PSA - If you enroll in Medicare Advantage, you could be stuck for life

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84. Generally I am a big admirer of your comments but you are consistently wrong about Medicare Advantag

I understand that you live in Europe and don't use it but your are consistently wrong about Medicare Advantage.

Usually you are citing sources that have an axe to grind.

My response in 75 below gives you links to government information and my experience.

This comment of yours is again, completely off the point.

There is fraud in Medicare, including regular Medicare and Medicare advantage but it isn't by the insurance companies but by the health providers.

1) Insurance companies in Medicare, Medicare Advantage and the Affordable Care Act all have a fixed gross margin which is called a Medical Loss Ratio and is generally fixed at 15 -20%

This means that insurance company's gross profit is not calculated on a bottom line result but is a fixed percent of sales. If an insurance company sells $ 100 million in premiums they will keep $ 20 million to pay for their advertising, administrative and net profit. Declining care or overcharging for care does not add to the bottom line.

2) Fraud or overcharging medicare (regular or advantage) comes from providers either making errors or deliberately committing fraud. I have seen both.

Before going to Banner I used Dignity health in Phoenix. They have terrible service and I switched and noticed that they got fined by the government for overcharging.

https://oig.hhs.gov/fraud/enforcement/dignity-health-agrees-to-pay-37-million-to-settle-false-claims-act-allegations/#:~:text=Dignity%20Health%20has%20agreed%20to,basis%2C%20the%20Justice%20Department%20announced


Dignity Health Agrees to Pay $37 Million to Settle False Claims Act Allegations
Dignity Health has agreed to pay the United States $37 million to settle allegations that 13 of its hospitals in California, Nevada and Arizona knowingly submitted false claims to Medicare and TRICARE by admitting patients who could have been treated on a less costly, outpatient basis, the Justice Department announced today. Dignity, formerly known as Catholic Healthcare West, is based in San Francisco and is one of the five largest hospital systems in the nation with 39 hospitals in three states.

Here is a more recent example

https://fronterasdesk.org/content/1680753/dignity-health-neurosurgical-associates-pay-10-million-billing-fraud-settlement

I don't know if they intended to overcharge (they are a not for profit).

Eight months ago I had a severe bacterial infection and had to go to the General Hospital in Yuma and had 12 hours of treatment and exams. I had to pay $ 105 and Medicare paid the rest.

The specialist set up a follow up exam at his private office which catered mostly to immigrants. I was informed that I would have to pay $ 200 up front. I explained that my co pay under my Medicare Advantage plan was $ 25 and they said that they needed the deposit and that they would then clear it with the insurance company and refund it back to me after they got approval. I knew that this was a lie that Medicare didn't require prior authorization for a simple office visit.

This was clearly fraud and obviously I didn't go there and I reported it to the fraud line for Medicare.


Again the fraud and/or over billing is being done by the health providers and the billing is going through the insurance companies because they handle the billing

3) It appears to me that you do some googling and find somethingthat sounds bad and assume that it is fraud because insurance companies are you know inherently evil

For example above you cite the OIG report that talks about non clinical reimbursements for $ 2.6 for non clinical HRA payments but you don't have any idea what these are and there is nothing in the citation indicating fraud. What they are is yet another free benefit for beneficiaries of Medicare Advantage aka as Medicare part C, a government paid for insurance.

It radically helped me AND didn't cost me a penny as my Medicare Advantage aka Medicare Part C is completely free

If you have Medicare Advantage you qualify for a doctor outside your health system to come to your house and give you a free consultation on managing your health care. So having a resource to a health care professional that is completely "unrelated to a clinical service" is not only not a bad thing but can significantly improve health outcomes, but is only available, without a copay and without any premium cost to members of Medical Advantage aka Medicare C

from your article
th
In-home HRAs generated 80 percent of these estimated payments. Most in-home
HRAs were conducted by companies that partner with or are hired by MAOs to
conduct these assessments—and therefore are not likely conducted by the
beneficiary’s own primary care provider

The whole point is to give the patient a resource to evaluate his primary care provider.

Costs the patient nothing with Medicare Advantage.

How good are these visits?

They are fucking fantastic. The doctor isn't there to bill anything, to charge anything but simply to help you evaluate your primary care provider.

I have had 3 of these and strongly recommend to anyone that they do it if called. The last one was able to confirm my suspicion that I was not getting the right care for my diabetes and I changed providers and my health improved 100% (which will also save the government money in the long term). The doctor was an exceptionally qualified doctor from Africa that was waiting for his US license to be completed so he could practice medicine but he could consult and he helped me a lot.

There was nothing in the article that indicated fraud but they did suggest changes in oversight.

Are there some insurance companies that do a better job than others than compliance issues? I am sure that is true.

I have to thank you for this link because

1) It does not indicate anything about insurance company fraud

but

2) It does articulate another benefit that Medicare C (aka Medicare Advantage) beneficiaries get for free that those with only A and B do not get: A home visit by a qualified doctor to help you evaluate whether or not you are getting top quality care by your medical provider. I wouldn't say that the home visit doctor saved my life but he helped me find a path to significantly improve my glucose control which is a pretty substantial morbidity factor for diabetics.


Every time I see a doctor I get an email from my health insurance company to ask about the quality of the service and where I can call to get questions answered. In the US it is impossible to call and talk to your doctor but you can get answers from a doctor that works for the insurance company. I am not sure if I didn't have the HRA that is only available for free through Medicare Advantage if my health would have not improved but since I have outlived my father by 12 years I have to consider that they HRA you have cited as a suspicious abuse by an insurance company could have saved my life.