Patient Advocacy: Healthcare on your side
by Martine G. Brousse,
Healthcare
Specialist, Patient Advocate, Certified Mediator
ADVIMEDPRO
Medicare Advantage Plans:
Unpopular with Medical
Providers
Created
a few years ago with the goal of improving efficiency, care and overall cost,
Medicare Advantage plans (part C) claim uneven success. While enrollment is
higher in some parts of the country, efforts at increasing the number of
subscribers have been met with obstacles, such as a low number of contracted
providers, or difficult access to care.
Before
blaming the cause on medical providers' greed or lack of caring, let's look
at things from their perspective:
1.
Straight Medicare is great
Consider
"regular Medicare": render service, send a bill, get paid. Follow well
published, simple instructions, and your payment will make its way into your
bank account within 14 days.
Advantage
plans are less transparent, more complex and obstructive. More resources, time
and manpower are needed for the same payment...in 30 days... maybe.
Disputed
claims, in general, are a minor reason for rejecting Medicare Advantage patients.
But there is no doubt that for each single appeal made to Medicare, there are
dozens made to Part C carriers.
Even
if the payment is eventually similar, the cost of the added paperwork, stress,
processes, appeals, calls and staff time bites through any profit, quickly
throwing a practice into losing money territory.
2.
It's complicated
The tedious
and often-delayed authorization process remains a major drain on resources and
staff time. Losing money (and patience!) on that end is common.
Fee
for Service or PPO (a misnomer as patients think providers are contracted with
Medicare when in fact it is with a specific plan administrator) plans are
more widely accepted. Less resources or staff time are required.
HMO
plans are disliked throughout. Any service, visit, treatment requires prior
authorization. This routinely takes 3 to 5 days (if no emergency) and the
patient must return to receive care. Schedules are burdened, diagnoses and
treatments delayed, frustration rampant. The exceptions are autonomous and self-contained plans like Kaiser.
Because
of cost and unrelated contract requirements, simple tests or labs must often be performed
by an outside provider. An authorization must be requested, paperwork sent to
the lab (for example), blood drawn, reports sent to the office, before the
patient can be notified of results which may have taken a few minutes
otherwise. This waste of time causes hardship and anxiety for patients, while
the added office administrative costs are not reimbursed.
I worked
with cancer patients whose HMO plan forced them to receive chemotherapy at
home. With no way of supervising the treatment, the stress on staff, doctors
and patients was crushing. Saving a relatively small amount of $ seemed the only
reason for the insurance to impose such a risky and potentially disastrous decision.
3.
Unpaid patient balances
Another
element has become important in the decision-making process of medical
practices: straight MCR patients usually have a secondary insurance. Patient liability,
though growing in recent years, remains low and easily collected.
Medicare
Advantage policies often come with much higher deductible and out-of-pocket
costs. Some plans have no patient limit for certain items (chemo drugs for
example), causing patients to either forgo treatment altogether or drain their
savings. Without secondary insurance, many cannot afford to pay their bills.
4.
Unclear policies
Straight
Medicare offers a vast range of guidelines, policies, webinars, educational
materials and contact methods to help offices determine whether a specific item
or treatment is covered, under what conditions, and at what price.
Commercial
carriers, the administrators of Part C plans, must offer equivalent coverage.
But they may impose which treatment to order (cheaper, non-surgical or less
drastic first), which drugs to prescribe (generic only), where and how patients get treated,
etc. Pre-authorization requirements vary, so calls must be made before any
treatment or service can be recommended or prescribed.
5. Patient Responsibility
If an
office bills incorrectly, or provides a non-covered service to a straight
Medicare patient, it must absorb the loss. Not always so with part C. Patients
are more likely to be hit with unpaid balances, especially if they see a
non-contracted provider or receive non-pre-approved care.
In
Conclusion:
Seniors
are caught in the middle. Between restricted access to medical providers, billing
surprises, treatment delays, widespread confusion and impositions of all sorts,
they are too often left to fend for themselves, with no way to change their
plan until the following January.
If you
are a Medicare Advantage patient, check and double check. Not doing so could
lead to bad and expensive surprises!
© [2016] Advimedpro.
© [2016] Martine G. Brousse.
All rights reserved.
My
objective is to offer you, the patient, concrete and beneficial
information, useful tips, proven and efficient tools as well as
trustworthy supportive advice as you deal with a system in the midst of sweeping adjustments, widespread misunderstandings and complex requirements.
AdvimedPro (424) 999 4705 or (877) 658 9446 fax (424) 226 1330
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