. Medicaid pays much less than other coverage and comes with many headaches. Unfortunately if you take Medicaid patients you are likely losing money and increasing administrative load.
→ More replies
3
u/Low-Temporary4439 1d ago edited 1d ago
What state does she reside in? Does your friend have state aka "traditional" Medicaid or one of the Medicaid managed care plans?
I ask because state Medicaid is more widely accepted by doctors and specialists (in my state of Illinois at least) than is a Medicaid managed care plan.
Also, since she's disabled, she can qualify for Medicare as her primary, and Medicaid as her secondary insurance. At least that's how it works in my state. I see you mentioned Medicare later in your post, did you mean Medicaid or is she on Medicare already?
3
u/cocteau17 1d ago
I know someone that struggles to find mental health providers on Medicare, and good luck getting a dentist on Medicaid.
10
u/BikerBoy1960 1d ago
Dentist here. Medicaid will only reimburse for a few select procedures for adults, slightly greater number of procedures for children. Add to that the fact that they are over 440 days out on paying claims(in Illinois,anyway), PLUS the reimbursement doesn’t begin to cover the overhead. Dentistry requires precision, time, quantity materials and especially, quality staff. And don’t come at me with the “you can make it up in volume” argument. Can’t buy something for $100, sell it for $45, and expect to stay in practice. The same problem exists for Medicine, though the MD’s overhead percentage is a lot less than the typical 65-70% that dental offices encounter.
Get out there and vote for change.
1
u/Optimal-Test6937 1d ago
My mother in law needed to have several teeth pulled so she could get dentures. She couldn't find a dentist who would pull them all in 1 visit. She was told Medicaid would only pay for 1 tooth to be pulled per visit & 1 visit was allowed per day, so the dentist wanted her to come back 7 (business) days in a row to let him pull 1 tooth a day.
I understand the dentist needs to maximize reimbursement to help pay the bills.
However torturing a wheelchair bound woman by making her go to the dentist 7 DAYS in a row to get 7 teeth pulled is barbaric. . . . looking right at you Medicaid!!
She refused.
2
u/curiousbabybelle 1d ago
I feel bad for her although I do understand why a dentist would have to do this. Could she look up a free clinic in your area? Many of then have dentist that will do extractions for free.
1
u/Optimal-Test6937 1d ago
She did eventually find a dentist willing to pull all of her teeth in 1 visit.
She passed away several years ago (not related to anything dental) so I am prettty sure she doesn't need dental services anymore.
Apologies for my morbid humor, it isnt funny to everyone, but mother in law would have laughed.
5
u/mekonsrevenge 1d ago
Medicare is different from Medicaid and far more doctors accept it. It varies widely state to state, though. I'd contact Medicare directly and ask for advice. Medicaid is a punching bag in Republican states and clearly inferior in blue states like mine. Rural areas have severe shortages of all tiers of healthcare and that's getting worse.
4
u/therewillbesoup 1d ago
Same issue in Canada with dental care. If you're disabled or on social assistance a lot of dentists won't accept you as a patient. The ones that do only take so many. They don't get reimbursed the same amount as if someone paid out of pocket.
3
u/suiluhthrown78 1d ago
Waiting lists are common around the world, you have to wait in line till its your turn unfortunately
In the UK there are 8 million people waiting for hospital treatment of all kinds, those who have the most urgent cases will keep getting prioritised so that waiting list is probably never going to be solved until you're at death's door.
3
u/merpixieblossomxo 1d ago
I don't have an answer, plenty of people here do - all I know is I got a letter of denial yesterday for an MRI that I desperately need for my back because the surgery I had nine months ago didn't fix the problem. I have a toddler and I can't pick her up most days.
When it gets bad enough that I can't move again, I'll have to go to the ER. They'll do the MRI then, and it will get approved. They want people to suffer as much as possible until they absolutely have to approve things, and sometimes even then they won't approve it.
3
u/Curmudgy 1d ago
Appeal the denial.
Maybe ask in r/healthinsurance for more info on appealing such decisions. Or r/medicare, if you’re on Medicare or r/medicaid if you’re on Medicaid.
1
u/curiousbabybelle 1d ago
Most insurances will do this. I think Uhc has a 90 percent denial rate. You should appeal it.
1
u/merpixieblossomxo 13h ago
It's the first denial I've ever gotten, and I've just been getting healthcare whenever I needed to for years through United Healthcare. It's weird that it happened now, and I have to admit I laughed at the irony of being denied after the shooting like they're doubling down on random denials in response. Maybe that's not true and I'm being a bit "conspiracy theorist" but that's what it felt like.
