EDITORIAL: Medicare (Dis)Advantage Plans

The following editorial was submitted by WJ Mangold Memorial Hospital

LOCKNEY – It is that time of year again for seniors 65 years old or older to decide if they want to enroll in Original Medicare or select a Medicare Advantage Plan such as Amerivantage, Humana Gold or United Health Care’s AARP Choice Plan. A Medicare Advantage Plan is Part C Medicare and is a replacement for Original Medicare not a supplement. There has been much information in the past 6 months regarding the Medicare Advantage Plans which are troubling and concerning. Last April the Office of Inspector General (OIG) published a report on a study that was conducted in June 2019 which raised concerns about Medicare Advantage Plans delaying or denying access to services even though requests met Medicare coverage rules.

OIG analyzed a random sample of 250 prior authorization denials and 250 payment denials issued by 15 of the largest Medicare Advantage insurers between June 1 and June 7, 2019. From that sample, the analysts extrapolated likely denial rates that fit within Medicare’s requirements. OIG found that 87% of prior authorization denials fit within Medicare coverage requirements, as did 82% of denied payment requests. These claims would not have been an issue if the patient would have been enrolled in Original Medicare.

In addition to those disturbing results, we have observed negative impacts on patient care caused by Medicare Advantage Plans to Floyd County residents. One patient had to pay out-of-pocket for lab services received when being treated by a Lockney doctor because the Medicare Advantage Plan wanted him to go to a reference lab in Lubbock. WJ Mangold Memorial Hospital has a contract with that Medicare Advantage Plan and the patient’s lab services should have been paid under that contract. Other recent examples include denials for inpatient hospitalization where outpatient treatment was not effective and the patient needed more active care.

Our experience has been that patients who choose a Medicare Advantage Plan may have care denied or delayed and these patients experience larger out of pocket costs for their care. In addition, many specialists are not in network with Medicare Advantage Plans so access to care is limited. WJ Mangold Memorial Hospital has contracted with a company to analyze underpaid claims by Medicare Advantage insurers. They have found over 55 claims worth over $250,000 that were underpaid which creates a financial stress on the hospital.

Seniors paid into Medicare all of their lives so they could have access to healthcare benefits as they get older. Services offered through Original Medicare require fewer pre-approvals and result in fewer restrictions than Medicare Advantage Plans. While Medicare Advantage Plans may offer certain perks not available through Original Medicare, they also funnel significant profits back to private insurance companies that operate these plans. Medicare Advantage Plans have an incentive to not spend money on your healthcare because they keep the extra dollars paid to them by the Federal Government.

Despite efforts by insurance companies to sell Medicare Advantage plans, WJ Mangold Memorial Hospital and the Cogdell Clinics favor Original Medicare. If you can afford it, a supplement and Original Medicare is the best coverage possible. You cannot buy a supplement to cover the out-of-pocket costs with a Medicare Advantage Plan. Don’t be swayed by all of the advertising, phone calls and salesmen insurance companies use to try and convince you to select a Medicare Advantage Plan (Part C). Know the truth is that Original Medicare is the preferred choice and recommend by your local hospital and doctors.

To review a helpful video and to learn more about the healthcare choices for those 65 years old and older, go to www.choosingmedicare.org. If you have any questions, please contact Saundra at 652-3373, ext. 300 or talk to your physician.