Whats The Issue On Medicare Advantage Plans.....

[dalton99a]

62. +1. Because of denials and refusals to pay

https://www.newsweek.com/texas-cancer-patients-may-need-new-doctors-after-insurance-changes-1976905

Texas Cancer Patients May Need New Doctors After Insurance Changes
Published Oct 29, 2024 at 6:26 PM EDT
Updated Oct 30, 2024 at 2:40 PM EDT

...

Chris Fong, a Medicare specialist and the CEO of Smile Insurance Group, said while insurance companies are attempting to save money by reducing the costs of services and adding on steps like prior authorization or referrals, medical centers are also experiencing inflation on medical supplies and doctor salaries.

"Unfortunately, the patients are some of the most affected through these contract negotiations," Fong told Newsweek. "The advice we give to our clients is to look at how they would like their healthcare to operate. If they prefer the flexibility to choose doctors and medical providers with less limitations, they should consider traditional Medicare with a supplement and prescription plan."

Ryan said insurance companies are increasingly using 'network narrowing' as a cost control strategy.

"They're betting that by excluding expensive providers, they can offer lower premiums," Ryan said, adding that they don't always consider the human cost.

-------------------------------------------------------------------------------------------

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

Denied by AI: How Medicare Advantage plans use algorithms to cut off care for seniors in need
By Casey Ross and Bob Herman
March 13, 2023

An algorithm, not a doctor, predicted a rapid recovery for Frances Walter, an 85-year-old Wisconsin woman with a shattered left shoulder and an allergy to pain medicine. In 16.6 days, it estimated, she would be ready to leave her nursing home.

On the 17th day, her Medicare Advantage insurer, Security Health Plan, followed the algorithm and cut off payment for her care, concluding she was ready to return to the apartment where she lived alone. Meanwhile, medical notes in June 2019 showed Walter’s pain was maxing out the scales and that she could not dress herself, go to the bathroom, or even push a walker without help.

It would take more than a year for a federal judge to conclude the insurer’s decision was “at best, speculative” and that Walter was owed thousands of dollars for more than three weeks of treatment. While she fought the denial, she had to spend down her life savings and enroll in Medicaid just to progress to the point of putting on her shoes, her arm still in a sling.

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.

...

-----------------------------------------------------------------------------------------------------

https://www.nytimes.com/2022/04/28/health/medicare-advantage-plans-report.html
http://web.archive.org/web/20240829155209/https://www.nytimes.com/2022/04/28/health/medicare-advantage-plans-report.html

Medicare Advantage Plans Often Deny Needed Care, Federal Report Finds
Investigators urged increased oversight of the program, saying that insurers deny tens of thousands of authorization requests annually.
By Reed Abelson
Published April 28, 2022 | Updated Dec. 3, 2022

Every year, tens of thousands of people enrolled in private Medicare Advantage plans are denied necessary care that should be covered under the program, federal investigators concluded in a report published on Thursday.

The investigators urged Medicare officials to strengthen oversight of these private insurance plans, which provide benefits to 28 million older Americans, and called for increased enforcement against plans with a pattern of inappropriate denials.

Advantage plans have become an increasingly popular option among older Americans, offering privatized versions of Medicare that are frequently less expensive and provide a wider array of benefits than the traditional government-run program offers.

Enrollment in Advantage plans has more than doubled over the last decade, and half of Medicare beneficiaries are expected to choose a private insurer over the traditional government program in the next few years.

The industry’s main trade group claims people choose Medicare Advantage because “it delivers better services, better access to care and better value.” But federal investigators say there is troubling evidence that plans are delaying or even preventing Medicare beneficiaries from getting medically necessary care.

...

-----------------------------------------------------------------------------------------------------

https://www.npr.org/sections/shots-health-news/2024/07/25/nx-s1-5050850/california-tries-but-fails-to-fix-a-major-medicare-loophole-for-seniors

California tries but fails to fix a major Medicare loophole for seniors
July 25, 2024 9:19 AM ET
By Kate Wolffe

...

In 2023, Scripps Health, a major San Diego hospital system, stopped accepting Medicare Advantage plans, saying the plans paid less than other insurers for the same treatments, and required doctors to navigate prior authorization protocols that were burdensome and time-consuming.

The move sent seniors in the San Diego region scrambling to sign up for traditional Medicare, supplemented by Medigap plans. The high numbers of people who found Medigap plans unaffordable drew the attention of State Senator Catherine Blakespear, who put forward a Medigap reform bill.

Four states reformed Medigap in the 1990s — Connecticut, Maine, Massachusetts, and New York. The rest, including California, allow Medigap insurers wide leeway in setting prices and issuing denials.

California’s bill would have created a 90-day open enrollment period for Medigap, every single year. That would allow seniors to opt-in or out each year and not be denied — or face exorbitant premiums due to pre-existing conditions.

“Cancer or any chronic illness is very, very expensive, and that's why having supplemental coverage is important,” said Adam Zarrin, a policy analyst for the [Leukemia and Lymphoma] Society. “The second part is about making sure that patients have access to the best health care available.”

Zarrin says leukemia and other blood cancers are more commonly diagnosed in older adults, after age 55.

...