Either way, yeah I'm going to appeal it.
3
u/MsRedditette 1d ago
I work in healthcare. I worked at a clinic that needed to close mainly because we couldn’t be sustainable with the abysmal reimbursement rates that Medicaid paid. It sucks all around frankly.
3
u/Humans_Suck- 18h ago
They don't get paid as much from Medicaid. Any time you have to ask why something is the way it is in America, the answer is profits.
2
u/SassyMoron 1d ago
If they COULDN'T decline it, then, essentially, the administrators of Medicaid would be able to decide who gets to practice medicine in the United States and what they can charge. The supreme Court doesn't believe the Constitution gives the federal government the power to do that. That's the real answer, legally.
2
u/Comfortable-Cozy-140 1d ago edited 1d ago
Yes, poor payouts and tedious hoops to navigate are causes, but… I’m surprised no one’s mentioning stigma as a component here too. There are plenty of physicians who openly admit to not taking Medicaid patients in particular because they’re poor/“dirty”/“too much drama”/etc.
2
1d ago
The elders of this time, helped built, this country and this is how we’re going to treat them.. it’s not that we can’t afford to feed the poor. Is that the rich can’t get satisfied
2
u/SpaceEyeButterfly 23h ago
People largely assume just because you have government medical, monetary, or housing aid, you're living an easy carefree life on their tax dollars. The red tape and time it takes to secure and utilize those "benefits" is anything but.
People SHOULD be pissed off at situations like you pointed out bc that is the kind of bureaucracy that costs taxpayers far more than simply treating the patient.
The answer to your question is simply this; the US government does not want to spend money to take care of its citizens. So they set up and allow things like this to happen. The idea is to create hurdles and make things take as long as possible in the hopes you'll give up, or if they're lucky, you'll heal or die or first. That's the bottom line, the Almighty Dollar.
2
u/SaintNutella 23h ago
In short, Medicaid and Medicare unfortunately do not reimburse enough and unless they're a Medicare-participating hospital or a type of designated hospital (e.g a FQHC/Federally Qualified Health Center), they don't need to accept Medicaid/Medicare and can deny care if there's no way of paying for it.
Hospitals that participate with Medicare, which is most of them (the elderly are overwhelmingly on Medicare and they take up the most space in hospitals proportionately, so most hospitals would likely lose out on money if they didn't participate) must provide screening, exams, and/or treatment for emergencies and also provide transportation if they can't treat the emergency.
Unfortunately, many services that are offered outside of the hospital setting such as dental or mental health service will not take Medicare/Medicaid because it does not pay enough.
1
u/Temporary_Earth2846 20h ago
This! Medical providers are human too! They need money to pay their bills so they limit the number of patients that get discounted care. Then they can only see so many people in a day. Places that accept a large amount have other departments or services that make up that difference. So in high demand areas you can get denied care.
2
u/Ok_Requirement_3116 21h ago
It has been a while so adjust for 20 years inflation. But my dad had a small practice in a tiny mountain town. Rather than go to the effort to bill Medicaid for the $7 they would reimburse for his $40 office visit he just saw a limited number of people pro bono. He couldn’t fill a day of visits with $7 (or free) people and keep his practice open.
2
u/Callec254 19h ago
Because Medicare doesn't pay enough to cover the cost, in some cases. The doctor would essentially be working for free, or even less.
2
u/iamhefty 18h ago
Medicare is why there is nobody in medicine supports single payer. They won't make as much money. Don't get me started in the AMA limiting the number of doctors. Everybody from nurses on up has a vested interest in keeping things the way they are. They get paid 2x what most medical professionals get paid anywhere else in the world. If we can't get past citizens United and the medical lobby I say we equalize all payoits to match Medicare regardless of insurance provider.
2
u/Both-Day-8317 16h ago
Because they don't pay enough. Over a third of Californians are on Medicaid but because of the low reimbursement rates, these patients still rely on emergency rooms because they have a hard time finding doctors to take them. Folks that are on Medicare still have to take out private insurance because Medicare alone doesn't cut it
2
u/mostlivingthings 1d ago
And yet people want to shift our entire corrupt and broken health insurance scam system into a gigantic version of Medicare/Medicaid.
Wheee.
1
u/ManyNeedleworker3693 1d ago
That's not at all what a single payer system looks like.
3
u/mostlivingthings 14h ago
It is, in reality.
