Never enroll in a Medicare Advantage Plan

Unless you live in a state that requires insurance companies to sell you a Medicare Supplement plan, NEVER enroll in a Medicare Advantage plan, no matter how enticing it seems.  People who live in Connecticut, Maine, Massachusetts or New York are not locked into Medicare Advantage plans if they make the switch.  HOWEVER, if they have a health crisis, they will not be able to easily switch to traditional Medicare until certain times of the year. 

Medicare Advantage is so bad that Scripps, a huge provider practice in San Diego, has stop accepting the plans:

https://thecoastnews.com/two-major-scripps-groups-drop-medicare-advantage/

Rural medical areas around the country are being decimated by how bad it is to deal with Medicare Advantage plans:

https://www.nbcnews.com/health/rejecting-claims-medicare-advantage-rural-hospitals-rcna121012

I don't post much anymore because there is nothing else I can say besides kick IBM to the curb and don't use their plan! Don't use any Medicare Advantage plans.  During Fall Open Enrollment, if you can, go back to using traditional Medicare and a medigap.  Your window to "go back" no matter where you live, is closing.  You can switch back to what you had until December 31, 2023 because you had a 12 month "Special Enrollment" such that the federal government allows you to go back.  After December, it is unlikely you can switch to traditional Medicare unless you live in the four states named above.  

IBM Medicare Advantage NYT report March 23, 2023 re federal government efforts to stop MA fraud

 The NY Times published another report about Medicare Advantage antics on March 23rd.  The federal government is trying to reduce the ways MA plans suck money out of the Medicare trust funds and the backlash, not only from the insurance industry but from some medical providers, is despicable. It seems more than just the insurance industry enjoys sucking taxpayer money into their cash registers. 

The insurance industry is fighting hard by not only lobbying but by running ads telling seniors to complain to their representatives that the government is trying to take away their Medicare Advantage plans.  The lengths to which companies go to make money by deceiving the public is mind numbing.  This is the article, but I am not sure if it will be available to non-subscribers:  

https://www.nytimes.com/2023/03/22/health/medicare-insurance-fraud.html

              This letter to the editor is from a retired doctor who applauds the federal actions:

Re “Biden’s Plan to Cut Billions in Medicare Fraud Ignites a Lobbying Frenzy” (news article, March 23):

As a physician for 50 years, now retired, I applaud this article. It shines a bright light on the abuses by Medicare Advantage plans.

These plans, profit-making corporate entities, are focusing on their bottom line. The way to increase profits for a health insurance company is to collect premiums while delivering as little care as possible. These reverse incentives do not occur with original public Medicare.

When I was in private practice I saw how these Medicare “DisAdvantage” plans attracted patients with deceptive advertising but ended up hurting them, delaying or denying care by requiring prior authorization for expensive drugs or procedures.

We should get rid of Medicare Advantage plans. They add cost but no value to the system of health care for seniors. Unfortunately, lobbying money talks, and these very profitable corporate entities have deep pockets, which permit these abuses to continue. This is shameful.

In New York State, passing the New York Health Act would eliminate this expensive middleman and bring affordable health care to all New Yorkers.

Elizabeth R. Rosenthal
Larchmont, N.Y.

IBM Medicare Advantage AI algorithms decide when to deny medical care

The following article, published on March 13,2023, describes how the insurance industry is using Artificial Intelligence algorithms to determine when treatment is no longer medically necessary.  It is truly a horror story.    Is it geriatric genocide?

https://www.statnews.com/2023/03/13/medicare-advantage-plans-denial-artificial-intelligence/

The full article is behind a paywall so if you don't subscribe, here's a summary: 

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Denied by AI: How Medicare Advantage plans use algorithms to cut off care for seniors in need.   March 13, 2023.  

From STAT, the health industry news site produced by Boston Globe Media.

 

Health insurance companies have rejected medical claims for as long as they’ve been around.

But a STAT investigation found artificial intelligence is now driving their denials to new heights in Medicare Advantage, the taxpayer-funded alternative to traditional Medicare that covers more than 31 million people.

