People are being switched from traditional Medicare to Advantage plans

[Helen]

This is alarming, patiets are being switched from traditional Medicare to Advantage plans without their permission and doctors are allowed a kickback for doing so according to this article.

https://www.levernews.com/seniors-medicare-benefits-are-being-privatized-without-consent/

 

[sengsational]

Maybe not "switched"?

We're all familiar with the barrage of cr*p we get before we turn age 65. It sounds like yet another salvo might come from your own doctor, who might get a kickback if you fall for it.

But I think if you have in your head "I want traditional Medicare", then the email from your doctor can just go into the trash, along with all of the other cr*p, and you can sign-up for traditional Medicare.

 

[Car-Guy]

I didn't read the entire article, but "my first thought", (silly me) is that you can always switch back to regular Medicare.... Has that changed?

 

[Helen]

You have to pass a health assessment to switch back to Medicare. If you have preexisting conditions they won't accept you.

 

[Car-Guy]

You have to pass a health assessment to switch back to Medicare. If you have preexisting conditions they won't accept you.

I have never heard that about Medicare part A&B. Should be able to switch back during the annual enrollment period w/o any problems.... "Maybe" for a drug plan or some supplements, but not basic Medicare.

 

[Teacher Terry]

I have heard about this before. My doctor is part of a hospital system and is not in private practice. I have gotten 2 emails saying you can opt into having them lookout for you through a special program but you have to opt in or stay in regular Medicare. I just deleted the emails. This is really awful.

 

[Helen]

I have never heard that about Medicare part A&B. Should be able to switch back during the annual enrollment period w/o any problems.... "Maybe" for a drug plan or some supplements, but not basic Medicare.

That's because I have it wrong, it's the Medigap insurance that requires underwriting.

 

[Car-Guy]

^^^^^^ Now it does seem that I've heard that ....

 

[Tadpole]

This letter is to give you information-only. No action is required on your part.

Beneficiary Notification Letter — BPCI Advanced

Your Doctor or Hospital Has Joined Medicare's New Payment and Service Delivery Model

Hello,
We wanted to let you know that your health care provider, Sound Physicians, has volunteered to take part in our Centers for Medicare & Medicaid Services (CMS) Bundled Payments for Care Improvement Advanced Model (BPCI Advanced). This doesn't change your Medicare rights or benefits and you don't need to do anything.

What are bundled payments?

A bundled payment combines, or bundles together, payments that Medicare makes to your health care providers for the many different kinds of medical services you might get in a specific time period. In BPCI Advanced, this time period could include a hospital inpatient stay or outpatient procedure, plus 90 days.

Why would Medicare bundle payments?

Bundled payments are thought of as a 'value-based" way to pay because health care providers are responsible for both the quality and cost of medical care they give. This is a relatively new way of paying health care providers compared to the "fee-for-service" way Medicare has traditionally paid, where providers are paid separately for each service they provide. Bundled payments encourage these providers to work together to provide better, more coordinated care during your hospital stay, or outpatient procedure, and through your recovery.

What does BPCI Advanced mean for me?

You're more likely to get even better care when hospitals, doctors, and other health care providers work together. In BPCI Advanced, hospitals, doctors, and other health care providers may be rewarded for providing better, more coordinated health care. Medicare will watch BPCI Advanced participants closely to make sure that you and other patients keep getting efficient, high quality care.

What do I need to know about BPCI Advanced?

What's most important for you to know is that your Medicare rights and benefits don't change because your health care provider is participating in BPCI Advanced. Medicare will keep covering all of your medically necessary services.

Even though Medicare will pay your doctor in a different way under BPCI Advanced, how much you have to pay won't change. Health care providers and suppliers who are enrolled in Medicare Will submit their Medicare claims like they always have.

You'll have all the same Medicare rights and protections, including the right to choose which hospital, doctor, or other health care provider you see. If you don't want to get care from a health care provider who's participating in BPCI Advanced, then you'll have to choose a different health care provider who's not participating in the Model.

How can I give feedback about my health care?

Medicare might ask you to take a voluntary survey about the services and care you received from Sound Physicians during your hospital stay or outpatient procedure and for a specific period of time afterwards. You can decide whether you want to take the voluntary survey, but if you do, it'll help Medicare make BPCI Advanced and the care of other Medicare patients better.

If you have concerns or complaints about your care, you can:
' Talk to your doctor or health care provider.
• Contact your Beneficiary and Family Centered Care Quality Improvement
Organization (BFCC-QIO). You can get your BFCC-QIO's phone number at Medicare.gov/contacts or by calling 1-800-NfEDICARE. TTY users can call 1-877-486-2048.

