Medicare Advantage Denying Claims to Save Money?

One of the most popular private insurance alternatives to traditional Medicare is Medicare Advantage. Covering more than 20 million people means 1/3rd of all Medicare beneficiaries are enrolled with Medicare Advantage. Unfortunately, recent reports say that it has been improperly denying many medical claims to both patients and physicians alike, denying claims in an attempt to increase their profits.

It is currently Medicare’s annual open enrollment period (Annual Election Period, or AEP), providing beneficiaries the opportunity to join Medicare Advantage plans, switch plans, or return to traditional Medicare, usually having access to 10+ private plans. But with recent findings regarding denials of care and payment in Medicare Advantage, consumers have a right to be concerned and hesitant to enroll.

Medicare Advantage has its appeals though, such as its including a doctor who can coordinate care, and an annual limit on out-of-pocket expenses. It is expected that Medicare Advantage plans will rise 22.6 million next year. The growth of Medicare Advantage is due in part to the policies set in Washington, including an increase in payments to private plans for 2019 and tax relief issued to health insurers, which allows them to reduce premiums and add the following benefits:

  • Transportation to the doctor’s office
  • Home delivery of hot meals
  • Safety features in the home like wheelchair ramps and bathroom grab bars.

So with all of these benefits coming down the pipeline, what is there to be concerned about with Medicare Advantage? Currently, patients of Medicare Advantage seem to be experiencing barriers to timely access to necessary care because of superfluous prior authorization requirements. Insurers defend the requirements saying that they “protect patients from unnecessary and inappropriate care” and help reduce costs. If treatments or payments are denied, very few people ever appeal the denial of claims, but of those that do, 75% of them are successful after their first level of review.

To shed more light on the topic, Medicare plans receive fixed monthly payments from the government, and in return, those plans are supposed to provide the full range of services needed by the patients. One way plans try to keep costs down is simply by keeping their patients healthy, reducing the need for hospitalization, keeping costs below what they are paid by Medicare.

Unfortunately, another way the plans can save money is by denying services. To put it in perspective, Medicare has imposed more than $10 million in fines against private plans for overcharging beneficiaries, denying coverage for prescription drugs, failing to respond to complains, etc. within the last two years. But this is nothing new; insurers have been accused of using similar strategies in the past, saving money when they don’t provide care.

Insurers say that 90% of people in Medicare Advantage are satisfied with their plans, but administration officials plan to step up the supervision of Medicare Advantage plans, providing beneficiaries with clear and easily accessible information about serious violations of Medicare requirements.

For questions or concerns regarding your plan in particular, contact SeniorQuote Insurance Services by calling 1-800-992-7724.

Originally Published in the New York Times, Oct. 14th, 2018
Original Author: Robert Pear
Original wording edited for reposting purposes.