Hospitals and doctors dropping Medicare Advantage Plans

[FIREd_2015]

Some hospitals and doctors are dropping some Medicare Advantage Plans - "Among the most commonly cited reasons are excessive prior authorization denial rates and slow payments from insurers...It's become a game of delay, deny and not pay..."

https://www.beckershospitalreview.c...opping-medicare-advantage-left-and-right.html

https://www.usatoday.com/story/news...dvantage-contracts-over-payments/71301991007/

 

[Teacher Terry]

It took a friend of mine 6 months to get approval for a knee replacement and then before it could be done the advantage plan cancelled the contract with the hospital system so she would have to start all over with another group. At that point she gave up.

 

[Z3Dreamer]

It took a friend of mine 6 months to get approval for a knee replacement and then before it could be done the advantage plan cancelled the contract with the hospital system so she would have to start all over with another group. At that point she gave up.

That is one of the issues/problems/features of MA plans - the gatekeeper. I am sorry your friend went through this. Is it possible that the MA plan wanted to explore physical therapy, steroid shots, etc before approving TKR? Obviously, they are asking for cheaper treatments.

I am not disagreeing with your story, just asking for more info.

 

[Z3Dreamer]

Some hospitals and doctors are dropping some Medicare Advantage Plans - "Among the most commonly cited reasons are excessive prior authorization denial rates and slow payments from insurers...It's become a game of delay, deny and not pay..."

https://www.beckershospitalreview.c...opping-medicare-advantage-left-and-right.html

https://www.usatoday.com/story/news...dvantage-contracts-over-payments/71301991007/

Another reason I think that providers would leave would be low payments.

I am on an MA plan. I noted that a 15 minute televisit with my gastro FNP was $86. Half an hour in person with my ENT PA and some assistants was $121. 15 minute with a teledoc was $49. My annual physical with my PCP was $248 including an EKG. These are the actual amounts they paid, not billed. I do not think they are enough. I believe that the eye doctor was paid about $80 for an eye exam.

On the other hand, my MA plan and Medicare paid my pharmacy a total of $336 for the RSV vaccine. In my uneducated opinion, this is too much. Yes, it could save me thousands, but...

 

[qwerty3656]

Here's youtube video talking about it:

 

[rk911]

Some hospitals and doctors are dropping some Medicare Advantage Plans - "Among the most commonly cited reasons are excessive prior authorization denial rates and slow payments from insurers...It's become a game of delay, deny and not pay..."

https://www.beckershospitalreview.c...opping-medicare-advantage-left-and-right.html

https://www.usatoday.com/story/news...dvantage-contracts-over-payments/71301991007/

We had just the opposite problem. Our PCP works for a large medical group and we had been seeing him for a number of years. A few years back he notified that unless we switched from traditional Medicare to a Medicare Advantage plan we would have fo find another doctor. Not wanting a MA plan we found anothed PCP in the same medical group. It all worked out for us. We're in suburban Chicago and the medical group has lots of doctors. But if we had been in a small town or a rural area we may have had no choice but to switch to a MA plan.

 

[RetMD21]

We had just the opposite problem. Our PCP works for a large medical group and we had been seeing him for a number of years. A few years back he notified that unless we switched from traditional Medicare to a Medicare Advantage plan we would have fo find another doctor. Not wanting a MA plan we found anothed PCP in the same medical group. It all worked out for us. We're in suburban Chicago and the medical group has lots of doctors. But if we had been in a small town or a rural area we may have had no choice but to switch to a MA plan.

Was it a particular MA plan? DW's solo practice primary care doc had a big promotional display for a MA plan. I was curious to know what he was getting out of it but I think it would have been rude to ask so I didn't.

 

[rk911]

Was it a particular MA plan? DW's solo practice primary care doc had a big promotional display for a MA plan. I was curious to know what he was getting out of it but I think it would have been rude to ask so I didn't.

Don't know, didn't ask.

 

[athena53]

We had just the opposite problem. Our PCP works for a large medical group and we had been seeing him for a number of years. A few years back he notified that unless we switched from traditional Medicare to a Medicare Advantage plan we would have to find another doctor.

I see ads for senior-focused primary care in the KC area all the time, mostly franchises. I called one because I liked the idea but they took only Medicare Advantage. Another advertised, "Our doctors get paid more if they keep you well!" Call me suspicious but I wonder if it's just a bonus for keeping treatment costs down- by whatever means.

 

[Walt34]

Call me suspicious but I wonder if it's just a bonus for keeping treatment costs down- by whatever means.

