In September 2018, a government report was released and was largely ignored by the mainstream press.
The report from the Inspector General at the Department of Health and Human Services (HHS) seductively titled – Medicare Advantage Appeal Outcomes and Audit Findings Raise Concerns About Service and Payment Denials – found that Medicare Advantage regularly denies claims and that when patients appeal those denials, the Medicare Advantage plan reversed three-quarters of their own denials.
The numbers were troubling because of the infrequency with which patients and providers used the appeals process – just one percent of those denied care.
“For these organizations to keep funds entrusted to them that were designated to pay for health care services that were actually delivered is worse than thievery because it is on such a massive scale,” said Dr. Don McCanne of Physicians for a National Health Program at the time of the release of the report. “This is racketeering at its worst.”
Diane Archer of Just Care USA would like to find out which Medicare Advantage Plans are denying care and at what rate.
But alas, those numbers are not available to the public.
“The Affordable Care Act does in fact require the Medicare Advantage plans to disclose the services they are covering,” Archer told Corporate Crime Reporter in an interview last week. “According to the Medicare Payment Advisory Commission (MedPAC) – they have failed to turn over complete and accurate data.”
Doesn’t MedPAC have the power to force them to turn over the data?
“No. The law requires the Medicare Advantage plans to turn over claims data to the government. They turn over data, but it’s incomplete and often inaccurate. Denial rates are not disclosed. People can’t compare plans based on denial rates.”
Are the plans required to turn over data on denial rates?
“That information is available to the government. But it doesn’t get released.”
Why isn’t it released?
“It needs to be released. I believe it’s the Centers for Medicare and Medicaid Services (CMS) that has the authority to release this data. But it hasn’t.”
Now, about forty percent of the Medicare population is in these Medicare Advantage plans. That means that the government is paying these for-profit health insurance companies to deliver what Medicare delivers.
“The government is paying these health insurance companies to deliver Medicare benefits. And it is allowing these companies to decide what that means in terms of what doctors, hospitals, nursing homes and home care agencies are available to deliver those benefits and what specific services and treatments are covered if you have those benefits. As of this moment, there is not comprehensive or accurate data as to what care Medicare Advantage plans are providing people.”
You make the point that Medicare Advantage plans are good for healthy people but not necessarily for sick people. They have narrow networks and some have high denial rates. You recommend that people of Medicare age choose traditional Medicare and not Medicare Advantage.
“The Medicare Advantage plans are all different. And we do not know which are delivering good quality care to people with cancer, heart disease and stroke when they need it. There is no one who will tell you – pick this Medicare Advantage plan if you want high value cancer care. And it is not clear which if any offer high value cancer care. They are certainly not out there telling you that they are.”
“Health insurance is not just about today. It’s about what might happen to you in the future. You want coverage for the healthcare services that you need if you do get diagnosed with some complex and costly condition. And the only way to ensure that you will get those services is if you are in traditional Medicare.”
“What we know from numerous studies is that people tend to leave Medicare Advantage plans when they can and return to traditional Medicare when they develop a costly and complex condition.”
“But most people who join Medicare Advantage are locked into their Medicare Advantage plans. If you do become sick and want to switch back to traditional Medicare you are not guaranteed the ability to buy supplement insurance to protect you from financial risks. You are only guaranteed that right under federal law when you enroll in Medicare at 65 or later. Traditional Medicare doesn’t have an out of pocket cap, so you would need supplemental coverage to pay the twenty percent differential between what Medicare pays and what your providers are allowed to charge you under traditional Medicare.”
“Except for in four states, if you switch from Medicare Advantage to Medicare, that Medigap coverage is generally either not available or unaffordable.”
You wrote recently this:
“In the last quarter of 2020, the Trump administration’s Department of Health and Human Services launched an experiment, euphemistically called, direct contracting, that could fully turn Medicare over to private health insurers. The Biden administration needs to halt this experiment before millions of older and disabled Americans lose their right to choose traditional Medicare.”
How does that work?
“The Trump administration opened the door to allow private insurers to take charge of traditional Medicare if they wanted to, much like they do in Medicare Advantage.”
Is there any way to find out whether or not you have been flipped over from traditional Medicare into a private plan?
“There are different direct contracting experiments, some of which are already underway. The Centers for Medicare and Medicaid Services assigns people who sign up for traditional Medicare directly into one of these direct contracting experiments. I assume they are told.”
“But, I don’t know for a fact what they are told and when they are told or whether they are told they can opt-out. The experiment underway does allow people to opt out. CMS just put a different experiment that has not yet launched “under review.” That experiment doesn’t allow people to opt out.”
Do we know how many people have been flipped into private plans?
“I do not know the numbers. It just launched at the end of 2020.”
Why hasn’t the Biden administration just reversed the Trump plan?
“The current administration is just now filling positions at the Department of Health and Human Services. Xavier Becerra has not yet been confirmed by the Senate as head of HHS. We don’t yet have somebody at the head of the Centers for Medicare and Medicaid Services. Liz Fowler just took up her position at the Center for Medicare and Medicaid Innovation and she put an immediate halt on the model that locked people in and doesn’t allow people to opt-out. Chiquita Lasure-Brooks has been nominated to be head of the Centers for Medicare and Medicaid Services (CMS).”
“At the Becerra confirmation hearings, he was asked about what he was going to do about Medicare Advantage. And he said he wanted to make sure that Medicare Advantage operated on a level playing field with traditional Medicare.”
What does it mean?
“It should mean that like Medicare Advantage, traditional Medicare would have an out of pocket cap so that people who wanted to enroll in traditional Medicare would have no need to buy supplemental insurance. And prescription drug coverage would be wrapped into traditional Medicare, as it is with private Medicare. Traditional Medicare would offer some additional benefits as do many of the private Medicare plans such as dental, vision and hearing.”
Can he do that administratively?
“I think that the Center for Medicare and Medicaid Innovation could do some of that administratively. They have the power to test the value of an out of pocket cap in traditional Medicare. It doesn’t cost much. According to the Commonwealth Fund, it would cost as little as $35 a month for a $2,500 out of pocket cap in traditional Medicare.”
“Right now, Medicare Advantage appears a lot less expensive. And the up-front costs are lower. You don’t need to buy the supplemental coverage. But, of course, if you do get sick and you need costly care, your annual out-of-pocket costs could be as high as $7550 just for in network care. And that’s far more than Medicare supplemental coverage costs.”
[For the Complete q/a format Interview with Diane Archer, 35 Corporate Crime Reporter 12(12), Monday March 22, 2021, print edition only.]