I am trying to advise a relative on whether to drop a Medicare Advantage plan and just have straight Medicare. They advertise that you need their plan because Medicare only pays eighty percent, but it appears that they only pay eighty percent, too. The complication is that they (like most insurers) have contracts with providers for discounts ("contractual adjustments") and they pay eighty percent of the difference.
Medicare basically does the same thing, except that instead of a contract, it’s “We decided it’s worth ____, take it or leave it." (Usually less than providers costs, which is why so many refuse Medicare patients.) So, I can see what the plan paid, but all I can predict for Medicare is that the patient responsibility will be twenty percent of the "Medicare approved amount."
I wanted to compare what their plan paid this year with what straight Medicare would have paid. I ran a search for one of the procedures they had done on a database in the Medicare website and got four different dollar amounts. I called Medicare for advice on how to interpret it, and got someone who adamantly insisted the database I was looking at didn't exist.
Can anyone here tell me somewhere I can find the "Medicare approved amount" for selected HCPCS codes? I recently retired from a large healthcare provider, and I could provide my former colleagues with SQL to answer the question, but they'd get fired (and maybe go to jail) if they run it for me (privacy laws).
With the plan, they pay medicare premium plus plan premium plus 20% of the plan adjusted bill. With medicare, they pay medicare premium plus 20% of the Medicare approved amount. Medicare approved amount is the unknown that I am trying to find.