Healthcare Issues

[O Really]

Another good reason not to fall for the "Medicare Advantage" schemes.

Private Medicare plans often deny care

Ken Alltucker

USA TODAY

A government watchdog report released Thursday found private Medicare plans routinely rejected claims that should have been paid and denied services that reviewers found to be medically necessary.

The report, completed by U.S. Department of Health and Human Services inspector general investigators, discovered private Medicare plans denied 18% of claims allowed under Medicare coverage rules. The denials often were a result of errors in processing claims, the report found.

The review also found private Medicare plans turned down 13% of authorizations for medical services that government- run Medicare would have allowed.

The inspector general reviewed hundreds of authorization and payment denials by 15 of the largest Medicare Advantage plans over one week in June 2019. Coding experts and physician reviewers examined the cases, and the agency estimated how often insurers denied requests that should have been covered.

The report cited two reasons private Medicare plans rejected authorizations that the watchdog agency’s physician reviewers found to be medically necessary. The private plans had coverage formulas beyond what Medicare required, such as first requiring an X-ray before allowing other scans such as an MRI. The plans also claimed the request lacked appropriate documents, but investigators said beneficiaries’ medical records were enough to support these requests.

The inspector general concluded the agency that oversees Medicare should tighten oversight, issue new guidance for clinical reviews employed by private Medicare plans, and order private plans to fix vulnerabilities that can lead to review errors.

These private Medicare plans cover more than 28 million older and disabled Americans and are an increasingly popular option, with total enrollment more than doubling over the past decade. By 2030, the Congressional Budget Office projects more than half of Medicare beneficiaries will be in a private Medicare plan.

Medicare Advantage plans tout perks such as limited out-of-pocket costs, vision and dental benefits not offered by traditional Medicare, and even gym memberships. But the plans employ private insurance industry tactics to reduce costs. These plans restrict networks of doctors other medical providers people can use, mandate authorization for some services and require referrals for specialists.

Rosemary Bartholomew, a Medicare Advantage expert who led the team that wrote the report, said beneficiaries may be denied care they need or might pay for services their plans should cover. Another worry is such routine claims and care denials could prompt doctors and patients to appeal the initial decisions, leading to extra work and an administrative burden.

Jack Hoadley, a Georgetown University McCourt School of Public Policy research professor emeritus, said the report suggests some private Medicare plans are aggressive at denying or delaying care.

“This is evidence that there needs to be increased scrutiny, more auditing and more oversight,” Hoadley said

[GoCubsGo]

Worst health care system in the western world.

[Whack9]

A friend just posted on social media that her hopsital bill is 77k. That's before surgery.

Best healthcare system in the world indeed.

[O Really]

A friend just posted on social media that her hopsital bill is 77k. That's before surgery.

Best healthcare system in the world indeed.

Sheeeet - was that her part of the charge or total? Did she have insurance at all?

Chart of ridiculous a "system" we have.
https://www.peoplekeep.com/blog/infogra ... -stay-cost

[Vrede too]

Another good reason not to fall for the "Medicare Advantage" schemes....

Couple of months I go on Medicare A & B, no Advantage. This break from private health insurance forever may be the most liberating moment I'll have for the rest of my life.

[O Really]

Another good reason not to fall for the "Medicare Advantage" schemes....

Couple of months I go on Medicare A & B, no Advantage. This break from private health insurance forever may be the most liberating moment I'll have for the rest of my life.

Maybe we're just lucky, but with several years of managing my folks' Medicare before they died, and several years after that of managing our own, we've had zero significant issues. And the minor issues we have had have been mostly created from the provider's office, not Medicare itself. Same with our supplement - United Healthcare (via AARP) - no issues.

But to be fair, insurance through our firm was also very good, including an Aetna plan, then a self-funded arrangement with Cigna administration. Probably makes a difference if the plan sponsor's primary goal is to be cheap.

[Ulysses]

Maybe we're just lucky, but with several years of managing my folks' Medicare before they died, and several years after that of managing our own, we've had zero significant issues. And the minor issues we have had have been mostly created from the provider's office, not Medicare itself. Same with our supplement - United Healthcare (via AARP) - no issues.

But to be fair, insurance through our firm was also very good, including an Aetna plan, then a self-funded arrangement with Cigna administration. Probably makes a difference if the plan sponsor's primary goal is to be cheap.

I've been on Kaiser Senior Advantage for about three years now. It seems to be OK, but then I was with Kaiser already from my last few jobs, going back at least 10 years.

My main gripe is that Medicare does not have decent dental coverage - it's minimal. Biden proposed addressing that, but I guess this was stymied by Congress.