Where can I learn more about BPCI Advanced?

Learn more about BPCI Advanced at https://innovation.cms.gov/initiatives/bpci-advanced/
• A list of all the hospitals and physician group practices in the country participating in BPCI Advanced.
• All of the inpatient and outpatient Clinical Episodes that are currently included under BPCI Advanced. A Clinical Episode is a grouping of medical conditions or diagnoses that are included in the BPCI Advanced Model.

My husband, recently deceased, received this letter from his "health care provider, Sound Physicians". It is legit even though we have never heard of this provider nor done business with them. I sent a letter to my Senator about this. My letter was ignored as far as I can tell. He was seriously ill at the time with pneumonia caused by swallowing problems due to Parkinson's disease. He died soon after. We had noticed strange things prior to this and attributed them to COVID impact on the hospitals. I don't know if this group of non-physicians had anything to do with it. In our case, apparently, we were exposed to coming under this umbrella of health managers when our primary care doctor's clinic merged with a larger clinic that underwent a takeover by Optum. At the time my husband was no longer using the primary care physician he had used in the past. He had switched to a physician at the nursing home he was in. It didn't matter. They got the contract despite the fact that this group has been fined by Medicare in the past for fraudulent charges. It's real. The CMS website is above.

 

[Tadpole]

I know these are long posts but, if anyone is interested, this is the letter I sent to my Senator.

My husband recently received a letter from a group in Tacoma, WA, "Sound Physicians". The letter began "We wanted to let you know that your health care provider, Sound Physicians, has volunteered to take part in our Centers for Medicare & Medicaid Services (CMS) Bundled Payments for Care Improvement Advanced Model (BPCI Advanced). This doesn't change your Medicare rights or benefits and you don't need to do anything. I scanned the letter to pdf and it is attached.

He is in the hospital and shouldn't be harassed by his medical insurers right now. He has never heard of "Sound Physicians" out of Tacoma, WA and has never consented to allowing these unknown strangers to manage his healthcare. This seems to be discriminatory toward the oldest and sickest of Medicare recipients who are targeted by this program at a time when they are so sick as to be defenseless. He needs HEALTHCARE not involuntary guinea pig selection.

And I see this same group has been fined by the government for past overcharges and misbehaviors. So, CMS assigned them to be his “health care provider”. How can you have the authority to make such as choice for him while he is in the hospital? Who are they besides an outfit fined for indiscretions?

Who is my husband? He is a 100% Permanent and Total (P&T) service-connected disabled Vietnam Veteran. He has Parkinson's disease presumed to have resulted from his service in the Vietnam War. If he lived in a VA flush community with hospitals and rehab facilities, I might be able to appeal to the VA for help. But, as it is, he must rely on Medicare primary and GEHA secondary. Note we purchased with our money MEDICARE and GEHA, not Sound Physicians. We would never have chosen that group as our health providers. But I guess you are removing choice from Medicare and turning it into a HMO without any choice of providers.

This program is so, so misguided and ignorant of elder needs. Yes, he was transferred with one of the targeted health problems but, no he isn't a candidate for a "best practices for other cases of pneumonia". He also has Parkinson's disease which requires daily care even while he receives respiratory rehab. Any decrease in his health condition exasperates his health MORE than people who do not share Parkinson's disease. Management should be left to the providers on the ground not in profiteering management offices miles away.

He deserves good healthcare and to be left alone to heal. Pneumonias are very, very dangerous for Parkinson's people. He needs special care, not average, money saving, practices.

Right now, the doctor says that nursing home rehab facilities won't take him. Is this because of this program? My husband and I don't know but that is the point. Messing with his billing is just one more stressor on a sick person.

In short, we want to be exempt from this experimental model program. And, yes, I see that the original intent (2018 document) was to disallow opt-outs. This tells me that you expected people to want traditional Medicare and not this program. So, if you must bar opt-outs, make opt-ins involuntary, and contract with previously shady organizations, I must assume that Medicare now does not hold to its primary mission but is led by medical lobbyists.

 

[Telly]

I first heard of the ACO (Accountable Care Organization) concept, and all of the other alphabet acronyms going on in the experimental group of CMMS, on Chris Westfall's Senior Savings Network youtube videos. That was a couple years ago or so. [an FYI if needed: Senior Savings Network is a Boomer Benefits-like internet broker]

Not long after that, I received a letter from a hospital health network telling me that my new PCP, Dr. Phibes, was now part of their organization. And that I had been enrolled in their ACO. And oh by the way Telly, we need you to log onto Medicare.gov and follow these directions to select Dr. Phibes as your PCP.

