Still Leaking after Robotic Surgery: Thoughts on water intake

tuckerp, Interesting insight, Thanks.
Does this ABN apply only to M's Advantage as I assume? ?
If so I'm glad to have Traditional M.

rlpostrp, and Thanks for your analysis. Also, is this DGR approach specific to either or both Advantage & Traditional M??

Also, and not that we can do much about it (except contact our US legislators and or CMS), did you find cases of what I've heard called "Up Coding"???
This is when a doctor/provider specifies a particular diagnosis code but some (usually non-medical) person that does their insurance submissions can find a code that pays more and can pretty much fit the provider's diagnosis or condition description.
I found this happening during my automotive career on warranty repair claims. Dealers would have clerical people and computer programs that did this "up coding" for them. Only a detailed (and time consuming) audit by the factory would find this.

Thanks again for your insight and experience.

Sorry guys...I wrote an absolute thesis on the subject of Medicare, Medicaid, and private health insurance reimbursement, but it overwhelmed this Mayo blog and wouldn't upload. So I am trying again in a more brief post.
I offered the entire history of Diagnostic Related Groups (DRG's) that came out of a Federal government study at a hospital in New Jersey in 1976 that resulted in 476 Diagnostic Groups for each disease known, each with its own amount of reimbursement, that is known to hospitals and physicians from the moment the patient is admitted to the hospital. This happened because within a very short time after introducing Medicare and Medicaid in 1965, less than 10years later, the Federal government was spending way more on Medicare healthcare and Medicaid (indigent care) than they thought they would (surprise, surprise). They had to reign in the expenditures, so they did the study with the hospital in New Jersey, and came up with 476 disease specific codes with known average length of hospital stays and costs incurred. So...
Simply put: Say a man is admitted for a radical prostatectomy, and the hospital will receive, say, $25,000 for that surgery and admission. If the patient stays in the hospital too long, they have "overstayed their financial welcome." The physician and/or care team did not do a good job of caring for the patient, and they spent more than the $25,000 they knew they'd receive for that admission. So now they have lost money. On the other hand, if they get the patient out of the hospital a day earlier than planned, they make a profit because they still get the $25,000. This form or "prospective payment" came from the results of that New Jersey study in 1976. Prospective payment was phased in over four years: Year #1 75% traditional "fee for service" reimbursement (spend a dollar, get reimbursed a dollar) and 25% DRG payment. Year #2 50% traditional "fee for service" and 50% DRG payment. Year #3 25% "fee for service", and 75% DRG, and finally Year #4 and thereafter, it was 100% DRG payment. The DRG payment was lower than traditional "fee for service" payment, and that is why it was phased in so hospitals could change levels of care, and cut back operational costs that would keep them from being profitable.
Hospitals had difficulty with this, so back in the mid-1980's they started "cost shifting"...increasing their billings to private insurance companies for patients with such insurance, to make up for their Medicare DRG losses. The private insurance companies quickly learned what was going on, and said "no more." That is when "captitated" payment through health plans started to take shape. If a health plan had a certain number of patient enrollees, then each contracted hospital or physician group got a flat amount of money per patient..."per capita." Health plans incentivized physician groups with bonus money to not over-utilize services and care, which quickly became motivation not to do certain types of care, procedures/treatments, and pharmaceuticals. The physicians then got to share in the bonus money if they achieved their goals of managing and under-utilizing their billable patient procedures. Many physicians hated this because it was an unethical temptation and means to provide substandard care for the sake of money from the health plans. It still goes on today no matter the form of health coverage (HMO, PPO, EPO, and group health plans, etc.). Hospitals have physicians and teams of nurses that review patient charts for compliance with "Standards of Care" that each hospital develops to manage the utilization of services for each type of diagnosis. The care for every patient admitted for a certain diagnosis must follow the Standards of Care protocols. Physicians who over utilize services that costs the hospital too much money are reprimanded. BTW...each DRG could be adjusted as follows: That same man admitted for a radical prostatectomy, might also have had high blood pressure, Type II Diabetes, and Crohn's disease of the bowel. Each of these has its own DRG, but they were additive for the admission because that RP patient had to have their high blood pressure, Type II Diabetes and Crohn's disease "managed"/cared-for while in the hospital for the RP. Also, there was/is adjustments for geographic location in the paid DGR amount. Due to cost of living, wages, costs of supplies, etc., it costs more to treat a patient in, say, metropolitan Los Angles, Chicago, New York, or Boston, than it does in Des Moines, Casper, Tulsa, or Jefferson City, etc. So, Medicare reimburses more for such patients in those metropolitan areas. Hope this clears things up.

@rlpostrp I did learn the hard way that you never want to sign an ABN(advanced beneficiary notice). The Medical facility/lab submits to Medicare their request for service on one of those 476 codes. In order for the facility to bill you for that service they must have you sign an ABN in advance. My lesson was on a $150 PSA test of all things. Lab Corp wanted me to sign an ABN or pay the $19 cash price. I called Medicare and they said it should be covered if its submitted correctly. However they wont tell you what code. So I signed the ABN then was billed $150. I appealed all the way to a judge. I know that Mayo Phoenix will only take Medicare traditional . I guess the additional restrictions placed by the HMO.