I'm sure in your imagination it's all rainbows and unicorns.
→ More replies
2
u/bones_bones1 17h ago
Healthcare providers aren’t slaves. They can choose what insurance systems they will accept or not.
→ More replies
1
u/BigWhiteDog 1d ago
I'm on basic Medicare and a local medical chain provider isn't taking new Medicare patients...
1
1
1
u/EquivalentCommon5 1d ago
Have someone on Medicare (for elderly so please forgive me if I mixed them up!), need to go into residential nursing facility- the good ones only have a few “beds” available because they have to per federal policy. Those “beds” are highly sought after but if a facility only takes Medicare they won’t be able to fund paying the good nurses, having good chefs for nutritional food, general care. My friend is very upset that her friend on Medicare will only go into one of the lesser ranked facilities… but has their friend on wait lists for the few “beds” at better ranked places… somehow expects the friend will get in soon? Not likely - those wait lists are huge! No idea why they didn’t put friend on the waitlist as soon as possible? My friend even has other friends that worked in the best ranked facilities, so I’m dumbfounded that they were that clueless. It is what it is and people seem to accept it until it impacts them or the people close to them! Even when told, people seem to just shrug when it comes to all healthcare issues we face in the US, I don’t understand why everyone thinks it’s ok unless it’s them? US is ________.
1
u/AzraGlenstorm 1d ago
I lost my job due to an industry-wide slowdown. I had to go on Medicaid. Absolute nightmare to find a doctor. It was a very difficult time in my life.
1
u/Affectionate_Tea_394 1d ago
Most smaller clinics cap Medicaid percentage so they can keep their doors open. If they didn’t, no one would be able to go there.
1
1
u/kittenofd00m 1d ago
Here is an excellent 2023 article on healthcare provider participation rates in Medicare. https://www.kff.org/medicare/issue-brief/how-many-physicians-have-opted-out-of-the-medicare-program/
1
u/CalTechie-55 1d ago
If she's on Medicare and can afford to buy insurance, why doesn't she buy a Medigap plan, which is expressly sold to people on Medicare?
1
u/ChipOld734 23h ago
Medicare and Medicaid are two different things.
But there’s two types of Medicare now. There’s Medicare and Medicare Advantage.
Medicare = Major medical Free Medicare part B 80/20 plan about $185 a month. Supplemental = private insurance that picks up the other 20% another $150 a month. Accepted most places.
Option 2 Medicare Advantage Cost is little or free. Government pays a private insurance company to handle all your medical and includes dental and eyeglasses, etc. However since it is operated by big insurance companies there’s some places that don’t accept it and many times you may get denied service if they don’t seem it necessary. Since the cost is little to nothing many lower income seniors take it. It does work well for some but others not so well. Many agents are discouraging people to take it until they understand every pro and con.
As I said, I don’t know much about Medicaid.
1
u/Eastern-Move549 22h ago
To answer the question of why I will start by asking my own question.
Why do you think that after winning the latest election trump hired some of the people that 'donated' vast quantities on money to his election campaign?
1
1
u/neverseen_neverhear 20h ago
Iv faced this same issue with my MIL. Needs a specialist. I called 8 different places no one takes her insurance. It’s infuriating.
1
u/seajayacas 20h ago
Some doctors (good ones who are in high demand) take no insurance at all, patients either pay out of pocket or see a different doctor.
1
1
u/Spirited_Season2332 19h ago
Because the Healthcare providers only have so many patient slots and they get paid less from the government then from private insurances. Why would they agree to take on someone they will have to see multiple times a month vs taking on 30 ppl they would see once a year (on average) and make more money for seeing?
1
u/Fun-Distribution-159 19h ago
medicare and medicaid are nightmares to deal with on the billing end.
1
u/Careflwhatyouwish4 17h ago
There's an obligation to accept it IF the provider agrees to participate. Unfortunately that's a money losing situation. Often doctors who do participate are taking as many medicate patients as they can afford to. If Medicare paid realistic rates and costs this problem could be resolved.
1
u/Amazing_Ad6368 16h ago
They’re not allowed to if it’s in their contract, but they do it anyway and no one who can do anything about it cares because it doesn’t affect them and they often benefit from it.
1
1
u/mslauren2930 15h ago
My doctor's office won't accept UHC for Medicare Advantage and hasn't for years, because of the hassle of the reimbursement process (which at times seems nonexistent from what my friend who is stuck with UHC has).
1
u/CMG30 14h ago
Because it's private. Like any other business they can choose their customers.
