BoneSmart® Hip / Knee Replacement Forum
Joint Replacement Patient Advocacy
and Online Community

Medicare Information for 2018 and beyond - USA Patients

Discussion in 'Knee Replacement Pre-Op Area' started by Jamie, May 4, 2015.

  1. Jamie

    Jamie ADMINISTRATOR Administrator
    Thread Starter

    Member Since:
    Mar 24, 2008
    Age:
    70
    Messages:
    52,960
    Gender:
    Female
    Location:
    Kansas
    Country:
    United States United States
    Changes are scheduled for 2018 in the way Medicare provides coverage for surgical procedures including joint replacement surgery.

    Currently surgery covered under Medicare provides a "bundled" payment for the entire procedure to the surgeon. The bundle includes visits by the surgeon while in the hospital, discharge, and post-op visits. For example, a knee replacement pays for 3 in-hospital visits, the discharge and 3 visits after surgery within the 90 day period from surgery forward (called the 90-day global period).

    Beginning in 2018, the global period will change to zero (0), meaning that payments will not cover any post-op visits in the surgery payment package, essentially unbundling the payment process for Medicare patients. The reason for this change is the government auditors determined that the number of post operative visits to doctors was consistently below the three visits paid for in the bundling process.

    So what might this mean for patients contemplating joint replacement surgery and the surgeons performing the procedures? For patients, there probably will be no direct impact as their needed post-op visits should be covered as an individual cost. But most certainly the surgeons will receive smaller payments for the surgery overall from Medicare. Assuming that 1 or 2 post-op visits are needed for an average case instead of the three now allowed under the bundled payment program, there will be less money going to your doctor.

    It remains to be seen if this reduction in payments will impact how surgeons handle post-op care or if the reduction will impact the number of surgeons who perform joint replacement and other surgeries. So far there has not been much discussion of this issue, but as the deadline nears it should become more of a topic for discussion in the medical community.

    Article link: http://orthobuzz.jbjs.org/2015/04/3...RG&l=7404097_HTML&u=476059589&mid=186947&jb=0
     
    • Informative Informative x 1
  2. robert johnson

    robert johnson member

    Member Since:
    Nov 20, 2010
    Age:
    69
    Messages:
    131
    Location:
    United States
    Jamie, do you happen to know anything about the case where Medicare acts as secondary coverage for in patient hospital stays?

    My wife and I still have Regence UMP (PPO) as primary insurance, and we both have Medicare Part A. We've had this arrangement for about 3+ years or so and so far (thankfully) neither of us has been hospitalized. Our understanding from conversations with my wife's HR department and from Billing at a local hospital (after an emergency visit or two), is that Medicare will act as dual coverage, secondary to Regence, in the event of an "in patient" hospital stay (but not "out patient" like an ER visit), with the understanding that "in patient" means you were admitted to the hospital, and you spent at least 24 hours there.

    My physical therapist also told me that he's seen a number of TKR patients younger and healthier than me requesting overnight stays for exactly this reason, where if you leave the same day, and it's considered "out patient", co-pays or co-insurance kicks in, costing potentially thousands of dollars.

    I've been assuming this is the case, but I haven't confirmed it yet and was wondering if you've heard of this before. I do plan on verifying this with the Hospital when the time comes.
     
  3. Jamie

    Jamie ADMINISTRATOR Administrator
    Thread Starter

    Member Since:
    Mar 24, 2008
    Age:
    70
    Messages:
    52,960
    Gender:
    Female
    Location:
    Kansas
    Country:
    United States United States
    @robert johnson ... I have no idea and it would be unwise of me to try and guess! Your best bet is to check with the hospital and call Medicare to get the information straight from someone who knows the rules.

    I do know that anything under 24 hours is considered "outpatient" for both private insurance and Medicare. There are copays for inpatient services just as for outpatient. If Medicare will act as a secondary policy (not really "dual" as they won't be paying the same as your primary coverage), they may then pick up the copay for you so you will have no out of pocket cost once you meet your annual deductible. These are all things to clarify with both carriers. It's the first of the calendar year and you may have deductibles to pay for both policies.
     
    • Like Like x 1
  4. robert johnson

    robert johnson member

    Member Since:
    Nov 20, 2010
    Age:
    69
    Messages:
    131
    Location:
    United States
    OK, thanks. I just thought it might be something that was bantered around over the years. No problem, I will definitely check with both the Hospital and with Regence before the time comes.

    You're right, I don't mean "dual" in the sense that they're both primary. One of them has to be the secondary, and we've been told it's Medicare, but only for "in-patient".
     

Share This Page

Sponsors
Close X