I stay on top of as much of the news related to Medicare as I possibly can. I came across this article from NBC News, and I thought it needed some pushback.
https://www.nbcnews.com/health/rejecting-claims-medicare-advantage-rural-hospitals-rcna121012
While these plans may not be for everyone, I do believe most Medicare beneficiaries serve to benefit from Medicare Advantage. As a seller of Medicare Advantage plans, I would like to address some of the negative points made in this article.
Denying Care
When care is denied, it is usually to prevent waste of an unnecessary costly treatment, or to protect the patient from undergoing a harmful procedure if there are safer options available.
MA (Medicare Advantage) is a version of managed care insurance, which plays a role in making sure beneficiaries are receiving both quality and necessary care. Carriers like UnitedHealthcare and Humana negotiate rates with hospital networks based on the volume of patients and their proven quality of care. MA carriers are also required to use Medicare’s coverage criteria to ensure at the very least they pay for services Medicare would also pay for. The key difference is that healthcare providers billing Medicare are required to make the honest determination themselves, and Medicare will just pay it. So when providers say “Medicare pays for this, but MA won’t” they may be getting paid by Medicare when they should not. Medicare may decide to audit a provider’s claims and take back any payment for services that should not have been covered, however, this does not seem to happen very often.
MA also pays providers more than Medicare for covered healthcare. Providers negotiate higher rates to be in a carriers network, and out-of-network providers are often paid 15% more than Medicare’s allowed rates. The quote in the article from the Humana spokesperson indicated this as well.
Long-term acute care (rehab) after an inpatient event are some of the more frequent denials with insurance. This type of care is extremely expensive, and healthcare providers would love patients to stay longer than needed. Insurance companies will insist on discharging a patient if they reach a point of either being clinically well enough to go home or transition to a lower level of care, or if they are just simply not getting any better. The purpose of insurance is to cover treatment; not provide long-term care. There is other insurance for Long-term care, and it is costly.
Shouldn’t my doctor get to decide?
Keep in mind that no single doctor has all the answers. While it’s great to have a knowledgeable doctor you trust, it doesn’t hurt you to have a second opinion. Yes, there may be times when MA denies necessary treatment. Remember, you and your doctor always have the right to appeal a decision, and these appeals can happen faster than you think. Your doctor has the ability to request an immediate, same-day, peer to peer review with your MA plan’s medical director. I worked for UnitedHealthcare many years and witnessed denials overturned many times in this way. The medical staff with the insurance carriers are highly credentialed, and often board certified. I believe if your doctor is as good as you think, there should be no issue getting the care you need covered.
Rural Hospitals
I believe rural hospitals struggle for the same reason many industries struggle in rural locations. Population. Quality healthcare depends on talented people with higher education, and attracting those individuals requires both a desirable place to live and quality pay. It is difficult for rural places with low populations to have access to quality goods and services. These hospitals would have the same difficulties
How can insurance decide who provides better quality of care?
Data analytics. Health insurance carriers have millions of members across the country with huge volumes of medical claims for data. For example, they can determine if one hospital has a fewer rate of readmission after an emergency than another competitor in the same region treating the same condition. The goal for everyone is to live healthy and stay out of the hospital. I’ve heard consumers say “the insurance just wants me to die so I stop costing them money”. It’s the exact opposite. They want you to live healthy and stay out of the hospital so they can keep making money. Your best interests are also theirs.
Record MA revenue
Determining funding for MA is complex and always changing. CMS (center for Medicare and Medicaid services) is working with limited Medicare funding and a rapidly increasing Medicare population. CMS pays MA carriers fixed rates based primarily on membership and Star rating, and the Star rating is also determined by CMS. The rating is meant to be an incentive for carriers to drive quality for its members.
In the aftermath of a pandemic and a round of high inflation, and now the baby boomers aging into Medicare, it may be difficult to predict healthcare costs. CMS has already lowered some of its MA funding for 2024 due to some of the recent realized overpayment. This is why you may have heard about large cuts and layoffs among the large insurance carriers.
How does Medicare Advantage help?
Medicare has invested in MA to do two things: Lower healthcare spending so Medicare lasts longer and improve quality of care for Americans.
A basic fundamental to insurance is risk, and the membership on a particular plan is a risk pool. Increasing a risk pool spreads out, or lowers, the overall risk involved. By increasing membership in MA, the cost per person goes down. As the MA program grows, everyone participating in that program benefits. Insurance 101. As insurance carriers compete with each other and grow, they are able to allocate Medicare dollars more effectively and help to improve care quality for their members.
Carriers also do more work to combat Fraud, Waste, and Abuse. The last estimate I saw this year was $100 billion dollars in annual Medicare and Medicaid fraud. It’s likely to be much greater since this is only based on known factors. As I indicated earlier, providers often bill Medicare and get paid for services Medicare shouldn’t be covering. If I were an auditor working for Medicare, I would be investigating any provider making statements about MA not paying for services Medicare pays for.
MA plans offer many incentives to keeping people active and healthy. Fitness programs, transportation services, home health visits, delivered meals, and personal in-home care are often free additions to these plans as ways to help eliminate gaps in care and keep people healthy longer. The plans also have care coordinators to help make sure you are addressing chronic health conditions. Furthermore, MA can help beneficiaries get access to lower premiums prescription drug coverage as well as benefits for dental, vision, and hearing.
Is Medicare Advantage right for me?
As I first stated, these plans may not be for everyone, but most people will benefit. Everyone’s circumstances are different, so I recommend consulting an agent who sells both MA and Supplement plans. As a licensed insurance agent, I always focus on what is best for my clients, and I am happy to discuss Medicare Advantage and Medicare Supplement options with anyone!
