Medicare Advantage Plans

[Vil_Riker]

Not even close to 25% denial how about 6%
Denial rates have nothing to do with costs of employer based plans, how can it if a procedure is denied. The same denials go out on employer plans too.

Not that it matters but only 11% of medicare denials were appealed of that 80% were over turned. How much more effective and efficient can that be. Would make one wonder being only 11% are appealed what medical groups were looking to overfill and Advantage plans put a stop to it.

From the link below "Of the 35.2 million prior authorization determinations, 33.2 million were fully favorable, meaning the requested item or service was covered in full. The remaining 2.0 million requests (6% of the total) were denied in full or in part in 2021."

https://www.kff.org/medicare/issue-...ubmitted-to-medicare-advantage-plans-in-2021/

Hey guess what, I got a denial once, I didnt realize I went out of network for my free contact lens (up to $200 at the time) on my Advantage C plan. I appealed, the process so stupid simple and not only got reimbursed but I was only covered for $200 at the time for contacts and they sent me a check for the full $300. I actually called them up (I guess no one does) the guy didnt know what to do when I told them they gave me an extra $100, he had me hold for quite some time and got back to me and said just go ahead and cash the check. *LOL* I love my advantage plan. I have NEVER run into a communication issue or felt I was being cheated.

The denial rates are north of 25% on average. This has been the case since the unmentionable pandemic - the last year and a half. And that's the reason why some health systems are getting out of the MA contracts.

I think you have a fundamental misconception of how healthcare works.

Traditionally, you have different types of payers - Medicare, Medicaid, Commercial payers and the uninsured. The hospital loses money on all types except commercial/employer plans and makes up the losses by charging high prices. The price has no relation on how much they get paid except for the commercial plans where it's a percentage of charges. For the other payers it's a fee schedule (or very little from the uninsured patients). Here is how the denials affect the charges, and costs to the employer plans.

You do two lab procedures at a cost of $300 each. One is for Medicaid and another one is employer plan. Medicaid pays you $15 so you are making a $285 loss on that patient. The employer pays you 50% of the charges. So your price has to be $600 to break even. However, for the two procedures your cost is $585 so your price has to be $1,170 to break even.

Let's say Medicaid denies and doesn't pay the $15. Now your price has to be $1,200 to break even, when you get paid by the employer based plan.

This is a very simple example, the real life is far more complicated.

 

[alarmguy]

I had the Part F SAupplemental for 20+ years. Finally dropped it. Get someone who specializes in Advantage plans. Premiums are now $9,600 per year. HighMark Advantage "Select" plan is $0 per year.

I can use my own Dr (zero copay), Specialist (zero copay). Emergency Room ($50).
Its a no brainer. Go with an Advantage Plan.

Insiders know.
The public not so much.
I always hope all the $$$$ spent on advantage advertizing (JJ, Broadway Joe, etc) instead of healthcare wouldn't work.

I’m not sure if you’re even sure of your posts but once you’re using healthcare insurance companies, you will understand.
Your posts are making no sense advantage plans just like your company health insurance have networks. Nobody’s denied medical coverage I mean I’m just answering you respectfully, but obviously there’s no sense having a conversation.
If you want to pay $6000 a year for insurance so be it but don’t tell other people it’s wrong because they only want to pay 2000

 

[alarmguy]

The denial rates are north of 25% on average. This has been the case since the unmentionable pandemic - the last year and a half. And that's the reason why some health systems are getting out of the MA contracts.

I think you have a fundamental misconception of how healthcare works.

Traditionally, you have different types of payers - Medicare, Medicaid, Commercial payers and the uninsured. The hospital loses money on all types except commercial/employer plans and makes up the losses by charging high prices. The price has no relation on how much they get paid except for the commercial plans where it's a percentage of charges. For the other payers it's a fee schedule (or very little from the uninsured patients). Here is how the denials affect the charges, and costs to the employer plans.

You do two lab procedures at a cost of $300 each. One is for Medicaid and another one is employer plan. Medicaid pays you $15 so you are making a $285 loss on that patient. The employer pays you 50% of the charges. So your price has to be $600 to break even. However, for the two procedures your cost is $585 so your price has to be $1,170 to break even.

Let's say Medicaid denies and doesn't pay the $15. Now your price has to be $1,200 to break even, when you get paid by the employer based plan.

This is a very simple example, the real life is far more complicated.

This is simply not true you people all need to read up on how the system works. Everything covered on Medicare is covered under an advantage plan and much more vastly lower prices
Your conception of how medical insurance works. I can’t get a discussion in a forum.

