Federal report finds Medicare Advantage plans often deny needed care

[REWahoo]

For those of you considering choosing Medicare Advantage plans vs Medicare Supplement (Medigap) plans:

THURSDAY, April 28, 2022 (HealthDay News) -- Coverage for eligible, necessary care is denied each year to tens of thousands of seniors with private Medicare Advantage plans, U.S. federal investigators say.

In a report released Thursday, the team from the inspector general's office of the U.S. Department of Health and Human Services said Medicare needs to improve oversight of these plans and strengthen enforcement against those private insurance companies with a pattern of improper denials of coverage.

The report also said that Advantage plans refused to pay about 18% of legitimate claims, about 1.5 million payments, in 2019. In some cases, plans ignored prior authorizations or other documentation to support the payment.

...the HHS findings challenge claims by the industry's main trade group that Medicare Advantage "delivers better services, better access to care and better value."

Instead, the investigators said they found "widespread and persistent problems related to inappropriate denials of services and payment."

 

[Car-Guy]

I have had my Advantage plan deny a couple of advanced requests for "procedures" in the past year. An appeal was filed in each case which they then approved. I'm not defending the insurance company (no way I'd typically do that) but it "seems to me that the doctors may not be supplying enough info initially. But OTOH, you'd think they'd learn what was needed. So far, I've never had anything "ultimately" denied.

 

[Silver]

It was always my understanding that the intent of Medicare Advantage Plans was to control Medicare costs. They are the Medicare HMO's. I assume that one day in the future, original regular Medicare will no longer be an option.

 

[Bamaman]

I have found that just about all hospitals accept Medicare. But not all hospitals accept Medicare Advantage.

Many doctors now are hospital employees as they've sold their practices to the local hospital. They too have to go by the hospital's rules, and they may not accept Advantage either for their services.

Those hospitals that don't accept the Advantage plans are often the only hospitals in town, and patients often have to go 50--75--100 miles away for services at a hospital that accepts the plan. It's the same way with doctors.

We are being bombarded with television ads and telephone solicitors trying to sell us Medicare Advantage programs. That almost tells me someone is making big money off that gov't. program. Nobody seems to solicit for my Medigap Plan F business.

 

[ivinsfan]

You guys do realize that these are basically 3rd party plans? The government pays them a monthly fee for your care. Anything they don't spend on you personally goes into their pockets. I've never understood why the government setup and ENCOURAGE this plan. It's a crock.

 

[Car-Guy]

I have found that just about all hospitals accept Medicare. But not all hospitals accept Medicare Advantage.

Many doctors now are hospital employees as they've sold their practices to the local hospital. They too have to go by the hospital's rules, and they may not accept Advantage either for their services.

Those hospitals that don't accept the Advantage plans are often the only hospitals in town, and patients often have to go 50--75--100 miles away for services at a hospital that accepts the plan. It's the same way with doctors.

In my case, I wanted to be sure to get (in writing) an Advantage plan that will cover any doctors/hospitals that accept Medicare. I already have to drive 50--75--100 miles away for services and I didn't want that to turn into 150 or more.

 

[jollystomper]

I am not surprised, given the heavy advertising and phone calls for them, with all sorts of wild promises. It is very like the "extended warranty" sales pitches. We will both be 65 within the next 12 months, and will go with Medicare + Medigap.

 

[oldtrig]

I am not surprised, given the heavy advertising and phone calls for them, with all sorts of wild promises. It is very like the "extended warranty" sales pitches. We will both be 65 within the next 12 months, and will go with Medicare + Medigap.

Good choice.

 

[ivinsfan]

In my case, I wanted to be sure to get (in writing) an Advantage plan that will cover any doctors/hospitals that accept Medicare. I already have to drive 50--75--100 miles away for services and I didn't want that to turn into 150 or more.

AFAIK this isn't the way this works or would certain facilities be considered out of network

 

[RetMD21]

You can appeal adverse determinations. We did appeals for patients. Maximus was our "independent review entity" and I had one case go to a level 3 review, administrative law judge. On the other hand, most patients give up and don't fight after a while.

https://www.medicare.gov/claims-appeals/file-an-appeal/appeals-if-you-have-a-medicare-health-plan

 

[foxfirev5]

Regarding the Advantage Plans - "If it doesn't make sense it isn't true" Judge Judy

Also, I question that the insane number of tests for my recent medical condition would have been authorized by a Medicare Advantage plan. Meanwhile I got a Mayo clinic worthy workup to determine that I'll probably die from some kind of cancer. Nice to have Medigap Plan G ?

