Medicare Advantage, More Oversight, Less Overpayment

[somarco]

While the industry is trying to convince lawmakers and public that MA is “better” than traditional Medicare, as discussed further below, providers continue to flee from MA plans – raising concerns about inadequate provider networks – while plans are pulling out of certain areas and scaling back benefits, despite continuing to be significantly overpaid.


One of the ways that Medicare Advantage plans “manage” care is their ability to restrict enrollees to a network of providers (either exclusively, in the case of most HMOs, or for lower cost-sharing in the case of PPOs). When groups of providers pull out of contracts with MA plans (or when a plan terminates contracts with providers) it raises the question whether the remaining provider network is “adequate” and in compliance with existing network adequacy requirements. Narrowing networks – particularly when an individual’s personal provider(s) leaves or is terminated – raises concerns about access to care for MA enrollees.


medicareadvocacy.org/medicare-advantage-needs-more-oversight-less-overpayment

 

[Chazm]

Sounds like it was written by a person who wants more government and less free enterprise

 

[InsuranceGuy29]

The reason providers don't like Medicare Advantage is simply rooted in their own self-interest. Medicare Advantage plans are much more paperwork, less pay (on average), and more regulations.

Original Medicare is "fee-for-service" and there are almost absolutely no checks and balances. Which means a doctor can bill a unicorn and a giraffe and get paid.

Medicare Advantage is a "healthy outcomes" model, which means providers are graded on how healthy they ACTUALLY keep their patients. They don't like that.

Why? Because the ones that are running fraudulent schemes can't get away with it on Medicare Advantage, and the ones with tons of kickback deals with big Pharma know if they keep throwing tons of toxic pills at their patients, they might end up getting really sick, and then their health grade goes way down, as does their payments from Medicare Advantage.

There is a good bit of fraud in original Medicare ($60 BILLION dollars a year's worth), and a lot of people don't understand that the major culprits are some hospitals, doctors, nurses, testing facilities, etc. This is the REAL reason why they hate Medicare Advantage....there's oversight.

Here's a great example.....just Google "Medicare fraud," click on "news," and then start reading. This fraud is all from original Medicare. Just a taste of the headlines....

https://www.cnn.com/2024/06/27/us/health-care-fraud-crackdown/index.html

"More than 190 defendants, including 76 doctors, nurse practitioners and other licensed medical professionals, were charged over two weeks in federal courts across the country, according to the Justice Department, and the government has seized more than $231 million in cash, luxury vehicles, gold and other assets."

If you supplement-only guys keep running a campaign against Medicare Advantage, as a strategy, none of us are gonna have jobs soon enough.

Regulators have no clue about anything insurance, and all they hear is guys like you bashing the program. As a result, they group all agents under the same umbrella and start HEAVILY regulating it all, which is what we've seen over the course of the past 5 years.

I have tons of clients on Medicare Advantage, and they are consistently very happy clients. My own parents have been on them for 15 years and they've never had a complaint.

I also have tons of clients on Medigap, and they also are consistently happy with those. Whichever one they choose, I don't care, as long as they're happy.

Are there some prior authorizations on some services? Yes. Do my clients ever not get the care they need? No. It might not be everyone's cup of tea, but MANY people are just fine with having some authorizations. It's no different than how 90% of people currently get their insurance in this country.

There is a place for both MAPD and Medigap. This is a time where agents need to be UNITED, because I hate to break it to you, but they're coming after us all. Supplements are also very much regulated by the government. If you think you're safe, you're not.

All health insurance is highly regulated, nowadays. Not nearly as much as Medicare Advantage, but the fact remains that supplements could be wiped out with the stroke of a clueless communist politician's pen, too.

 

[steveadlman]

You are correct that Medicare fraud costs us millions of dollars annually. But it is not just Original Medicare. The evidence also clearly shows fraud in the Medicare Advantage program.

 

[Millwood]

So let me get this right. Providers can/ and do screw Origanal Medicare. BUT the same crooked providers won't screw a Medicare Advantage Plan. Is there some honor code among these theives?
We know the crooked plans screw Medicare, screw agents , screw policyholders, but they are immune to being screwed by crooked providers. GOT IT.

 

[straightnochaser]

You are correct that Medicare fraud costs us millions of dollars annually. But it is not just Original Medicare. The evidence also clearly shows fraud in the Medicare Advantage program.

Wherever there are billions of dollars involved there'll be fraud.

 

[rousemark]

So let me get this right. Providers can/ and do screw Origanal Medicare. BUT the same crooked providers won't screw a Medicare Advantage Plan. Is there some honor code among these theives?
We know the crooked plans screw Medicare, screw agents , screw policyholders, but they are immune to being screwed by crooked providers. GOT IT.

It is not necessarily the providers committing the fraud with MA. some of the insurance companies have been involved in massive misappropriation.

 

[MedicareWAA]

Do you know who loves MA the most? The large primary care groups holding capitated deals with those plans … including a good number of hospital systems.

All those people who claim plans are out trying to find reasons to deny care? Don't point at the plans. Look at the medical groups taking on the financial risk. The plans often do nothing but collect a toll. They either don’t take any of the risk or they share in it, usually no more than 50 percent.

And then sometimes those groups get pissed that their risk deal isn’t as generous as someone else’s deal. So they walk away and act as if the plan is the central bad actor.

It never ceases to amaze me how many insurance agents don’t actually know how any of these plans work under the hood. MA, supps, indemnity, Pt D.

 

[somarco]

More than 3 out of 4 doctors (77.6%) are employed by hospitals or corporate entities, according to a new report issued this week by the Physicians Advocacy Institute and Avalere.

For the first time, corporations or corporate entities now own more physician practices than hospitals and health systems, according to the report. Corporate entities own 30.1% of physician practices, while hospitals own 28.4% of practices.

Corporate groups pass hospitals in ownership of physician practices

The shift is one of the key findings in a new report by the Physicians Advocacy Institute. Fewer doctors are working in private practices.

www.chiefhealthcareexecutive.com

UnitedHealth Group has about 90,000 employed or affiliated doctors, approximately 10% of all physicians in the U.S.

UnitedHealth Group now employs or is affiliated with 10% of all physicians in the U.S.

The rapid growth of UnitedHealth’s physician base, including 20,000 doctors in the last year alone, underscores how the company is looking to control more of the health care delivery system.

www.statnews.com

 

[InsuranceGuy29]

You are correct that Medicare fraud costs us millions of dollars annually. But it is not just Original Medicare. The evidence also clearly shows fraud in the Medicare Advantage program.

There's some fraud absolutely everywhere, my friend. No place in society is immune, but in the context of me saying my original quote, I mean that healthcare providers like Original Medicare WAY more because fraud is insanely easier to perpetrate under Original Medicare. Moreover, even if they're not engaged in direct fraud, physicians don't like extra regulations and oversight. I get it. Who does? But my issue arises when they start bashing Medicare Advantage coverage, as a whole, simply for their own self-interests.