Let’s put it this way, a retired person has Medicare. You can choose the government version or the private version.
Simple stuff really simple
Both systems ensure you for exactly the same procedures bar none
Let me repeat that both systems ensure you for exactly the same procedures bar none
The only possible, let me repeat that the only possible exception can for experimental treatments

The medicare system is far better than your corporate health insurance

You’re not responsible for anything other than your contracted copayment.
For goodness sakes, you don’t even have a deductible

Your denial rates are completely wrong and let me repeat this one more time, every medical procedure known to American citizens that is covered by Medicare has to be covered by Medicare advantage plans

But go ahead and pay 20% for all your medical costs and go with just government insurance with no out-of-pocket limits
Need a $500,000 procedure go ahead and pay 20% = 100,000.00
I’ll be glad with my advantage plan to pay 4500 of the 500,000

 

[alarmguy]

I had the Part F SAupplemental for 20+ years. Finally dropped it. Get someone who specializes in Advantage plans. Premiums are now $9,600 per year. HighMark Advantage "Select" plan is $0 per year.

I can use my own Dr (zero copay), Specialist (zero copay). Emergency Room ($50).
Its a no brainer. Go with an Advantage Plan.

Thank you for your input Al
I feel like I’m talking to a wall here LOL
It’s all good they just don’t have any conception as to how it works which drives me crazy is they’re not even in the system and they’re in here commenting with inaccurate statements
This country is doomed as critical thinking, goes out the window

It’s the simplest of all concepts, no matter what you do with Medicare Advantage Plans you have full coverage of all accepted medical procedures in the United States of America which of the same procedures covered by government Medicare and with government Medicare, you responsible for 20% of all your costs

That’s another thing in here don’t realize in order not to be responsible for 20% of all your cost. You have to buy private insurance from the same companies that offer Medicare advantage plans, which you know and you were in.

How some people don’t get that I don’t know.

 

[Al]

Thank you for your input Al
I feel like I’m talking to a wall here LOL

Yea. We all like to argue our points. And we all have built in "I know I'm right"
But we can hope that others see through these built-in deflections. Like I said after 20+ years of spending $150,000 (at least) for supplemental Insurance- instead of Advantage. I learned the hard way. Take care my friend!

 

[RAVL]

I recently read an article about Medicare Advantage plans. Some interesting points. They are ripping off Medicare by billions.

They try and get doctors to code as many diagnostic codes so they get more in the flat fee they get from Medicare.

Recruit healthy people They get $10K to $12K in a flat fee person from Medicare. And some they never pay a dime in claims

If you need rehab they try and push you to Medicare.

I get a yearly home visit from a nurse practitioner as part of the Medicare Advantage plan. I thought it was odd as I see my primary doctor 2X a year. So the goal here is to see if they can find additional diagnostic codes to fill in for you. The sicker they can make you appear on paper the more money in the yearly flat fee they will collect from Medicare. They just want you sicker on paper. Not in reality.

This was the article in the WSJ correct? Well done and thoroughly researched. Shocking too but not surprising.

 

[Donald]

This was the article in the WSJ correct? Well done and thoroughly researched. Shocking too but not surprising.

I think so. The WSJ is one of the papers I read.

 

[wavinwayne]

Every time I read one of these threads I get a mini panic attack thinking of the day I have to be on Medicare, or an Advantage plan, or Medi-Gap, or this plan or that plan.... It all seems endlessly complicated and I'm sure there are elderly people who die before their time just because of the stress of dealing with this crap!

 

[Donald]

It certainly could be easier to navigate. Medicare Advantage plans were susposed to be an incentive for insurance companies to develop better alternatives than plain Medicare. Looks like it ended up as a way insurance companies could rip off Medicare by telling Medicare that participants were sicker than they actually were.

 

[CKN]

Every time I read one of these threads I get a mini panic attack thinking of the day I have to be on Medicare, or an Advantage plan, or Medi-Gap, or this plan or that plan.... It all seems endlessly complicated and I'm sure there are elderly people who die before their time just because of the stress of dealing with this crap!

Get a good agent. It's their job to figure it out based on your needs. My guy (agent) has been doing it for twenty years. The dudes got all the answers.

I pay him a personal visit every year for 30 minutes-only because I like him. Could be handled with a phone call or Zoom.

 

[wavinwayne]

Get a good agent. It's their job to figure it out based on your needs. My guy (agent) has been doing it for twenty years. The dudes got all the answers.

I pay him a personal visit every year for 30 minutes-only because I like him. Could be handled with a phone call or Zoom.