Indeed. The treatment costs go way down if you're dead....

 

[Teacher Terry]

That is one of the issues/problems/features of MA plans - the gatekeeper. I am sorry your friend went through this. Is it possible that the MA plan wanted to explore physical therapy, steroid shots, etc before approving TKR? Obviously, they are asking for cheaper treatments.

I am not disagreeing with your story, just asking for more info.

They had tried other methods the year before. During the 6 months they required her cardiologist and pulmonologist to both say she was healthy enough for surgery. She had asthma and a mild heart issue and both doctors said surgery would not be a problem. It took forever to get these 2 appointments and by the time she did it was too late.

 

[ShokWaveRider]

When the ads for MA focus on the perks rather than the quality of healthcare, you know there is a problem.

"Money Back to SS"
"Fitness Program"
"Extra Benefits that you are Entitled to"

All aimed at Gullible Seniors. The list goes on, should be a red flag.

 

[aja8888]

One guy in my ROMEO group is 61 and working for Humana selling MA plans. I think he is the top salesperson for them in Texas.

He's still working, as he married late in life and has three kids in college and one a senior in H.S. (so he needs the income and he does VERY WELL) His wife is an airline stewardess for United.

In our old man coffee group of about a dozen regulars, no one has an MA plan, and our guy selling MA plans refuses to sell any one of us a Humana MA plan.

Tells you something.

 

[Breedlove]

Now we are puzzled , we are changing to Humana this year Advantage plan . Now we called our doctors and they all accept Humana . We have a PPO , we get to use our doctors . All our doctors accept the Humana Advantage . We had been with Mutual Of Omaha and last year I paid almost 200.00 a month. .One of the doctors office told us that most doctors in big cities accept the Advantage plan and if you live outside of a major city it could be bad.

 

[Teacher Terry]

Another friend has Humana and has had countless problems getting approval for procedures. Most of my friends have Providence and they are thrilled with the free money monthly for groceries and drug stores without paying a premium. I will keep paying for my medigap plan as long as I can afford it.

 

[ShokWaveRider]

I was in my doctor's office the other day and saw a sign saying as of January 2024 they will no longer be accepting Humana and Aetna MA insurance plans.

So it is starting even at local doc's offices.

 

[Breedlove]

I am getting concerned , we will try it for a year and if it fails move to Scott And White . That seems to be the preferred around here . A friend has Wellcare and he talks how great it is .

 

[ShokWaveRider]

I think once one is retired and 65+, one of the Benefits is regular Medicare A & B. It takes a lot to beat it. Most docs take it, especially in areas where there are a lot of retirees. Then with a good medigap plan (G in our case and D) it removes all the worry. OK it cost a little more but at least one knows what it will cost on an annual basis. Is it really worth nickel and diming on one's healthcare?

We love it, it is what we worked for, for both of us it is $745 ($371 each) all in for 2024. The part B premium comes out of our SS, so we do not notice it, we pay the $397 for both of our Medigap Part G to AARP/UHC, we get a small deduction for both of us being on the same plan.

We simply do not worry about it, that is priceless! No medical approvals needed.

The only thing that really grinds my gears about it is the Medicare deductible that IMHO should be added to the Medicare Part A or B premium. It probably costs the medical providers more than this to administer and collect it from their patrons. I would rather pay it all up front. As it is I have to watch for the letters that come so far past the service dates that it is hard to correlate. Then make sure we pay it. Just another unnecessary government-imposed hassle.

 

[aja8888]

Now we are puzzled , we are changing to Humana this year Advantage plan . Now we called our doctors and they all accept Humana . We have a PPO , we get to use our doctors . All our doctors accept the Humana Advantage . We had been with Mutual Of Omaha and last year I paid almost 200.00 a month. .One of the doctors office told us that most doctors in big cities accept the Advantage plan and if you live outside of a major city it could be bad.

One thing to make sure of when they say they "accept" the Humana MA plan:

Make sure they are IN NETWORK for it. Accepting the plan does no mean they are in Network. Being out of network, they can still send the bill to Humana and an "out of network" payment may be paid by them (or not paid at all), and you will be billed for the difference.

 

[MBSC]

One thing to make sure of when they say they "accept" the Humana MA plan:

Make sure they are IN NETWORK for it. Accepting the plan does no mean they are in Network. Being out of network, they can still send the bill to Humana and an "out of network" payment may be paid by them (or not paid at all), and you will be billed for the difference.