@rlpostrp
This” Kickback” Scheme is not quite as simple as described

Federal law generally prohibits insurance companies from paying doctors directly to withhold medically necessary care. Incentive plans must follow regulations (such as Stark Law and Anti-Kickback Statute) ensuring bonuses are not solely based on reducing care.

Bonuses are typically tied to quality benchmarks, ensuring that care is not withheld to the detriment of patient health

@tuckerp Anyone can find the "CPT Code" for any test or procedure. Just type in your computer search bar, or "ask Siri", - "What is the CPT Code for a PSA test?" Or "What is the CPT Code for an Ultra-Sensitive PSA Test?" But...to make life easy for you, here are the CPT Codes for the various PSA tests: 84152, 84153, or 84154.
84152 - Prostate Specific Antigen (PSA); complexed (direct measurement)
84153 - Prostate Specific Antigen (PSA); Total ***This is the most commonly performed/billed.
84154 - Prostate Specific Antigen (PSA); Free (a.k.a. "Free PSA").
BTW: CPT stands for "Current Procedural Terminology". Every last test, procedure, or treatment..."anything"...that can be done to your body, your blood, your tissue, etc., has a CPT Code for billing purposes. There is also what is known as ICD-11. It is for coding "diseases." It is an internationally used system. There has been a progression of updates through the many years this has been used. ICD-11 began its use, replacing ICD-10 in January 2022. Before I retired in 2016, ICD-9 was being used. It is reviewed every year, but only updated when enough updates warrants it. Someday there will likely be ICD-39, ICD-52, ICD-74 (unless some other system is developed)...but we'll all be dead and gone by then.
Also, for those having a challenge with getting their Decipher Score test covered, you can do the same thing. The test usually needs prior authorization, but most plans should not have a problem approving it.
Sometimes two codes are offered. The Decipher Test is a genetic screening test for "22" genes. The CPT Code is 81542. There is a separate code 81541 for 46 genes, but that is not for the Decipher Test Score. The CPT Code does not have/use the name "Decipher Score Test" in the CPT Coding book. It is known as "Multianalyte Assay with Algorithmic Analyses" ("MAAA"). In the CPT Book it is further described as: "Oncology (prostate), mRNA microarray gene expression profiling of 22 content genes, utilizing formalin-fixed, paraffin-embedded tissue, algorithm reported as metastasis risk score."
You - any of us - should not have to personally justify reimbursement for either assay with our health plan. Your urologist's office should do that simple work...they have billers and coders who do this "pre-authorization" stuff all day long. If your urologist has not already ordered the Decipher Score test for you, you should ask/demand it. You should just get an e-mail with a hardcopy Pre-Authorization Approval form attached. It should take no more than 1-3 days "max". The test is done on your biopsied tissue, or more often on the tissue from you post-RP surgery so they can send specific tissue from the visibly most-tumorous appearing areas of the prostate. Good luck to all having the CPT challenge. You should not need to be going through this, unless you have no health insurance whatsoever.

@retireddoc
So glad to see a retired doc recommending Vagnita's book. I got it early on and it seems like she has lots of counterintuitive advice that a lot of programs don't talk about much, but seems really solid. I'm a month away from surgery, but working on getting ready.

I was hoping to hear from folks who had tried her approach to see if they were helpful. Are there others who have used Vanita's methods out there??