My audible response when reading that was "Stuff It, Clowns!"

Every year now, they send me a letter on a letterhead that has their network name, and CMMS (Medicare). It continues to say that I can go to any doctor I want, etc. etc. but that this will be so much better for me. Yawn.

This year's letter, which I got about 2 months ago, told me that I would have all sorts of helpful benefits, as listed below. There was no "below"! The clowns put the stupid letter together, and the place below was blank!
Needless to say, though they think I am in their ACO, I have not signed up for anything, nor will I. I continue to go see any doctor/facility I want to, as long as they "Accept Medicare Assignment", the magic words of Medicare.

As for that PCP, I have been negatively impressed by his office, and last fall's Wellness Visit seemed to be a tussle between me and his PA (he wasn't there) and office staff trying to get me to let them do all sorts of things to me. After repeating it over and over again, I finally got them to agree to order up the ColoGard test I wanted, and I dealt with the ColoGard company just fine.

The whole ACO-whatever-acronym-it-is-this-year-scheme is just a way for insurance companies and certain "health systems" to get their hands on the big money steering wheel. If I wanted to be in an "ACO", I would have gone the Medicare Advantage route, and had an HMO

As I am writing this, I can hear the words of a Pollyanna... "but Medicare as it is, costs TOO MUCH, you can't fault them for finding ways to reduce the cost". But the ACO concept has NOT reduced cost, and Medicare Advantage costs the government more per person enrolled than Original Medicare does! But if there is money snorted up from the federal trough, the little (Big!) piggies want to be in on it, and better yet, control the feed rate too!
Okay, I'll get off my soapbox now.

 

[Bamaman]

We were in Plan G and changed over to Plan F in the middle of the year before I needed a new insulin pump and my wife needed an electric wheelchair. The change meant we didn't have any substantial 20% deductible to pay on Part B.

I do know that we wouldn't have been able to get on Plan F had we not already been enrolled in Plan G--without going thru "underwriting."

My wife is in the hospital as I write this after having a 2 day back surgery that required two surgeons, and anesthesiologist and a Physicians Assistant that's specialized in spinal surgeries. She had to be readmitted last weekend for a blood clot (thrombosis) and leg pains on a 1-10 scale that are a 15. We hope to get her into rehab facility the next day or two, and they're just about as expensive as the hospitals. There's simply no way to tell how much the hospital bills will be.

I do know that there's no way any pain management doctor or spinal surgeon will be willing to prescribe enough pain medications to keep her comfortable as the States are keeping tabs on all doctors' volume of controlled substances. Hospitals and rehab facility doctors are free to prescribe pain killers without being questioned.

And we are quite thankful to have great insurance for my wife in her 7th major medical procedure in 4 years. I do wish the government would make it a crime for telephone marketing of Medicare Advantage Plans as I'm tired of talking to "Angie".

 

[sengsational]

We're all familiar with the barrage of cr*p we get before we turn age 65. It sounds like yet another salvo might come from your own doctor, who might get a kickback if you fall for it.

But I think if you have in your head "I want traditional Medicare", then the email from your doctor can just go into the trash, along with all of the other cr*p, and you can sign-up for traditional Medicare.

Given my only exposure to the concept was this biased article (like too many things nowadays, going for outrage to increase clicks), I came away thinking the wrong thing.

I see now that nothing changes except how the service providers are paid. If you don't like being in the program, you can walk away and be precisely where you were before with the majority of service providers who aren't doing the alternative approach.

 

[qwerty3656]

Given my only exposure to the concept was this biased article (like too many things nowadays, going for outrage to increase clicks), I came away thinking the wrong thing.

I see now that nothing changes except how the service providers are paid. If you don't like being in the program, you can walk away and be precisely where you were before with the majority of service providers who aren't doing the alternative approach.

Is that right? It seems to me that the "default" if you do nothing is that you are switched.

 

[youbet]

We were in Plan G and changed over to Plan F in the middle of the year before I needed a new insulin pump and my wife needed an electric wheelchair. The change meant we didn't have any substantial 20% deductible to pay on Part B.

Best wishes to your DW!

Just as an FYI, when you switched from Plan G to Plan F, that didn't change the 20% co-pay. Both G and F cover that. What did change was the Part B deductible. With Plan F, it's covered. With G it isn't. But it's not very much: $233 for 2022.

Good luck with all the health issues.

