Medicare Advantage Investigation by OIG | Denials For Profit
Medicare Advantage Practics Draw Scrutiny from HHS
The Office of Inspector General (OIG) for the Department of Health and Human Services (HHS) has published the findings of an investigation into claims denials for members of Medicare Advantage Plans. The report concluded that there is a profit motive, stating specifically, “A central concern about the capitated payment model used in Medicare Advantage is the potential incentive for MAOs to inappropriately deny access to services and payment in an attempt to increase their profits.”
Medicare Advantage plans are becoming a popular choice for seniors as they enter Medicare years (65 year’s old) and often has a monthly premium of $0. The monthly premium is subsidized by the government’s payment to private insurance companies who then manage the care the senior receives. The incentive to closely scrutinize what is approved for care is what amounts the insurer’s profit – that is, the difference between the government’s monthly pay for the senior’s care, at a fixed rate, versus the actual cost of care provided.
Most seniors joining Medicare Advantage plans are aware that there are usually network limitations and restrictions on providers where they can seek treatment. This is the most recognized trade-off for a very low, or even zero monthly premium in comparison to original Medicare and a Medicare Supplement, which pays what Medicare does not pay, typically 20% of medical costs. Unlike original Medicare, however, the restrictions put in place on most Medicare Advantage plans go beyond merely agreeing to abide by a network of contracted providers and having co-payments when services are utilized.
The OIG study found that during 2014-2016, Medicare Advantage plans overturned 75% of their own preauthorization and payment denials, overturning approximately 216,000 denials each year. Even more, denials were overturned when the beneficiaries went further into the appeals process, beyond the first stage. The report states, “The high number of overturned denials raises concerns that some Medicare Advantage beneficiaries and providers were initially denied services and payments that should have been provided.”
The alarming conclusion of this study points to the fact that only 1 percent of denials were appealed to the first level during the examined period. This means that 99% of denials to beneficiaries went unchallenged and those services were just not provided. When 75% of appeals were ultimately won by the beneficiary, it would appear that most beneficiaries are not aware of the success rate or the appeals process at all.
At the Senior Savings Network, seniors are shown the options available to them when they are joining Medicare. These options include original Medicare and a Supplement, which offers the freedom of choice to visit any doctor and any hospital that accepts Medicare; or a Medicare Advantage program with its inherently unique set of network and procedure conditions. The Medicare Supplement route means that the senior can travel from coast to coast, without restriction, and there are no significant deductibles, pre-authorization procedures, or maximum out of pocket concerns when seeking the care their chosen physician feels is best for them, as long as the procedure is deemed medically necessary by Medicare.
While the Medicare Advantage network can be searched to see if the beneficiary’s doctor is within the network, that network can still change during the plan year, as doctor and hospital contracts are not always calendar-year contracts and providers can choose to leave the networks. A provider leaving the Medicare Advantage plan in the middle of the plan year does not provide the beneficiary with a Special Election Period to change plans. In that scenario, the beneficiary must stay in the plan and simply choose a different plan-authorized doctor or hospital. A recent story from the Mississippi Clarion Ledger on October 29, 2018 “Hospitals Dropping Medicare Advantage agreements leaves patients in lurch” reported, “North Mississippi Health Services CEO Shane Spees recently told the Northeast Mississippi Daily Journal that only 4 percent of his company’s patients use Humana Medicare Advantage, but they account for 85 percent of payment denials for all payers.
The benefits within a Medicare Advantage plan, as announced at the beginning of the year are fixed for the duration of the calendar year, but not beyond that one-year period. This means that a member of a specific Medicare Advantage plan who signed up for a set premium (or no premium), after finding out that their favorite doctor is in the network might find that the next year the premium, co-payments, and provider networks have changed. This is announced in their “Annual Notice of Change” received by the members in October which outline what changes will happen to their program on the next January 1.
Conversely, with original Medicare and a Medicare Supplement plan, the benefits of the Supplement are guaranteed renewable. This means that the benefits are guaranteed not to change in the future as long as the premiums for that plan continue to be paid. This provides more certainty with regard to the future benefits of their chosen plan. While the monthly premiums can change, the benefits and freedom to choose any Medicare doctor or hospital from coast-t0-coast, does not.
In their audit, the OIG recommends that the Center for Medicare & Medicare Services (CMS) “enhance their oversight of Medicare Advantage contracts, including those with extremely high overturn rates and/or low appeal rates, and take corrective action as appropriate.” It was also recommended that CMS implement strategies to communicate with beneficiaries in a clearer way about the appeals process available to them. The Medicare Advantage appeals process can be quite daunting and has various layers of complexity.
See the video:
Senior Savings Network
1-800-729-9590
Warning to Seniors on Medicare Regarding Scams
Seniors on Medicare are especially vulnerable to scammers and sometimes those doing the scamming are actually insurance agents trying to hide their identity.
Seniors can verify the identity of an insurance agent by getting the agent’s name, license number, and callback number and then verifying their license with the state’s department of insurance. The numbers for each state department of insurance can easily be found with this link. Contact your department of insurance before giving out any personal information to someone who has contacted you by phone.
The good rule of thumb is – if they call you, you do not know who they are – regardless of what the CALLER ID says.
If you contact them, you are in control of who you are talking to. So, verify who they are, then call back their legitimate number
Here is the helpful video on the topic:
Christopher Westfall, National Producer # 596926
1-800-729-9590
Medicare Supplement Plan N
Medicare Supplement Plan N can be a good value, depending on your location (ZIP code), Age, and whether you’re a male or female. Meaning all rates and rate comparisons are personalized depending on YOUR situation.
For any agent to make a complete blanket statement that ONE particular plan is the best for everybody all the time, is simply not aware of all of the options out there. I provide personalized service by pulling up all available plans and companies for our potential clients. As always, my service is Free.
Plan N Medicare Supplement can be a good value, or it might not, depending on your situation. To find out whether Plan N or Plan G or Plan F is the best for you, give us a call at 1-800-729-9590.
It takes less than 3 minutes to give you the breakdown of what is available.
Are you working with someone else? At least get a second opinion (and more options) Call me today!
2017 Medicare Updates
Please see the video for the important briefing on 2017 Medicare benefits.
Also, we have a new Dental+Vision+Hearing plan available in most states.
See the new plan here.
We are always here for you at 1-800-729-9590.
Aetna Medicare Supplement in the News
You might have seen it in the news…
Aetna was in the news this week about their pulling out of certain states in the “ObamaCare” exchanges.
This only impacts those UNDER 65 on regular health insurance, not your plan with Aetna.
This is a smart move for AETNA, as they’ve been losing money – like all insurers have, and Aetna has already lost over $400 million by participating in the “ObamaCare” exchanges.
Aetna’s Medicare plans are stronger than ever and are delivering the best value in the market right now with their below-average rate increases at renewal time. Part of the reason Aetna is able to deliver great renewals is because they recognize vulnerabilities, like the continued participation in the UNDER 65 health insurance market would continue to bring.
Thank you for allowing me and my office to help you with your Medicare Supplement plan.
Please remember that we are here to help if you have ANY questions at all about anything having to do with Medicare.
Sincerely,
Christopher Westfall
Senior Savings Network
1-800-729-9590