[Whack9]

A friend just posted on social media that her hopsital bill is 77k. That's before surgery.

Best healthcare system in the world indeed.

Sheeeet - was that her part of the charge or total? Did she have insurance at all?

Chart of ridiculous a "system" we have.
https://www.peoplekeep.com/blog/infogra ... -stay-cost

I don't really know the deets. Surely she has insurance but maybe not. I'm guessing it'll get knocked down a bit even if no insurance.

I had a friend that for gallbladder surgery with no insurance and it was like 30k after everything was said and done.

[billy.pilgrim]

A friend just posted on social media that her hopsital bill is 77k. That's before surgery.

Best healthcare system in the world indeed.

Sheeeet - was that her part of the charge or total? Did she have insurance at all?

Chart of ridiculous a "system" we have.
https://www.peoplekeep.com/blog/infogra ... -stay-cost

I don't really know the deets. Surely she has insurance but maybe not. I'm guessing it'll get knocked down a bit even if no insurance.

I had a friend that for gallbladder surgery with no insurance and it was like 30k after everything was said and done.

Yeah, they'll take off a little here and there, but the hospital and the doctors will make way more than they do on insurance claims.

It's only some items that are insane crazy.
Check out your EOBs for things like blood tests and scans.
I have a blood test with a Charge Amount at close to $1,800, but bcbs and now Medicare won't allow for more than $100.
Scans are big too. Charges are $2,000 to $3,700. In the days before Medicare, bcbs would only pay for outpatient scan from a stand-alone place, they paid around $300. Medicare doesn't allow for much more than $600.

If prices were real, your friend paying cash should be a cheaper deal as it doesn't require all the insurance paperwork.

[neoplacebo]

Worst health care system in the western world.

But also the most profitable. That's where the problems are.

[O Really]

If prices were real, your friend paying cash should be a cheaper deal as it doesn't require all the insurance paperwork.

There is no "paper" in insurance paperwork anymore. It's all electronic, and it's easier to collect from an insurance carrier than an individual. What they do is inflate the charge so as to increase the write-off.

[neoplacebo]

Ah, a system of self defeating increasingly dysfunctional policies that have become self perpetuating. What a concept.

[Vrede too]

If prices were real, your friend paying cash should be a cheaper deal as it doesn't require all the insurance paperwork.

There is no "paper" in insurance paperwork anymore. It's all electronic, and it's easier to collect from an insurance carrier than an individual. What they do is inflate the charge so as to increase the write-off.

Are you sure? Providers have to navigate the different rules for scores of different insurers, and they still need to collect from individuals when the insurers deny claims.

[O Really]

Are you sure? Providers have to navigate the different rules for scores of different insurers, and they still need to collect from individuals when the insurers deny claims.

I can't speak for 100% of everybody, but most providers other than mom-pop practices either (a) have software to manage billing; or (2) use a third-party billing service. Either way, the system knows all the rules for all the insurance the provider accepts. So when you go into the office and give them your card, the system will know what is covered, what deductible if any you have, and what your co-pay is, if any. If they've checked the coverage properly and code the procedure properly, there should be very few claims denied. We had a run around a few years ago - Lady O, like many women of her age, takes Prolia to prevent osteoporosis. It's a shot taken twice a year. One year the insurance was balking and it took a few calls to fix it. But the problem was that the provider had coded it as an "infusion" not an "injection," which would have been an entirely other procedure.

Also, the same software/processor sends out invoices for remainder, if any. The providers' offices have to do very little except enter data correctly.

[Ulysses]

If prices were real, your friend paying cash should be a cheaper deal as it doesn't require all the insurance paperwork.

There is no "paper" in insurance paperwork anymore. It's all electronic, and it's easier to collect from an insurance carrier than an individual. What they do is inflate the charge so as to increase the write-off.

Are you sure? Providers have to navigate the different rules for scores of different insurers, and they still need to collect from individuals when the insurers deny claims.

This is why an HMO like Kaiser might have an edge. AFAIK, all the coverage comes through a Kaiser plan. Although there may be different types of Kaiser plans, such as Medicare Advantage vs. standard Kaiser HMO, as well as different arrangements with different employers (IDK), it's all within Kaiser and that probably cuts down on the nonsense, paperwork.

AFAIK, Kaiser got its big start in WWII caring for workers at the West Coast shipyards. However it also came into being years earlier at the height of the Great Depression caring for workers building the Colorado Aqueduct, and later the Grand Coulée Dam. I remember when we moved to San Francisco back in the early 60's, my mom, who had worked in DC during WWII for the gubmint, was all enthused about finally being able to join the Kaiser plan.