Behind the scenes, insurers are using unregulated predictive algorithms, under the guise of scientific rigor, to pinpoint the precise moment when they can plausibly cut off payment for an older patient’s treatment. The denials that follow are setting off heated disputes between doctors and insurers, often delaying treatment of seriously ill patients who are neither aware of the algorithms, nor able to question their calculations.

Older people who spent their lives paying into Medicare, and are now facing amputation, fast-spreading cancers, and other devastating diagnoses, are left to either pay for their care themselves or get by without it. If they disagree, they can file an appeal, and spend months trying to recover their costs, even if they don’t recover from their illnesses.

“We take patients who are going to die of their diseases within a three-month period of time, and we force them into a denial and appeals process that lasts up to 2.5 years,” Chris Comfort, chief operating officer of Calvary Hospital, a palliative and hospice facility in the Bronx, N.Y., said of Medicare Advantage. “So what happens is the appeal outlasts the beneficiary.”

The algorithms sit at the beginning of the process, promising to deliver personalized care and better outcomes. But patient advocates said in many cases they do the exact opposite — spitting out recommendations that fail to adjust for a patient’s individual circumstances and conflict with basic rules on what Medicare plans must cover.

“While the firms say [the algorithm] is suggestive, it ends up being a hard-and-fast rule that the plan or the care management firms really try to follow,” said David Lipschutz, associate director of the Center for Medicare Advocacy, a nonprofit group that has reviewed such denials for more than two years in its work with Medicare patients. “There’s no deviation from it, no accounting for changes in condition, no accounting for situations in which a person could use more care.”

Medicare Advantage has become highly profitable for insurers as more patients over 65 and people with disabilities flock to plans that offer lower premiums and prescription drug coverage, but give insurers more latitude to deny and restrict services.

Elevance, Cigna, and CVS Health, which owns insurance giant Aetna, have all purchased these capabilities in recent years. One of the biggest and most controversial companies behind these models, NaviHealth, is now owned by UnitedHealth Group.

In comments to federal regulators and interviews with STAT, many providers described rigid criteria applied by NaviHealth, which exercises prior authorization on behalf of the nation’s largest Medicare Advantage insurers, including its sister company UnitedHealthcare as well as Humana and several Blue Cross Blue Shield plans.

“NaviHealth will not approve [skilled nursing] if you ambulate at least 50 feet. Nevermind that you may live alon(e) or have poor balance,” wrote Christina Zitting, a case management director for a community hospital in San Angelo, Texas. 

 

She added: “MA plans are a disgrace to the Medicare program, and I encourage anyone signing up..to avoid these plans because they do NOT have the patients best interest in mind. They are here to make a profit. Period.”

“I’ve still got friends who say, ‘Oh, I’ve got UnitedHealthcare Advantage, and it’s wonderful.’”

“Well, it is,” she said. “Until you need the big stuff.’”

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This is a 3/15/23 "Here & Now" broadcast from WBUR (NPR) interviewing one of the authors of the article (Bob Herman):

https://www.wbur.org/hereandnow/2023/03/15/ai-algorithms-medicare-advantage

Centers for Medicare Advocacy is a stellar non-profit and reported on this issue in April 2022.  It has taken media organizations over a year to do investigative reporting.  Meanwhile, NOTHING changed.  Medicare eligible people are still being sold Medicare Advantage plans as a godsend, while the sellers force the sick ones out of rehabilitation without impunity:

https://medicareadvocacy.org/ai-plus-ma-equals-bad-care-decisions/

"Skilled Nursing News" also discusses the issue in their publication:

https://skillednursingnews.com/2023/03/ai-use-by-medicare-advantage-blamed-for-increased-denial-of-nursing-home-services/

Updated 3/17/23:

This Vox report in the following link is an easy to understand, concise analysis of Medicare Advantage plans.  It includes a reference to the use of AI.  The only aspect missing, is an analysis of the deceptive ways Medicare Advantage insurance agents lure seniors into the plans, much of which is illegal.  Seniors don't have the wherewithal to know what's happening.  In fact, many seniors rely on their insurance agents the way they rely on their doctors.  They believe the agents are working for their best interests. Often, if/when they discover the truth, it's because they are in failing health.