 

[Gotadimple]

Every Medicare beneficiary has the right to file a complaint with Medicare. See Link below. It has helpful steps.

https://www.cms.gov/Center/Special-Topic/Ombudsman/Medicare-Beneficiary-Ombudsman-Home

That some here are contacted repeatedly by their healthcare providers says to me, if at all feasible, it's time to get care from a different medical group. The plan above is not available everywhere and is an experiment. Some of these investigative plans don't pan out and members on those plans are put back on traditional Medicare, unless they select a Medigap provider or a Medicare Advantage plan. If you did not authorize switching from traditional Medicare, I think it would be reasonable for the Medicare Ombudsman to hear about it.

- Rita
https://www.cms.gov/Center/Special-Topic/Ombudsman/Medicare-Beneficiary-Ombudsman-Home

 

[Helen]

Given my only exposure to the concept was this biased article (like too many things nowadays, going for outrage to increase clicks), I came away thinking the wrong thing.

I see now that nothing changes except how the service providers are paid. If you don't like being in the program, you can walk away and be precisely where you were before with the majority of service providers who aren't doing the alternative approach.

ACOs sound more like HMOs which are limited to certain doctors and hospitals whereas Part B has a much wider range of coverage. That's a lot more of a change than how staff are paid.

I don't like the way they are encouraging people to switc and the email doesn't sound clear. I think many who make the switch won't know that they have until they hit a snag.

 

[MichaelB]

I know these are long posts but, if anyone is interested, this is the letter I sent to my Senator.

A well written letter, thanks for sharing

 

[MichaelB]

ACOs sound more like HMOs which are limited to certain doctors and hospitals whereas Part B has a much wider range of coverage. That's a lot more of a change than how staff are paid.

I don't like the way they are encouraging people to switc and the email doesn't sound clear. I think many who make the switch won't know that they have until they hit a snag.

Thanks for bringing up this topic, it’s relevant and timely for many members. It’s been discussed here in the past (here and here)

The Medicare web page for this program (here) is unhelpful, definitely not written for consumers. Another Medicare web page gives an overview of the ACO program (here) and Boomer Benefits gives a nice summary that is much easier to understand (here)

From the Medicare ACO overview and Boomer Benefits description, this program is different than as described in the OP link. The insured remains in traditional Medicare, and if enrolled in a MediGap program, that continues as well. The insured is also free to see any provider in Medicare.

From the sources linked this is not a back door into Medicare Advantage. It’s more like an effort to improve care of people with chronic conditions by sharing patients info among different providers. It’s an effort to move away from pay for service for people that need lots of continuous and ongoing health care services, such as diabetics.

The way eligibility is determined and enrollment carried out is a bit murky, with little involvement by the insured. The presence of private investor owned provider organizations also has negative overtones. These two aspects rightfully cast dome doubt on the objectives and administration of this program.

Still, the literature clearly says Medicare participants in ACOs continue with the same traditional Medicare and have no obligation to see only ACO providers. It’s up to the provider to show why a patient should participate and continue see them.

This was developed by “Medicare Innovations”, which is a department in CMS charged with looking for ways to improve service and reduce cost. To their benefit, they develop lots of initiatives, and drop most.

 

[sengsational]

ACOs sound more like HMOs which are limited to certain doctors and hospitals whereas Part B has a much wider range of coverage. That's a lot more of a change than how staff are paid.

I don't like the way they are encouraging people to switc and the email doesn't sound clear. I think many who make the switch won't know that they have until they hit a snag.

Rather than "how staff are paid", I'd say "how Medicare compensates the provider organization".

I stand by my original thought that there seems to be no "switch" from the Medicare recipient point of view; if they're in traditional Medicare, they stay there.

Maybe the snag you think people who are being treated by an ACO might hit would be getting "limited to certain doctors and hospitals"? But it sounds to me like if the person finds that their provider decides to get paid under the ACO rules, then they are free to leave that practice and go elsewhere that gets paid the traditional way; they still have their parts A and B.

Maybe there's a rule in the new law that prevents people from leaving an ACO practice, even though they still are paying participants of traditional Medicare parts A and B? That would certainly be something to worry about, but I haven't seen that claim being made.

 

[Katsmeow]

This is alarming, patiets are being switched from traditional Medicare to Advantage plans without their permission and doctors are allowed a kickback for doing so according to this article.

https://www.levernews.com/seniors-medicare-benefits-are-being-privatized-without-consent/

ACOs sound more like HMOs which are limited to certain doctors and hospitals whereas Part B has a much wider range of coverage. That's a lot more of a change than how staff are paid.