How does one go about finding such an agent? I would assume it's someone different than my home and auto insurance guy.

 

[CKN]

How does one go about finding such an agent? I would assume it's someone different than my home and auto insurance gu

Ask someone who has an Advantage Plan. Also Google/Yelp. However-make sure it's someone who specializes in those plans. Not someone selling all other types of insurance (home, auto, etc).

 

[Pablo]

The interesting question that the article answered is why they send out a nurse practitioner on a yearly basis to do a health assessment. The person while knowledgeable has no lab or tests results. Just reviews medications, take BP and weight. No relationship with me from past visits. I see a primary 2x a year, dermatologist and cardiologist once a year. They all can see the lab test results and primary can see notes from specialists.

Seems a duplication except if they are trying to gather more diagnostic codes to bilk Medicare for a larger flat fee.

Not sure what you are talking about or even if you know what you are talking about.

Is this what YOUR insurance does? Because my advantage plan doesn't do that.

I'm on my second year of Medicare with Advantage Plan. Not one problem. Even pays my gym membership.

Do some insurance companies cheat? Do some health care providers cheat? Does the government cheat?

They are run by humans so the answer is easy. Why the shock? Why the need to start another Medicare thread???

 

[CKN]

Some are so dead set against Medicare Advantage Plans they spew nonsense against them.

 

[Pablo]

Some are so dead set against Medicare Advantage Plans they spew nonsense against them.

Seems like that.

Nothing is perfect. Can they be improved? For sure, but what will the trade offs be?

 

[Donald]

Not sure what you are talking about or even if you know what you are talking about.

Is this what YOUR insurance does? Because my advantage plan doesn't do that.

I'm on my second year of Medicare with Advantage Plan. Not one problem. Even pays my gym membership.

Do some insurance companies cheat? Do some health care providers cheat? Does the government cheat?

They are run by humans so the answer is easy. Why the shock? Why the need to start another Medicare thread???

Both Humana and United Health Care have sent out a doctor or nurse to my home for a health assessment. Part of my Medicare Advantage plan. They are some of the top companies in Medicare Advantage plans. I wondered why since I see my primary care doctor 2X a year and other specialist yearly.

As a plan participant you don't see any interaction between your provider and Medicare. Are they telling Medicare I am sicker than I really am? No idea. But many of the companies that run Medicare Advantage Plans have been reported to be doing that and Medicare is investigating.

As a tax payer I don't want to see Medicare paying more than it should. And don't want Medicare concluding Medicare Advantage plans are too expensive to keep going with them.

From a personal perspective my UHC plan has paid the medical bills for me pretty well. One blood thinner they don't really cover well. And while they say they cover dental, that part of the coverage is not worth sending in the claim forms

 

[Pablo]

Both Humana and United Health Care have sent out a doctor or nurse to my home for a health assessment. Part of my Medicare Advantage plan. They are some of the top companies in Medicare Advantage plans. I wondered why since I see my primary care doctor 2X a year and other specialist yearly.

As a plan participant you don't see any interaction between your provider and Medicare. Are they telling Medicare I am sicker than I really am? No idea. But many of the companies that run Medicare Advantage Plans have been reported to be doing that and Medicare is investigating.

As a tax payer I don't want to see Medicare paying more than it should. And don't want Medicare concluding Medicare Advantage plans are too expensive to keep going with them.

From a personal perspective my UHC plan has paid the medical bills for me pretty well. One blood thinner they don't really cover well. And while they say they cover dental, that part of the coverage is not worth sending in the claim forms

I have Humana, and no assessment. Never heard of this with with a MA plan. The only time I have heard this happening is when someone wants to change to a different Medicare option. Or just a guess, maybe a state thing??

 

[Donald]

I have Humana, and no assessment. Never heard of this with with a MA plan. The only time I have heard this happening is when someone wants to change to a different Medicare option. Or just a guess, maybe a state thing??

My MA plans are through IBM group MA plans. Maybe it's specific to some plans. But the article in WSJ did mention these at home health assessments. So it's not just me. They nurse or doctor is busy for 30 to 45 min putting information into their laptop about my medical conditions. But really do not tell me much as far as medical advice. Certainly not going to come up with some medical advice my primary care doctor has not already told me.

On the positive side the nurse or doctor does give me a gift for spending my time on the health assessment. Last year a cutting board and this year a cooler bag.

 

[PontiacHO]

Basic Medicare is all that’s needed. The “advantage” plan payouts are contested more than any other medical plans.

 

[Pablo]

My MA plans are through IBM group MA plans.

It's because your group. Not a Humana or MA requirement.