There is no balance billing of covered services in Medicare Advantage. The PPO out-of-network coinsurance/copay on the allowed amount is typically higher so a person should stay in-network when possible.

Medicare Managed Care Manual
Chapter 4 - Benefits and Beneficiary Protections
Section 50.5 – Guidance on Other Enrollee Out-of-Pocket Liability

No balance billing: As indicated in section 170 below, an enrollee is responsible for paying non-contracted providers only the plan-allowed cost-sharing for covered services.

Section 170 – Balance Billing

When enrollees obtain plan-covered services in an HMO, PPO, or RPPO, they may not be charged or held liable for more than plan-allowed cost-sharing.

MA plans must clearly communicate to enrollees through the Evidence of Coverage (EOC) and Summary of Benefits (SB) their cost-sharing obligations as well as the enrollees’ lack of obligation to pay more than the allowed plan cost-sharing as described above.

Reference: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/mc86c04.pdf

 

[Gotadimple]

When the ads for MA focus on the perks rather than the quality of healthcare, you know there is a problem.

"Money Back to SS"
"Fitness Program"
"Extra Benefits that you are Entitled to"

All aimed at Gullible Seniors. The list goes on, should be a red flag.

All those ads AND the perks are approved by CMS. Every. Single. Word.

 

[Breedlove]

Before we bought in to the Humana program we had to find our doctors on their lists of doctors . Every one of our doctors were listed Last Friday I got a call from one of my specialists office to remind me of an upcoming visit I have this Thursday and to be sure to get my blood tests . I asked if they too Humana the girl didn’t know ,she put me through to billing . Billing told me , yes they did . Yesterday I got my blood tests at Houston NW Med center. Of course , I asked do you accept Humana , they laughed at me and said yes.




I am no genius but If you live near a big city where many people have say a Humana you almost have to accept it and be in network. We have a friend who went to Med. school in Mexico because he was older and no US college would accept him. He is a GP in a small north Texas town and he accepts nothing but credit card and cash. …He said he doesn’t have time to wait to get paid.

 

[sengsational]

Here's another "gotcha"...they enroll "X" number of people in their "Advantage" plan, then define the network such that there are enough doctors to support 90% of "X".

Did you ever wonder why, when you need to go to a specialist, and your insurance has a limited network, every doctor is booked out 4 months? Even the ones that barely speak English, got their MD in some other country. I'm sure they're smart and capable, but I want a doctor where language/communications are not going to get in the way. So what's the deal? Well, the deal is there's no choice! This explains why every specialist in-network is completely booked, and when you call one that's not in one of these over packed networks, they'll see you next Tuesday.

I've been dealing with limited networks for 10 years with my ACA plans, and it's only getting worse. I'm going to be happy to leave limited networks behind with traditional Medicare + Medigap. I don't care how many "free" gym memberships and eye care exam bones they're offering...not even close to making up for going to any doctor I want, anywhere I happen to be (in the US), and not having to wait months.

Here's another annoyance. Pre-approvals. They put the burden on your doctor to get things pre-approved, and the customer (patient) is locked out of the process; no visibility. I had a case last year where I asked for in-network pre-approval, and was assured I had been pre-approved. Then it turned out it was out-of-network pre-approval, and the insurance didn't even apply for out of network procedures. It would have been cheaper for me to pay cash.

Another pre-approval case was where there was some wires crossed, and the procedure happened before the approval. The procedure was perfectly legit, and would have been approved, but because it wasn't approved BEFORE the procedure, the insurance company wasn't going to pay. What? They make it a jumble that customers/patients don't have control of, more complicated and less visible than it needs to be, just so they can get a few "gotchas" and so not end up paying. What a crock! In this case, I had an external review (consuming hours of my time), and the external reviewers agreed with me and forced the insurance company to pay.

 

[rk911]

I am getting concerned , we will try it for a year and if it fails move to Scott And White . That seems to be the preferred around here . A friend has Wellcare and he talks how great it is .

Be careful. As I understand it you can always switch back to traditional medicare but you may need to undergo underwriting to get a medicare supplement.

 

[pb4uski]

Be careful. As I understand it you can always switch back to traditional medicare but you may need to undergo underwriting to get a medicare supplement.

Absolutely. I went through this with a friend recently. He wasn't on MA but had neither Medigap or MA and the 6 month window to but Medigap without underwriting was long gone.

Luckily he was able to pass underwriting so he now has a Plan G Medicare Supplement that cost IMO a very affordable $163/mo.