[Vrede too]

Are you sure? Providers have to navigate the different rules for scores of different insurers, and they still need to collect from individuals when the insurers deny claims.

I can't speak for 100% of everybody, but most providers other than mom-pop practices either (a) have software to manage billing; or (2) use a third-party billing service. Either way, the system knows all the rules for all the insurance the provider accepts. So when you go into the office and give them your card, the system will know what is covered, what deductible if any you have, and what your co-pay is, if any. If they've checked the coverage properly and code the procedure properly, there should be very few claims denied. We had a run around a few years ago - Lady O, like many women of her age, takes Prolia to prevent osteoporosis. It's a shot taken twice a year. One year the insurance was balking and it took a few calls to fix it. But the problem was that the provider had coded it as an "infusion" not an "injection," which would have been an entirely other procedure.

Also, the same software/processor sends out invoices for remainder, if any. The providers' offices have to do very little except enter data correctly.

I just had a non-generic med denied by my insurer. We're considering alternatives but at "hundreds of dollars per month" I'm going without for now.

All that software and those contractors/in house managers cost $$$ and there are constant updates to deal with, and coding the procedure properly for each insurer adds complexities for the provider.

I know that collections from individuals can be problematic, but the billing is simpler for them and Medicare/Medicaid than it is with private insurers.

[Ulysses]

Are you sure? Providers have to navigate the different rules for scores of different insurers, and they still need to collect from individuals when the insurers deny claims.

I can't speak for 100% of everybody, but most providers other than mom-pop practices either (a) have software to manage billing; or (2) use a third-party billing service. Either way, the system knows all the rules for all the insurance the provider accepts. So when you go into the office and give them your card, the system will know what is covered, what deductible if any you have, and what your co-pay is, if any. If they've checked the coverage properly and code the procedure properly, there should be very few claims denied. We had a run around a few years ago - Lady O, like many women of her age, takes Prolia to prevent osteoporosis. It's a shot taken twice a year. One year the insurance was balking and it took a few calls to fix it. But the problem was that the provider had coded it as an "infusion" not an "injection," which would have been an entirely other procedure.

Also, the same software/processor sends out invoices for remainder, if any. The providers' offices have to do very little except enter data correctly.

I just had a non-generic med denied by my insurer. We're considering alternatives but at "hundreds of dollars per month" I'm going without for now.

All that software and those contractors/in house managers cost $$$ and there are constant updates to deal with, and coding the procedure properly for each insurer adds complexities for the provider.

I know that collections from individuals can be problematic, but the billing is simpler for them and Medicare/Medicaid than it is with private insurers.

Chlorpromazine
Generic name: chlorpromazine (oral/injection) [ klor-PROE-ma-zeen ]
Brand names: Ormazine, Thorazine, Thorazine Spansule
Dosage forms: injectable solution (25 mg/mL); oral tablet (10 mg; 100 mg; 200 mg; 25 mg; 50 mg)

Chlorpromazine

[neoplacebo]

I wrote a book about somebody that had to go to the hospital and by fortuitous error was given a massive infusion of cash. Two people got fired over it. The name of the book is "I Got Bashed But Came Away With Cash" and it's been inspirational for thousands and actually curative for several.

[Ulysses]

I wrote a book about somebody that had to go to the hospital and by fortuitous error was given a massive infusion of cash. Two people got fired over it. The name of the book is "I Got Bashed But Came Away With Cash" and it's been inspirational for thousands and actually curative for several.

I tried Googling that book title, but nothing matching it came up.

Was it in English?

[O Really]

I just had a non-generic med denied by my insurer. We're considering alternatives but at "hundreds of dollars per month" I'm going without for now.

All that software and those contractors/in house managers cost $$$ and there are constant updates to deal with, and coding the procedure properly for each insurer adds complexities for the provider.

I know that collections from individuals can be problematic, but the billing is simpler for them and Medicare/Medicaid than it is with private insurers.

I don't know about your insurance, but usually they deny a brand name only in instances where either it's not medically necessary, isn't approved for the stated use, or there isn't an alternative or generic available. With Lady O's Prolia, for example, it comes with a steep co-pay even though there's no generic because there are other osteoporosis-prevention medications available.

I still disagree about how onerous billing systems are. The variation in insurance plans isn't infinite. Employers will typically have no more than 3-4 variations; private plans maybe 5-6. All the parameters are pre-loaded into the system and once the patient's plan number is entered, the system knows the rules. About as complex as a good payroll system.