People in the US have been brainwashed into thinking this is some kind of freedom where, in reality, it's the opposite. You need to go begging for care even if you have the ability to pay.
Medical services are highly specialized and require staff with years of training and tons of money to set up. As a result, they're a natural monopoly. Private, for profit, (capitalism) only works for consumers if there's a wide variety of choice all competing against one another for your dollar. This is the opposite of how medicine works.
1
u/Equal-Science-6079 14h ago
As a mental health therapist, Medicaid pays terribly and we are not allowed to charge no-show fees to these clients, who unfortunately are frequently unreliable. Medicaid also expects more documentation than commercial insurance. In reference to payouts, I receive about $50 for a Medicaid session and $80-$120 for commercial plans. I have a chronic condition that makes working a traditional full-time job impossible, so I try to fill my schedule with mostly higher paying insurances and a few lower paying because I have bills to pay.
1
u/psychologicallyblue 14h ago
I used to work at a community mental health clinic that was Medicare/Medicaid. The paperwork burden was immense and there's so much documentation around proving that people meet the requirements for treatment (medical necessity). There is high burnout at these types of clinics, the pay is shockingly low, the workload is immense, and the types of problems that patients have tend to be more severe.
I work at a private hospital now and we do accept Medicare/Medicaid but again, there is more paperwork for these patients and more rules to follow. If I go into private practice, I would not take any insurance, let alone Medicare/Medicaid because I don't want to work for a pittance and spend 50% of my time dealing with insurance companies and documentation. I went into this field because I love helping people but I'm not a martyr.
1
u/FinanciallySecure9 13h ago
Believe it or not, many doctors have a full caseload and don’t accept new patients.
Since Covid, there are fewer doctors overall, so that makes it harder to find a new doctor.
Your best best is to utilize your mother’s insurance company provider list.
1
u/Ok-Refrigerator-3691 13h ago
It’s the reimbursement rate/administrative overhead/don’t want that type of clientele thing. . . Healthcare is a business, not a charity 😉.
1
u/InfamousFlan5963 13h ago edited 13h ago
I work somewhere that accepts Medicaid and sees a bunch of patients because of it.
1 - not really your point but I will say I am 100% on Medicaid for all. IF you can find somewhere that accepts it, it's so easy on the patient side. Im sure it varies based on specialty, but everything we offer is covered in our state so it makes it so easy to be able to just reassure them all care here is fully covered, compared to private insurance where you have to deal with the specific benefits plan on what is and isn't covered, how much, etc and it can be so complicated - both for us and the patient - to understand and explain what costs they may or may not have. Especially since many of our patients can be younger (like 20s) and so we might be first provider they are seeing without their parents in the sense of trying to understand how insurance works.
2 - that all being said, Medicaid does not reimburse us well (much less than insurance or paying out of pocket) and some types of Medicaid (tbh not sure "proper" name, but like how some insurance companies have a Medicaid version, like at least around me blue cross blue shield has one etc) can be HORRIBLE at reimbursing. The majority of providers who don't accept Medicaid around me is because of those 2 factors. They also often limit patient numbers because of the lower reimbursement. But like, I have a friend whose kid is on one of the "other" Medicaids and has a chronic condition, the hospital branch they go to just told them they no longer accept that type of Medicaid. That kind of pick and choose seems to be pretty common around here, mainly with the ones who suck at reimbursing in reasonable timeframe (we accept all types at my job which is how I know the timeframe changes for different ones, I'm not in billing to know the exact details but Ive heard them complain along the lines of "of yeah that one never pays us" etc (I mean, they WILL eventually but they just mean in reasonable timeframe).
But reimbursement can be horrible. I can't remember the fancy name but Medicaid basically makes a list of all covered options and sets a price for it, and that's what they'll pay whether you like it or not. Some of our services thankfully got increased because we were losing HUGE amounts of money on some services becuse of the reimbursement rate they set. And they set it (at least for some things) per service. So like, if patient came in for this visit type it was 1 set price. The frustrating part was that the individual steps of that appointment would have gotten better reimbursement separately but we arent allowed to bill it that way (like if we could bill the lab work, talking with provider, medication, etc all as separate charges we would have gotten a higher reimbursement than just saying they had this 1 appointment. But we had to bill all as one)
Also I'm not sure if it varies at all, but Medicaid in my state is always secondary, so if they got another insurance that would go first). I'm not sure where Medicare falls (although as others said, it is 2 different programs so not sure if the person you know has Medicare/Medicaid combo or just Medicaid?). Buuuuut you do always need to bill them, so places that don't take Medicaid might still say no. The way it works at my office (and really, in my state as a whole then since it's a standard thing) is that you have to bill the primary (private) insurance first, then anything that insurance doesn't pay will get billed to Medicaid. My state (and seems to be common in at least a few others but not sure if everywhere or not) also does now allow you to collect money from Medicaid patients (beyond of course if Medicaid has charged something. Everything we offer is 100% covered by Medicaid but I know some plans do charge like a few dollars for some medications so the pharmacy would charge those copays then and be ok). So it can make things very complicated and a lot don't want to deal with that
1
1
1
u/FewOutlandishness60 7h ago
They pay horribly, their contracting process is a nightmare, they can take MONTHS to pay claims and they require a ton of extra paperwork for billing.
