MEDICARE ADVANTAGE IS NOT MEDICARE!

MEDICARE ADVANTAGE IS NOT MEDICARE!

By Margaret Brownlie DC

I have a lot of questions….I have Original Medicare. I pay for the premiums plus I  need a Medigap policy. It comes at a sizable cost.

I do not have Medicare Advantage…which is NOT Medicare but is private insurance.

Friends of mine who have “Medicare” Advantage (Not Medicare) pay no or very low premiums and sometimes no co -pays and often includes coverage for dental, hearing and vision. And no need for Medigap coverage (the 20 % Medicare does not pay).

Medicare Advantage plans have grown in popularity in recent years, with enrollment more than doubling nationwide since 2013…… some 31 million Americans (about 50-55% of eligible people)  have Medicare Advantage plans (introduced in 2003 by Congress to encourage greater efficiency in health care.) Sounds good, right?  So what am I missing here in being advised to use Original Medicare.

LACK OF QUALITY IMPROVEMENT PROMISES:

To learn more, I  began to dig around and found out some startling facts about the very low upfront costs of Medicare Advantage (which is private insurance) and their promise of more “efficient” care.

To my disappointment, the nonpartisan Medicare Payment Advisory Commission found it could NOT conclude Medicare Advantage plans “systematically provide better quality care.”….(the real reason MA plans were set up).

Furthermore, a federal audit from 2013 showed 8 out of the 10 largest plans had submitted inflated bills to Medicare. (I learned this is called “UPCODING).This often  means your billing charges with a diagnostic code  deemed technically more serious than the condition you actually are experiencing.  This affects the quality of your care. It also lines the pockets of the insurance companies income wise.

Another issue that can affect the quality of your care, you no longer can always keep  the physician of your choice if the Doctor is “out of Network”.

DENY DENY DENY

By law, Medicare Advantage plans are supposed to base their reimbursement on Medicare rules.  But there is room for “interpretation”, says the Dept of Health and Human Services.

*Hospital Officials such as Dr Craig Pendergast, (Ozarks Community Hospital in Arkansas)says “Any study we order.X ray, CT, MRI, stress tests…they’re going to deny.  With straight (Original) Medicare we just schedule it.”

*Dr Kenneth Williams of Alliance HealthCare has stated “They (Medicare Advantage plans)do not want to reimburse for anything…deny, deny, deny.  They are taking over Medicare and taking advantage of elderly patients.”

*Last year, the department’s Inspector General found that in June 2019, the 15 top Medicare Advantage plans denied authorization for 13 percent of claims that had met Medicare Rules.

The CEO of Ozarks Community Hospital (Arkansas), Paul Taylor, conducted a two year study of what his hospital received  monetarily treating traditional Medicare patients versus what it received from Medicare Advantage plans and he found that the Advantage plans paid his hospital $4.5 million less for the exact same treatments by denying care. ( NBC Television recently presented a segment on this very topic. See link below)

The Ripple Effect……Because the plans routinely deny coverage for necessary care, the existence of struggling  and especially rural hospitals nationwide is being severely threatened and many hospitals are  being forced to close. And many physicians are lost  along with this! By denying claims, Medicare Advantage plans hurt rural hospitals, say CEOs (nbcnews.com)

 DENIALS and RE-DETERMINING ELIGIBILITY for Medicare Advantage

Artificial Intelligence bots will now be incorporated in determining if you will be allowed to stay enrolled in your Advantage Plans as well.  1 out of every 5 contracted Advantage enrollees will possibly be  denied coverage based on the BOT algorithms. “

Denials by MA Plans for authorization occur because some plans have been hiring subcontractors and using  algorithms to deny care”, according to Fred Klonsky, a local activist for Medicare for All.   This will never be allowed to happen if you are already enrolled in Original Medicare.

Sounds like the good old days of pre existing condition issues to me. Remember Death Panels?

“ We have more chance of getting a gun than good health in America under this privatization project for seniors ”, states Fred  Klonsky.

PRE- AUTHORIZATION REQUIREMENT

“Pre-authorization is just one of the things wrong with the privatization of health care (via Advantage programs) in the United States–

..99% of Advantage plans require some form of pre-authorization”, writes Fred Klonsky on substack.com.

“ David Lipschutz, associate director of The Center for Medicare Advocacy, calls prior authorization “endemic”.”

.  Advantage plans cater to a healthy level of patient and when things go south, they have the right to deny care and even eliminate the enrollee.

BROKER COMMISSIONS: Brokers selling the  Advantage Plans make larger commissions from the government (between $611 and $762 for the first year of a contracted Medicare Advantage plan), with roughly half of that for each annual renewal. Brokers selling Original Medicare receive about $300 in one year.

Something seems very wrong here.

Wonder now why you get so many snail mail letters and emails and ads on TV and RADIO (looking at you Joe Namath!)  They have oodles of moola to seduce you into The Advantage (private insurance plans) which means more money to the Insurance Executives and their shareholders. Making money is perfectly fine but should it be at the expense of the patient who may or may not be receiving high quality and ethical care? Medicare Advantage is pilfering the National Treasury while Advantage Insurers are being heavily rewarded according to ProtectMedicare.net

Jason Lemon wrote “Medicare for All Would Save $450 Billion Annually While Preventing 68,000 Deaths” in Feb 18, 2020 Newsweek.

MISLABEL ON MEDICARE “ADVANTAGE” Legislation has been introduced to demand the word MEDICARE be removed from the sales pitches for these Advantage Plans. Marc Pocan (D-Cal) and Ro Khann (D-Cal) are two legislators insisting the name Medicare Advantage drop the name Medicare.  It should be called what it is “alternative private health plan…Seniors are being misled”  They would like to then use funds made available at that point to help Original Medicare provide hearing, dental and vision.  All possible if we get the financing of Medicare more fair and level the playing field. (Field Healthcare by Robert King, Oct 13, 2022.)

With huge profits for the Insurance Companies providing these ‘Advantage” plans with  a motive, can you see why Medicare itself could be obliterated if we continue at this pace and we can end up where we started?:

Insurance Companies calling the shots and destroying the Original Medicare we have come to depend upon and like.

Original Medicare could likely cover the costs of all premiums, eliminate a need for Medigap and still cover dental, hearing and vision if we demanded no more privatization of Medicare!  The Insurers last year demonstrated a profit of between 124-140 Billion dollars.  Think what Medicare could do with that money.

Economically, Advantage Plans can make sense. Long term, it is a problem for the survival of Original Medicare.  A conundrum….what do you think is the solution?

How about we do all we can to save Medicare? LINK: ProtectMedicare.ne

There is still time for anyone who enrolled in an advantage plan to change back to Medicare by March 31, 2024. After that, you can attempt to return to Medicare next year, but then some of your coverage options may be reduced.

Some related links to articles to learn more.

LINK: ProtectMedicare.net

#House letter on AI use in Medicare Advantage denials/AHA News  aha.org

#Medicare Advantage routinely denies reimbursements for necessary care, hospital execs say

(Nbcnewscom)

#Medicare For All Would Save $450 Billion Annually by Jaso Lemon  Newsweek 2/18/20

#FredKlonsky.substack   (Fred is a Chicago Progressive  activist,writer, a one time Union Leader and colorful figure who wants to save Medicare and prefers Medicare For All.

#AARP Bulletin October 2023   and Pages 4-18  The Future of Original Medicare

Fierce Healthcare  Robert King report  10/13/22

More LINKS not referred to in this article :

# PNHP (Physicians for National Healthe Program)

info@pnhp.org