Sorry guys...I wrote an absolute thesis on the subject of Medicare, Medicaid, and private health insurance reimbursement, but it overwhelmed this Mayo blog and wouldn't upload. So I am trying again in a more brief post.
I offered the entire history of Diagnostic Related Groups (DRG's) that came out of a Federal government study at a hospital in New Jersey in 1976 that resulted in 476 Diagnostic Groups for each disease known, each with its own amount of reimbursement, that is known to hospitals and physicians from the moment the patient is admitted to the hospital. This happened because within a very short time after introducing Medicare and Medicaid in 1965, less than 10years later, the Federal government was spending way more on Medicare healthcare and Medicaid (indigent care) than they thought they would (surprise, surprise). They had to reign in the expenditures, so they did the study with the hospital in New Jersey, and came up with 476 disease specific codes with known average length of hospital stays and costs incurred. So...
Simply put: Say a man is admitted for a radical prostatectomy, and the hospital will receive, say, $25,000 for that surgery and admission. If the patient stays in the hospital too long, they have "overstayed their financial welcome." The physician and/or care team did not do a good job of caring for the patient, and they spent more than the $25,000 they knew they'd receive for that admission. So now they have lost money. On the other hand, if they get the patient out of the hospital a day earlier than planned, they make a profit because they still get the $25,000. This form or "prospective payment" came from the results of that New Jersey study in 1976. Prospective payment was phased in over four years: Year #1 75% traditional "fee for service" reimbursement (spend a dollar, get reimbursed a dollar) and 25% DRG payment. Year #2 50% traditional "fee for service" and 50% DRG payment. Year #3 25% "fee for service", and 75% DRG, and finally Year #4 and thereafter, it was 100% DRG payment. The DRG payment was lower than traditional "fee for service" payment, and that is why it was phased in so hospitals could change levels of care, and cut back operational costs that would keep them from being profitable.
Hospitals had difficulty with this, so back in the mid-1980's they started "cost shifting"...increasing their billings to private insurance companies for patients with such insurance, to make up for their Medicare DRG losses. The private insurance companies quickly learned what was going on, and said "no more." That is when "captitated" payment through health plans started to take shape. If a health plan had a certain number of patient enrollees, then each contracted hospital or physician group got a flat amount of money per patient..."per capita." Health plans incentivized physician groups with bonus money to not over-utilize services and care, which quickly became motivation not to do certain types of care, procedures/treatments, and pharmaceuticals. The physicians then got to share in the bonus money if they achieved their goals of managing and under-utilizing their billable patient procedures. Many physicians hated this because it was an unethical temptation and means to provide substandard care for the sake of money from the health plans. It still goes on today no matter the form of health coverage (HMO, PPO, EPO, and group health plans, etc.). Hospitals have physicians and teams of nurses that review patient charts for compliance with "Standards of Care" that each hospital develops to manage the utilization of services for each type of diagnosis. The care for every patient admitted for a certain diagnosis must follow the Standards of Care protocols. Physicians who over utilize services that costs the hospital too much money are reprimanded. BTW...each DRG could be adjusted as follows: That same man admitted for a radical prostatectomy, might also have had high blood pressure, Type II Diabetes, and Crohn's disease of the bowel. Each of these has its own DRG, but they were additive for the admission because that RP patient had to have their high blood pressure, Type II Diabetes and Crohn's disease "managed"/cared-for while in the hospital for the RP. Also, there was/is adjustments for geographic location in the paid DGR amount. Due to cost of living, wages, costs of supplies, etc., it costs more to treat a patient in, say, metropolitan Los Angles, Chicago, New York, or Boston, than it does in Des Moines, Casper, Tulsa, or Jefferson City, etc. So, Medicare reimburses more for such patients in those metropolitan areas. Hope this clears things up.

@rlpostrp

Interesting read and pretty factual. I actually learned something about the history of DRG that I didn't know. Thanks.

Just wanted to give an inside perspective. I practiced medicine for 40 years and admitted many patients to the hospital. The last 5 years of my career I was in hospital administration, first as CMO (Chief Medical Officer) and eventually as President/CEO of a healthcare system that included a large Level 1 trauma Center/tertiary care hospital. As CMO I chaired the Utilization Committee you refer to. I mention these credentials only to give credence to the following information.

I am unaware of physicians that would alter their practice in order to financially benefit, even if they could ( they don't profit if patient discharged early or they don't utilize a service etc). Our large tertiary care hospital was constantly at capacity and on diversion (not accepting transfers except emergencies) and thus an email would go out each morning asking physicians to round and discharge patients earlier in the day, if appropriate. Physicians were never enticed or coerced into discharging patients earlier than medically appropriate in order for the hospital to benefit from shorter stay and more profit from a DRG. Physicians were never asked/encourged/coerced/enticed to utilize less hospital services to increase profits.

I am unaware of any PPO/government plans that have shared profits with physicians. There are some insurance plans that have shared profits with doctors/hospitals but these are based on quality measures and not just discharging patient early or avoiding tests/procedures.

Physicians in general don't pay attention to length of stay in regards to individual DRGs for their patients and I would be surprised if many are even aware of the average length of stay od Medicare DRG for, say, an uncomplicated cholecystectomy. They are interested in taking appropriate care of their patients and secondarily (if at all) concerned/interested in the profitability of the hospital.

Most hospitals now operate on a very slim profit level. Most large hospitals are about 2/3 government pay (Medicare/Medicaid), some portion self pay (equates to no pay >90% of time) and the rest commercial insurance (Anthem, Aetna etc). If the hospital is very efficient they may break about even on Medicare patients. They lose money on Medicaid and, obviously, no pay. They usually make a profit on commercial insurance to keep the whole thing a float. We were constantly juggling resources to decide whether to build a new cathedral lab, give the nurses needed raise, renovate the 4th floor etc.

The vast majority of physicians are only interested in their patient's care and doing their job. Yes, most make a very good living but not at the expense of patient care. Hope this helps.

@fritzo
I got the book read it than gave it to Goodwill,
she definitely has some good points and methods. I especially appreciated her attention to psychological connections to resisting dependence on pads. (push ourselves towards continence as opposed to surrender)
the big 'however' from my perspective is, research does not support ten weeks.
Of course some men get better in ten weeks.
Some men have zero incontinence.
However, research ( good research from NIH and the urological association) advances that the majority of men are incontinent. the majority resolve somewhere around the one year mark.