Medicare Advantage Plans

[Donald]

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.

 

[Boomer]

. Yep. Much happier with a medicare supplement!!

 

[Sayjac]

Link or citing the referenced "article" please?

 

[alarmguy]

You can find articles about everything both good and bad. When you say "They are ripping off Medicare by the billions" that is the medical practices that are doing it, not everyone steals.

Agree on the home practitioner push, the thing is my plan will pay me $50 to allow them to come to my house. (truly I am not being a wise guy) Im glad for it.

If it's allowed by medicare, it's not stealing as long as fraud isnt involved, then that is fine with me. I paid into the system my whole life and continue paying today. ALMOST half of all money spent is spend on the less fortunate and get free health care without paying anything into it. Let them spend every cent that is allowed on me. I love to stay in great shape.

I still haven't done one of those home visits but I think I am going too. It's a great time to be able to asks opinions and thoughts on anything that concerns you.

I actually think it's a great idea for inputs on your treatment. They also pay me $15 for scheduling my annual physical, they pay me money to get vaccines, heck they just bought me a new Apple Watch 9 and pickleball paddle. Goes to show it works on the contracted price the government (we the people) pay them for health care vs the standard government program that you are liable for 20% of all your medical care for the rest of your life with no limit.

Get a heart procedure with standard medicare of lets use a family member of mine as an example. His cost for one year 2 years back was $3000. If he had to pay 20% with standard medicare A & B it could have been as high as $100,000 though chances are a reduced medicare rate he would have owed $65,000 instead of his advantage plan of $3000

A system with a budget of around 800 billion dollars will have losses in the billions, there is no company or organization on earth where that is not true percentage wise but makes good "news" stories. Im only posting blindly as another pointed out, we dont have a link to the story. I love my plan, it works, the system is very solvent as one must keep in mind almost 50% of all payouts go to people who pay nothing towards the system. Meaning it goes towards Medicaid support not Medicare for retired people who are paying into the system and have paid into the system.

 

[CKN]

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.

There isolated examples of fraud everywhere. The issue is that any article you read is going to be "agenda driven" and bias-when it comes to Medicare.

The primary medical provider in Utah runs a very efficient ship. My Medicare Advantage plans pays for my gym membership, a $50.00/month healthy food supplement, and will also pay for any recreational activities (bowling, golf, etc.) I may choose to participate in. It also uses the same doctors and hospitals I was using when I had traditional Medicare and about $500.00/more a month.
My wife had Cataract surgery-and ended up costing less than $2,000.00-after the plan paid.

This is yet again another subject (Medicare) that gets dredged up on this forum every so often. Much repetition on this forum these days.

 

[Vil_Riker]

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.

The hospital coders tend to be conservative. If the care is between two levels, the coders will choose the lower level most of the times. Higher codes enable the private insurers get more money from the federal government so they will push the hospitals to code higher levels. It's not fraud because it's a gray area until the CMS cracks down. Unfortunately for us, the taxpayers, the health care policy is driven by these private insurance companies.

It is true that Medicare Advantage plans do not like to pay their claims. The denial rate is about 25% so 1 out of 4 procedures is not paid. Which in turn increases the costs on the employer based insurance plans.

It's a cluster, and it is going to get worse in the future.

 

[jetman]

"Advantage Plans", don't do it, it's a trick.
Ask anybody that works in the industry (my wife and co-workers).

 

[wpod]

The medical industry is so corrupt that corrupt himself would call it corrupt.

 

[Donald]

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.

 

[loneryder]

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.

I get calls wanting to set up a home visit. I hang up. They are subcontractors paid by the Advantage plan that get paid if you cooperate with them. Anyone seeing their Dr twice a year doesn't need a home visit. I've had Aetna MA plans for 10 years with no problems. They don't make me jump through hoops to get a Dr. or procedure. The few times I've had problems or questions, they have been very helpful. I've had nothing to complain about. I went with advantage plans because I figured it would be easier to deal with a company that's supposed to serve you rather than the Fed. govt.!

 

[alarmguy]

The hospital coders tend to be conservative. If the care is between two levels, the coders will choose the lower level most of the times. Higher codes enable the private insurers get more money from the federal government so they will push the hospitals to code higher levels. It's not fraud because it's a gray area until the CMS cracks down. Unfortunately for us, the taxpayers, the health care policy is driven by these private insurance companies.

It is true that Medicare Advantage plans do not like to pay their claims. The denial rate is about 25% so 1 out of 4 procedures is not paid. Which in turn increases the costs on the employer based insurance plans.

It's a cluster, and it is going to get worse in the future.

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.

 

[alarmguy]

"Advantage Plans", don't do it, it's a trick.
Ask anybody that works in the industry (my wife and co-workers).

Except for the majority of Americans who have Advantage C plans that is.

Other option is pay private insurance companies an extra $400 a month. Hmmmmmm ... $5,000 a year for the same doctors and hospitals. I dont see the trick among those that use it.

Actually though I hope people who talk negative about advantage plans stops some Americans form getting them. They have become so popular that they are now the majority of Medicare plans and I hate that, companies will lose interest in more and more incentives if everyone is signing up for them.

 

[jetman]

Except for the majority of Americans who have Advantage C plans that is.

Other option is pay private insurance companies an extra $400 a month. Hmmmmmm ... I dont see the trick among those that use it.

Majority?
They got cha

 

[alarmguy]

Majority?
They got cha

You need to do some research. I got to go get my haircut. *LOL*
Factual data we have crossed the line, over 51% of people are now selecting Advantage plans over traditional private Part G and Part N and Part D plans.

 

[CKN]

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.

Take a picture of said article with your cellphone (if it's not online). Save said picture to your album. Email to yourself. Save to desktop and post it on here.

 

[jetman]

You need to do some research. I got to go get my haircut. *LOL*
Factual data we have crossed the line, over 51% of people are now selecting Advantage plans over traditional private Part G and Part N and Part D plans.

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.

 

[Al]

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.

 

[CKN]

Here is the rub-
I can't think help to think those vocal against "Advantage Plans" is because of "perceived control" they have over their medical care. When in reality now-many plans no longer require a referral to a specialist. What control are you giving up?
Respectfully-with this site full of "cheapskates" I am wondering why saving a $1,000.00 (or more) a year is not popular?

 

[Vil_Riker]

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.

They get a bonus for those visits. It's called Annual Wellness Visits.

 

[mk378]

There definitely has been fraud where an insurance company adds diagnoses that don't exist in order to push the policy into a higher rate tier from the government. This scheme does not need to involve a doctor since it is between the company and the government.