1
u/Straight_Violinist0 2h ago
Accepting private insurance can be challenging administratively at times, but the additional paperwork layered onto Medicaid and Medicare insurance plans added to extremely poor communication from these government run insurance plans added to the low reimbursement rates and more clinically complex cases… it’s challenging to maintain a private practice when the administrative needs are so high. The shift goes away from healing to paperwork. It’s not sustainable. While teaching hospitals are legally required to accept Medicaid it’s a horrendous system.
1
u/Straight_Violinist0 2h ago
Medicaid and Medicare plans function very differently so I’d start by separating them into two questions. Then dive into the complex answers from there.
0
u/PeekyMonkeyB 1d ago
Corporate lobbyists are the seeds to all of the hidden laws allowing consumer theft...usually by getting stuffed into the background of passing legislation. Ban lobbyists and whatever the engine is that drives political donations.
6
u/ResoundingGong 1d ago
Medicaid patients are money losers for health care providers. Nothing to do with corporate lobbyists. The corporate lobbyists would love it if Medicaid paid the same as commercial insurance.
0
1
u/carbonatedcobalt 1d ago
i searched my entire state (including up to 5-6) hours away) for a dental emergency, that would accept medicare. only one would, and of course they couldn't help during an emergency, they would only give you an appointment months and months away. the best part about this is that if you have medicare you legally can't pay out of pocket - so i just genuinely couldn't see a dentist for the emergency, no matter what i did, because every dentist in my entire state denied me.
1
u/Curmudgy 1d ago
Are you on a Medicare Advantage plan? Regular Medicare doesn’t cover ordinary dental work at all. Medicare Advantage plans are known for having small networks, especially for dentists.
1
u/carbonatedcobalt 19h ago
no, i do have dental too
1
u/Curmudgy 18h ago
Is it Medicaid and not Medicare? Otherwise it makes no sense. People with just traditional Medicare normally pay out of pocket for dental work or have separate dental insurance with no rule prohibiting paying of pocket.
1
u/carbonatedcobalt 18h ago
no, medicare with a different insurance plan attached, not sure how or why
1
u/curiousbabybelle 1d ago
Check out a free clinic. They can help you.
1
u/carbonatedcobalt 19h ago
the emergency is over thankfully but there was no free dental clinic near me, just healthcare (not dental)
1
1
u/PAXICHEN 23h ago
American in Germany here…this happens in Germany too. Because reimbursement rates suck for “public” insurance (which is the statutory insurance you must purchase) doctors limit the number of said patients.
Would you sell your product or time at a loss consistently?
1
u/msackeygh 23h ago
This is the American health care industry. It sucks big time and it has so far been what people have voted for. I was shocked too that care providers can refuse Medicaid holders.
1
u/hiricinee 22h ago
You really have to flip it around. Why do healthcare providers have to see anyone? You aren't accepting Medicare for payment for health services, why should they?
1
1
u/Tinman5278 18h ago
Because the 13th Amendment outlawed slavery. Service providers are allowed to decide who they will provide services to (with the exception of discrimination based on a protected class status) and accept payment from.
1
0
u/themodefanatic 1d ago
Simply put. Because healthcare is for profit here. Like everything else. It doesn’t matter the moral implications. PROFIT above all else.
274
u/Somethingpretty007 1d ago
Reimbursement rates are often lower than private insurance rates, and the administrative burden of billing Medicaid can be high. These factors can make it difficult for practices to sustain themselves and provide care to all patients.
Patients with Medicaid may have more complex needs that require more attention and resources.
Practices that are smaller, independent, or located in urban areas with low poverty may be less likely to accept Medicaid.
Some physicians may oppose national health insurance and the role of the government in clinical medicine.