Your Medicare Advisor

Studies Prove That Medicare Advantage Plans Wrongly Denied Care to Beneficiaries

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When it comes to Medicare Advantage plans, some people are all for them, enjoying the lower monthly premiums and additional benefits. On the other hand, some people are completely against them due to the restrictive nature of provider networks and pre-authorizations. Everyone could find different reasons for having this type of plan, but a recent study may make you think twice before considering an Advantage plan.

A shocking new report was released last week by the Office of Inspector General (OIG) concerning the unscrupulous practices of some of the top Medicare Advantage plan carriers. It is important to know that Medicare Advantage plans use a “capitated” payment model. This means that they pay providers a fixed amount up front over time for each patient. Although the practice itself is not unethical, many are worried that this may incentivize carriers to wrongly deny claims in order to keep profits higher. Unfortunately, it seems their concerns may already be a reality.

According to the Centers for Medicare and Medicaid Services (CMS), yearly audits of Medicare Advantage plan carriers have shown “widespread and persistent problems related to inappropriate denials of services and payment”. This prompted the OIG to conduct a random investigation on the top 15 Medicare Advantage carriers. Several experts reviewed hundreds of real-life cases that resulted in denials. What they found was infuriating to say the least.

Regarding pre-authorizations, the OIG concluded that Medicare Advantage plan carriers often “delayed or denied Medicare Advantage beneficiaries’ access to services, even though the requests met Medicare coverage rules”. These cases shed light on strict regulations set by Medicare Advantage plans that were over and beyond what is required by Medicare coverage rules. These strict guidelines ultimately cause delayed care for beneficiaries.

What’s even more frustrating is that some claims did not have the supporting evidence to be approved, but the patient’s medical file had more than enough information to prove the services were medically necessary. Imaging services and injections were among the most common services to be denied. It looks like the burden of pre-authorization was either on the shoulders of the carrier or doctor’s office itself.

Now, when they examined payment request denials, they found that about 18% of claims met Medicare coverage rules and the Medicare Advantage plan’s rules, but still resulted in a denial due to erroneous claims processing. Some of the reasons they attributed this to were human errors like over-looking documents, and system errors when the system used was not updated correctly. It seems like even if you jump through all the hoops, you still have a chance of getting denied services for reasons that are out of your control.

What can you do to ensure you do not fall victim to these sloppy insurance handlings? Stay on top of your care. With over 26 million people currently in Medicare Advantage plans it is easy to slip through the cracks. Hold your insurance company accountable to their processing timelines and make sure they have the documents they need to process your claims. The same diligence needs to be applied to your provider’s office. Be sure to advocate for yourself– if you need to file a grievance or appeal, then do so. Remember, no one is going to push for your best interests but you.

If you or someone you know could benefit from our complimentary services, give us a call at 

855-611-4856 and one of our licensed, knowledgeable advisors will be happy to help.


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TomL
3 months ago

My 85 year old mother in law seems to be one of those that has been taken by a carrier. My wife and I do not live close to her and it is difficult to help her with these kinds of decisions. Unfortunately, she would not be able to remember or handle the discussion if she called AMAC, so we are having to help her. Also, unfortunately, we didn’t find out about her situation until it was too late to cancel the coverage and must now wait for open season to cancel / change it. It really bothers me how unscrupulous these companies have become, in the name of the dollar.

Herb S
3 months ago

We have had excellent service from the Advantage plans that we have used. That includes 3 different providers in 2 states. It would be more helpful if we were told who the miscreants are.

Chris
3 months ago

When it comes to Medicare Advantage plans, some plans will take Advantage of you.

Susabella
3 months ago

If the plans that regularly deny coverage were listed, it would certainly help decide what plan to sign up for during the enrollment period. Supplement plans are extremely expensive for someone my age, and out of the question. I get the best advantage plan I can afford and that is offered in my region, but apparently it still isn’t enough. I need an MRI but probably will be denied, so I can expect to continue my life in pain.