https://www.vox.com/policy/2023/3/17/23639685/insurance-health-care-medicare-advantage-enrollment-growth

IBM Medicare Advantage NYT report March 10, 2023

 Once again, there is a report about employers shifting retirees to Medicare Advantage plans.  The New York Times published this online yesterday and specifically talks about IBM in the article:

https://www.nytimes.com/2023/03/10/business/medicare-advantage-retirement-nyc.html

You need to be a subscriber to read the full article.  It will be in tomorrow's print edition.   There wasn't anything "new" in the article.  Just another acknowledgement that this is happening. 

It is particularly disheartening to read how NYC retirees appear to be the next group of retirees affected by this scheme even though they have what seemed to be an ironclad union contract.  It is also disheartening that, once again, the reporter writes how retiree health insurance benefits are provided because of the good graces of employers.  NO media outlet will acknowledge these benefits were consistently considered as a form of compensation.  

I particularly remember when the unions were negotiating with NYC for salary increases in the 1970's when the city was almost bankrupt but the strike was settled when the city counteroffered with enhanced retiree benefits. I particularly remember it because, at the time, reporters wrote about how the city and the union were "kicking the can down the road" by freezing salary increases but promising retiree benefit enhancements and how the cost of these benefits would overwhelm future administrations.  Neither the union nor NYC acknowledge that history, and now they scream about the cost of retiree benefits being out-of-hand. 

In IBM's case, when IBM promised retiree benefits, for a long time the executive team actually set aside funding for those benefits.  However, as the benefits trust value increased, and the executive team changed players, the demand for ever higher executive compensation needed to be satisfied. Those trust funds were "raided" to satisfy the demand.  It's in "Retirement Heist", by Ellen Schultz.  I referenced that book in an earlier post.

Meanwhile, the travesty of Medicare Advantage depleting Medicare trust funds by pushing more and more seniors into the plans while continuing to maliciously deny policyholders adequate healthcare continues.  The current administration is trying to rein in some of the Medicare trust fund abuse by Medicare Advantage plans (this is described in the NYT article) but it is modest.  Even so, the political opposition scream it is an attack on Medicare.  If they had Pinocchio noses, this lie would give them ten foot long noses. 

Centers for Medicare and Medicaid Services also claim they are putting pressure on MA plans to tap down the denials, but, if anything, it is getting worse. CMS rarely puts pressure on MA insurance providers, no matter who is in the White House. Maybe it's because most CMS leaders end up working for the insurance industry when they leave public service?  Why is that even legal?

Yesterday I counseled someone whose parent was another victim of an MA denial of coverage.  As usual, the MA plan denied additional inpatient treatment at a Skilled Nursing Facility and forced the facility to discharge the patient.  They never advised there could be a second opinion provided by the parent's doctor as part of appealing the discharge. Why would the MA plan do that?  The patient was sucking too much money out of their claim payment bucket so they had to be discharged.  So, the person tried to find "another place" for the parent to go, because going home was not an option given the condition of the parent. And that, my friends, is why Medicare Advantage plans are horrible.

IBM Medicare Advantage enrollment funding problems

 I don't know the details of the situation, because I did not enroll in the UHC Medicare Advantage plan.  I just read a news article about it and it sounds miserable.  

If you are affected, I recommend you complain to Medicare about UHC not being "ready" to handle new enrollees for the IBM Corporate plan.  It appears UHC is blaming IBM.  That's no excuse.  UHC needed to be absolutely sure everything was setup properly before "going live".  Medicare is at  1-800-633-4227.  File a complaint and ask for a tracking number so that you can check on the status.

IBM Medicare Advantage Appeals Process for Claim and Pre-Authorization Denials

 If you decided to enroll in the IBM UHC Medicare there is a much higher probability (than in Original Medicare) that your plan will deny coverage for pre-approvals or for treatment you received.  I've written extensively about why it is done.  In this post, I will describe what to do when it happens.  