 

[MichaelB]

On the other hand, most patients give up and don't fight after a while.

This is an important reason for so many denials, and it was pointed out to me early in my corporate finance days. “The best way to prevent something without saying no is to just never say yes”. Perseverance often does pay, but it’s surprising how many people just accept and walk away.

 

[Time2]

I am not surprised, given the heavy advertising and phone calls for them, with all sorts of wild promises. It is very like the "extended warranty" sales pitches. We will both be 65 within the next 12 months, and will go with Medicare + Medigap.

As those of us that watch TV know, Medicare Advantage Plans generate way to much money and afford the Medicare Advantage Plans the luxury of buying many hours a day of television advertising.
I suspect* the Medicare Advantage Plans must pay out a certain percentage of their intake. If it is not already so, advertising should be taken from the part of the percentage that Medicare Advantage Plans get to keep and not be part of the payout. Something needs to limit the advertising, it is just wasting dollars that go into the giant pool of money generated by Medicare Advantage Plans. Stop the madness!!!







*but don't know.

 

[Car-Guy]

AFAIK this isn't the way this works or would certain facilities be considered out of network

I haven't needed a lot of medical care but I'm sure it's coming. However, my DW has and when she turned 65, (earlier this year) I wanted to be sure she had the maximum flexibility in her choices. I just re-checked our Medicare Advantage plan "book" and it clearly says in the "highlights section" up front that there are no "in or out of networks" and coverage extends to all doctors/hospitals that accept "Medicare assignments". (I think that's the correct terminology).

 

[ivinsfan]

I haven't needed a lot of medical care but I'm sure it's coming. However, my DW has and when she turned 65, (earlier this year) I wanted to be sure she had the maximum flexibility in her choices. I just re-checked our Medicare Advantage plan "book" and it clearly says in the "highlights section" up front that there are no "in or out of networks" and coverage extends to all doctors/hospitals that accept "Medicare assignments". (I think that's the correct terminology).

That's good and from what I've read pretty unusual good on you..

 

[Car-Guy]

That's good and from what I've read pretty unusual good on you..

From what I read/heard that's true... It's a plan that is offered by my former employer. It's also subsidized which makes it even better and is one of the last few benefits I'm still getting from them.

 

[Walt34]

I am shocked, simply SHOCKED, that insurance companies lie to keep from honoring their contracts.

BTW, anyone have the sticker symbols for the worst offenders? Asking for a friend....

 

[foxfirev5]

This is an important reason for so many denials, and it was pointed out to me early in my corporate finance days. “The best way to prevent something without saying no is to just never say yes”. Perseverance often does pay, but it’s surprising how many people just accept and walk away.

And what better way to prey on the older people than to make this a business strategy.

 

[mpeirce]

It was always my understanding that the intent of Medicare Advantage Plans was to control Medicare costs. They are the Medicare HMO's.

Sigh. Not all advantage plans are HMOs.

My DW, DM, and DF all have PPO based Advantage plans. They have all gotten excellent care, including treatment for a few serious conditions.

Advantage plans vary a lot - geographically and from various companies. Some are better, some are worse. No way would my family members want to give up their plans. They are are quite satisfied.

I realize there seems to have a serious dislike of some of these plans, but it’s certainly not everyone.

 

[Dash man]

My DFIL has a supposedly “good” union Medicare Advantage plan, where he can go to any doctor/hospital that accepts Medicare assignment. But in 2020 he had urothelial cancer. PET scans and some other tests were denied, and a surgery delayed. He was 87 at the time, and if it weren’t for my wife’s persistence, he probably wouldn’t still be with us today.

 

[Car-Guy]

He was 87 at the time, and if it weren’t for my wife’s persistence, he probably would still be with us today.

He would or wouldn't be with you?

 

[Turbo29]

From what I read/heard that's true... It's a plan that is offered by my former employer. It's also subsidized which makes it even better and is one of the last few benefits I'm still getting from them.

I have one like that too, can use any doctor/hospital that accepts Medicare. Also from my former employer (well actually the state pension plan), also subsidized.

 

[Car-Guy]

I have one like that too, can use any doctor/hospital that accepts Medicare. Also from my former employer (well actually the state pension plan), also subsidized.

Yep as much as I hated/distrust medical insurance companies, it's seems to be a pretty good plan. The other thing I really like is it has an max annual OOP cost of 3k. Which unfortunately she will hit every year.

 

[Dash man]

He would or wouldn't be with you?

Thanks for catching the error! Corrected.