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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

 

How to Find a Part D Drug Plan

This video explains how to find the BEST Part D drug plan for seniors when turning 65, or during the Annual Election Period.

For complete and unbiased help in obtaining the lowest total cost Part D plan, go through the Medicare.gov Plan Finder tool, or use their 24/7 call center (Our Tip: Use the call center late-night to avoid long holds!) 

 

We can also provide recommendations if you call us first at 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.

Verify an Insurance Agent License

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 very personalized service by pulling up all available plans and all available companies for our potential clients. As always, my service is 100{57afd372ef552335ba870edf523b8e4a4ddf98dad7cf21c72091c800f1bfac05} 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.

Working with someone else? At least get a second opinion (and more options) Call me today!

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

¿Cuál es el mejor plan de Medicare Supplement?

¿Cuál es el mejor plan de Medicare Supplement?

Si está considerando su primer plan de Suplemento de Medicare, o está considerando cambiar a un plan de Medicare Supplement más asequible, debe ver este video.

La mayoría de los agentes de seguros que trabajan con personas de la tercera edad presionarán a Plan F como la mejor solución. Mientras que el Plan F cubre todo, a menudo es a una prima tremenda, innecesaria. Los mismos beneficios exactos se pueden obtener con el Plan G, con el deducible pequeño, ahorrando así cientos al año. Pero, se pone mucho mejor.

Por favor, vea este video que explica los muchos beneficios del Plan G vs. Plan F:

¿Quieres ver las tarifas de TODOS los planes y todas las empresas? Podemos hacer eso, y mi servicio es 100{57afd372ef552335ba870edf523b8e4a4ddf98dad7cf21c72091c800f1bfac05} gratis. ¿Cómo? De la misma manera que su seguro de automóvil y los agentes de seguros del propietario trabajan – se les paga de las primas al transportista, que luego paga a los agentes. Trabajamos de la misma manera. No te cuesta nada.

Llámenos aquí o llame al 1-800-729-9590 las 24 horas del día.
¡Gracias por leer!

Chris Westfall

GE Retiree Options Outside the “Exchange” Save Money

GE employees should get a second opinion because they can save up to $1,000 per person, per year, starting in year ONE.

See the video:


Can you buy a Medicare plan outside the exchange? Yes.

As long as you buy at least the drug plan OR the Medicare plan through the exchange, you WILL get the reimbursement money.

When this same thing happened to AT&T retirees in 2014, we successfully helped them save, collectively, millions of dollars that would have otherwise gone to the most expensive insurers in their markets. They used those savings for other policies and as a cushion against future rate increases.

All they had to do was purchase the Part D drug plan through the exchange, and then entire reimbursement money was there to pay both premiums.

We provide a second opinion, and independent review of ALL of the plans available to you.
If you prefer to work with the exchange, a huge call center where you are likely to get a different new-hire every time you call in, you certainly can. If you want the benefit of 20 years of experience and true independence, call us for that second opinion.

You can call us 24 hours a day at 1-800-729-9590

If we’re not in the office, please leave your information on our phone so that we can call you first the next morning.

 

 

Weiss Medigap Report – only $49 for free rates

Over the 4th of July weekend, I received an e-mail offering a comparison of all of the Medicare Supplement rates in my area for ONLY $49!

This was such a deal because their usual cost is $99 for an unbiased quote of all Medicare Supplement plans in my area.

What a deal, right? Wrong.

I’m often asked by potential clients what my service costs.. for me to look up the rates and also provide them the background on the companies listed in the results.

Very happily, I tell them that our service costs them nothing, as it is included in the cost of the premiums, whether they went direct to the carrier OR used the service of an experienced agent.

No extra cost!

I did a video about my reaction, and show the e-mail from the company offering the $49 Medicare Supplement quote.

For the record, we do free quotes all the time and help with plan selection.
You can call us at 1-800-729-9590, even the call is free!

 

Medigap Hospital Discount Card Confusion

Yes, this is a pet peeve of mine – any time you can avoid confusion with senior clients, you should. Anything that introduces uncertainty and confusion in the mind of a brand new client is bad for business. It is therefore my goal to let you know what some insurance companies are sending to your clients with their policies and how you should get in front of it and answer the calls about it. –

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