There are lots of reasons why MA plans deny claims for treatment such as being medically unnecessary, requiring a referral from your primary care doctor or requiring pre-approval for the procedure.  In most situations, you will be able to reverse the denial so that the MA plan will have to allow the treatment or pay the claim.  The claims that have the lowest chance of being reversed are denial claims related to procedures Original Medicare does not cover such as dental or vision treatments.  An MA plan cannot hold you accountable for not having a pre-approval or a pre-authorization if the doctor treated you.  It is up to the doctor to know to not treat you. 

The most important sentence to remember in this post:  

A PHONE CALL TO THE PLAN IS NOT A FORMAL MEDICARE APPEAL.  

The only way it is a FORMAL MEDICARE APPEAL is if it is done it in writing and sent to the request for reconsideration address provided by your plan in their denial letter (it is an "Explanation of Benefits" or "EOB" letter).  

The claim denial appeals process is defined by the federal government, not by your plan.  There are also levels of appeal which allow you to appeal to different levels of authority.  You cannot go to the next level of appeal unless the lower level denied the claim:

1. Appeal level 1 is a review done by the Medicare Advantage plan.  If they deny a second time then
2. Appeal level 2 is a review done by an independent review board (they are called "Maximus").  This is an independent group who work for the federal government Medicare agency. If they deny and the cost of the claim is at least $180 then
3. Appeal level 3 is done by an administrative law judge (ALJ) and is a phone call between you and the assigned litigator. You do not need to have a lawyer to request this appeal.  Medicare now refers to this level as the "OMHA" level of appeal (Office of Medicare Hearings and Appeals) but you will see documentation that uses "ALJ".  If the ALJ rules in your favor, you still might have to go to your state attorney general to get the MA plan to pay the claim.  If the ALJ denies and the claim is at least $1,850 then
4. Appeal level 4 is to the Federal District Court.  It is recommended you get a lawyer for this level.

The MA plan will throw some gibberish into a claim denial letter about having "60 days" to do a appeal.  The truth is, if you have a good reason why it took longer to appeal (like you were in the hospital) and you explain it in writing in your request for appeal, you can do the appeal.  

Appeals are not all that easy to do and you will need supporting information from your provider, but don't be intimidated by it!  MA plans expect you to be intimidated.  Disappoint them!

If you need help to do this, every state has an agency know as the State Health Insurance Assistance Program (SHIP).  Call and ask for help.  You can find your agency at this website:

https://www.shiphelp.org/local-medicare-help?utm_source=google&utm_medium=cpc&utm_campaign=220228-Search&gclid=Cj0KCQiAzeSdBhC4ARIsACj36uGCGk_z2oOk48Y5LOUFEibAVGzDIlfGWIZjjxzDcVR5479jMnRrpvQaAlyeEALw_wcB

Updated 1/9/2023:

Medicare Advantage will deny:

https://www.statnews.com/2022/11/15/replace-medicare-advantage-failure-with-medicare-part-f/

https://www.medpagetoday.com/special-reports/features/102966

Updated 2/27/2023:

Congress is proposing rule changes to try to rein in the antics of Medicare Advantage plans.  If nothing else (and it is highly likely nothing happens), this is a good summary of the problems with Medicare Advantage plans:

https://jayapal.house.gov/2023/02/16/jayapal-delauro-schakowsky-lead-effort-to-reform-medicare-advantage/

Updated 3/6/2023:

More about how MA plans deny.  This is about hospital inpatient stays not being "medically necessary".  Maybe it isn't if the patient is young, but the older you are, the more likely something "goes wrong".  Doctors, rightly, want to be sure it doesn't.  MA plan make money so they deny:

https://www.marketwatch.com/press-release/medicare-advantage-plans-deny-more-inpatient-level-of-care-claims-than-all-other-payor-types-2023-02-15

Updated 3/23/23

This is about the complexity of dealing with and health impact of prior authorization denials:

https://wusfnews.wusf.usf.edu/health-news-florida/2023-03-18/feds-move-to-rein-in-prior-authorization-a-system-that-harms-and-frustrates-patients