I don't like the way they are encouraging people to switc and the email doesn't sound clear. I think many who make the switch won't know that they have until they hit a snag.

This is not correct. People are not being switched from traditional Medicare to a Medicare Advantage plan and are not being switched to an HMO. That is not happening.


This is about Direct Contract Entities. I don't like this but people are not being switched to Medicare Advantage.

https://thehill.com/blogs/congress-...threat-to-medicare-youve-never-even-heard-of/

I do think this is a huge threat.

 

[Another Reader]

I'm confused here. Apparently Medicare reviews its' records and automatically enrolls people that have seen a participating provider in the last two years. It sounds like you can be enrolled even if the provider was not participating in the ACO when you saw that provider. How do you extract yourself once you have been enrolled by Medicare?

 

[Telly]

I do think this is a huge threat.

I agree!

As it rolls bigger and bigger, it will be harder to stop. What was first an "experiment" can get switched to "permanent", under the guise of "helping our older citizens maintain their health, while reducing costs" or some tripe like that.

In one of the links that MichaelB posted, that was to my previous discussion of the ACO concept, I mentioned that at that date, the University monitoring it said the ACO concept was costing more $$ than just Original Medicare as it was. The Insurance/health networks spokesman's rebuttal said that was because patients were choosing their own doctors, and not closely following the ACO concept. (those bad, bad old people, we need to reign them in, they need to stay in their ACO we put them in with no consent from them, THEN it will all work out. We could call it an HMO... Helping Medicarians Out)

I'm confused here. Apparently Medicare reviews its' records and automatically enrolls people that have seen a participating provider in the last two years. It sounds like you can be enrolled even if the provider was not participating in the ACO when you saw that provider. How do you extract yourself once you have been enrolled by Medicare?

When I first went to the PCP mentioned in my post above, he and another doctor had their own practice. They were not a member of any bigger health organization. We even talked about that he was independent, as I came from what was an independent group of doctors office, that was gobbled up by an aggregator.

Within a year of that first contact, I got the first ACO letter saying that his practice was now a part of their organization, and I was now in their ACO.

As far as "getting out", I don't know how I could do that. So I am just ignoring it. I'm using practices of my choosing for what I need. None of those practices so far are PCPs. If I went to a different PCP, who was part of some other organization that had their own ACO, would they fight with Medicare as to whose ACO "owns" me?

I have the luck (cynicism!) of being in a large metro area that was one of the CMS Innovations Group early targets for the ACO scheme.

 

[Katsmeow]

I have the luck (cynicism!) of being in a large metro area that was one of the CMS Innovations Group early targets for the ACO scheme.

This is all very confusing (perhaps by design if I want to be cynical). After the uproar late last year about the Direct Contracting Entities (I linked to an article raises concerns). They apparently tried to change ti and started using the ACO name.

This is talking about the testing of ACO Reach which is supposedly the "new" model after 2022. It says that they will do the direct contracting model this year and do the new one next year. This is apparently something different from the both the Direct Contracting Model and the "old" ACO model.

While the changes seem "better" than what was originally proposed the fundamental problem of "inserting a profit-seeking middleman between beneficiaries and their providers" remain.

https://www.healthcaredive.com/news/cms-direct-contracting-medicare-biden-value/619507/

(I haven't followed up on this in a few so haven't heard if there have been any developments since the above in February.

 

[Time2]

Thanks for bringing up this topic, it’s relevant and timely for many members. It’s been discussed here in the past (here and here)


From the sources linked this is not a back door into Medicare Advantage. It’s more like an effort to improve care of people with chronic conditions by sharing patients info among different providers. It’s an effort to move away from pay for service for people that need lots of continuous and ongoing health care services, such as diabetics.

This doesn't seem right economically. If a person is chronically ill and needs more care, more visits, more of the doctors time, why would the doctor want a fixed limited amount of money rather than a pay per visit?
Or do I just misunderstand Medicare Advantage?


My peave with Medicare Advantage, I think the government is paying way to much money into that system, why? Because they have so much money they can buy hours of TV commercials and hire a dozen actors, athletes and whoever to push the product. And also most of the ads are misleading with lines about free dental, free rides to the doctor, free hearing, free prescriptions etc. As my neighbor who works in the system says, that is only for those on Medicaid. She is tired of hearing I want what Joe* has. And then having to convince them they are not eligible. A link to stories about the misleading ads. https://tinyurl.com/2p8mavmz Or,

https://duckduckgo.com/?q=how+are+M...e+plans+misleading&t=newext&atb=v330-1&ia=web


*Namath