PaulE
3 months ago

There are several versions of so-called Medicare Advantage plans being offered by various insurers out there. Some are bargain basement and deliver little real value, while others offer more and have less restrictions and offer a better value. It is impportant to do a comparative analysis of the plans before you settle on one to ensure the plan you’ve chosen meets your needs. Like anything else in life, if your sole selection criteria is to lock in the lowest possible bargain basement price, you should realize that what you’re going to get isn’t going to provide you that much value in terms of coverage and benefits. Everything is a trade-off in life.

Dan W.
3 months ago
Reply to  PaulE

You’re right about tradeoffs. I said “No” to Medicare Advantage plans.

I pay a little more in total monthly premiums when I add in my Medicare Supp (Medigap) premium and separate dental and prescription drug premiums but don’t have to worry whether the best doctors available are in any given Medicare Advantage carrier’s network.

PaulE
3 months ago
Reply to  Dan W.

Agreed. What I found is most insurers think everyone is willing to trade off access to the broadest range of best doctors in the area and excellent drug treatment plans for so-called bargain basement or free rates. So that is what they pitch to 99 percent of the people and sadly a lot of folks jump at it. Only to be disappointed a short time later, when they need something their bargain basement plan doesn’t provide for. That of course is a fool’s choice, as you ultimately get what you pay for or more accurately what you don’t pay for.

The objective of health coverage is to get the best possible coverage all around that you can afford. After all, we’re not buying some widget, that you can just toss after a few months when it doesn’t work anymore. Most insures do have much better coverage plans, with access to much better doctors. They just cost more. So what. At the end of the day, you get what you pay for and your health is not something you should be nickel and diming.

Editor
Sabrinah Cave
3 months ago
Reply to  PaulE

That’s right Paul!

It is always important to compare your options before you enroll into a new plan. If you or someone you know needs assistance, feel free to give us a call at 855-611-4856 and one of our licensed advisors can help you compare plan options.

Last edited 3 months ago by Sabrinah Cave
Will
3 months ago

No doubt in my mind. When I first started getting medical care from the gov I chose a medadvantage plan. It wasn’t long before I found out I had made a big mistake. That was the last time I selected an Advantage plan.

Karla
3 months ago
Reply to  Will

Which do u recommend ! I’m in Indiana

Dan W.
3 months ago
Reply to  Karla

I can’t recommend the right plan for your situation but I have copied the phone number below from an earlier article posted last month by AMAC’s Medicare Advisor:

“If you or someone you know could benefit from our complimentary services, give us a call at 855-611-4856 and one of our licensed, knowledgeable advisors will be happy to help.”

Hopefully, AMAC can direct you to local resources that can help you select a plan.

I have two general comments that would apply to anyone looking for medical coverage.

One, select a well known carrier (examples: Aetna, Anthem Blue Cross/Blue Shield in Indiana, Cigna, United Healthcare) and,

Two, before you decide to select any plan with a network of providers, call each of your current hospitals and doctors and confirm that they are in the network for the plan that you are thinking about selecting.

Editor
Sabrinah Cave
3 months ago
Reply to  Dan W.

Thank you for your wonderful contributions to these discussions Dan!

Editor
Sabrinah Cave
3 months ago
Reply to  Karla

Hello Karla,

We can help you compare all options in your area and we can look up your doctors/hospitals for you. At AMAC, we strive to give you all the information you need to make an informed decision so you don’t have to do all the research alone.

Feel free to give us a call at 855-611-4856 and one of our advisors who is licensed in Indiana would be happy to assist you!

Editor
Sabrinah Cave
3 months ago
Reply to  Will

Hello Will,

Thank you for your comment. I always say insurance is like a pair of glasses, what works for you may not work for the next person, and vice versa. I hope you found an alternative that works for you since the Advantage plans did not.

We are always here to help if you need to compare plan options- you can reach us at 855-611-4856. Remember, our Medicare advisory services are complimentary to all!

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