A Patient’s Warning to Others - Medicare Advantage may not be an Advantage

When Tim Stephenson and his wife decided to retire, it was supposed to be a time to laze around their Shiloh home and watch the world go by. Instead, the couple’s golden years have been swamped by a barrage of junk mail and an unrelenting stream of commercials and telemarketers hawking everything under the sun. While most of the pitches are merely irritating, one product—Medicare Advantage insurance plans—represents something more potentially damaging for seniors at a time when they are most vulnerable.

“My agenda is to warn elderly people who are retired that they need to pay attention to this stuff,” Tim Stephenson said. “When you’re getting a handful of junk mail every day on insurance, you tend to just trash it and not even study it or look at it because there’s so much of it. From my perspective, seniors are being victimized by these plans through marketing and solicitation. ”Despite the name, Medicare Advantage plans are not government insurance, but products offered by private companies, something that’s hard to tell given ‘Medicare’ is right in the name.

Marketing materials are equally confusing and loaded with promises of bargain-basement prices, while at the same time making it difficult to learn basic information regarding hidden costs and coverage limitations. These tactics serve as powerful lures for people to enroll in a Medicare Advantage plan, especially among a patient population eager to save money.“ The name ‘Medicare Advantage Plan’ is really a misnomer,” said Dr. Stephen Wilber, hospitalist with Baxter Regional. “The more appropriate term is ‘Medicare Replacement Plan.’ They pull people in by telling people they get vision and dental paid for. Everyone who is of retirement age wants to save a little money, including my parents, so you can’t blame them. “But these insurance companies are not trying to be nice and give away free vision and dental; they’re doing that to entice you to buy plans that aren’t going to be there to care for you when you really need them.

”One of the primary drawbacks of Medicare Advantage is an extremely shallow network of physicians who will accept the plans. Medicare Advantage companies have become so aggressive with managed care tactics, it’s caused many hospitals, physicians, rehab facilities and nursing homes to cancel contracts and exit their physician networks. This means patients are often forced to travel to receive medical care or leave their families to enter rehabilitation or nursing home facilities in other communities, because there are limited or offer no in-network facilities where they live. If the policyholder is fortunate enough to find a local in-network provider, working with these insurance companies is cumbersome and slow. As Baxter Regional medical providers have discovered, it’s becoming increasingly difficult to get necessary authorization from insurance companies for high-cost imaging or surgical procedures under Medicare Advantage plans. “Numerous times requests for authorizations are denied,” said Wilber. “Some decisions can be overturned with significant advocacy from the physician, but there have been several cases recently where physicians’ recommendations of care have been denied. Medicare Advantage plans are delaying, denying and rationing care.”

Jean Gaylord, program director for acute inpatient rehab at Baxter Regional, said the overriding problem with the plans boils down to who is in charge of medical decision-making. “If you have original Medicare A and B, your medical care is managed by you and your primary care physician or, if you’re in the hospital, your hospitalist,” she said. “You all act as a team to make decisions together for your health care. “If you have an Advantage plan, your health care is managed by the insurance company, not by you and not by your physician. Care has to be preauthorized, meaning submitting the patient’s clinical documentation to the insurance company and they decide whether or not the patient meets inpatient rehab criteria. To make matters worse, turnaround time for approval typically takes three to seven working days, but can go as long as two to three weeks depending on what medical records or physician consults the insurance company may require.

“One of the biggest things with these plans is most of them require authorization for almost every service that’s done,” said Kattie Laney, Baxter Regional patient financial services director. “If a patient has traditional Medicare, we put them in the first available slot for a procedure or test. But the majority of Advantage plans require us as the provider to spend hours on the phone or online, delaying care. There is just a lot more red tape to deal with. “That’s another big reason why we highly encourage traditional Medicare coverage with an added commercial insurance supplement plan to defray out of pocket costs.” Laney also said in dealing with patients who have Advantage plans, she’s seen it more than once when people discover what’s in the fine print the hard way.“ People really need to be aware of how their plan works,” she said. “These plans are limited to a small number of physicians and hospitals. Some patients have discovered their plan isn’t even accepted by a physician they already have a relationship with. “Also, patients need to be aware of higher co-pays for services, which can come as a surprise to a lot of people. They sign up for plans because a sales representative told them how much money they’ll save or what they’re getting for free. Well, that cost has to come from somewhere, and it’s usually by limiting the services they are going to cover.”

”To make matters worse, the required authorizations and other red tape must be repeated with every phase of treatment, Gaylord said, such as a stroke patient discharged from the hospital into acute rehab who then needs in-home care and later requires nursing home care, down to basic durable medical equipment at any time during recovery and rehab. None of which, of course, is guaranteed to be accepted. “Do I believe a lot of people get these plans for financial reasons? Yes. Do I believe a lot of them do it because they see TV commercials? Yes,” Gaylord said. “But what they don’t do, and this is part of what we’re trying to do in providing education for the community, is they don’t always read and in some cases don’t have access to the fine print. “That’s why we really try to encourage people to speak with somebody, such as a trusted local insurance agent, who is familiar with these plans and can help lay out all of your options. That’s the best way to go over what each individual plan covers and see the true cost and limitations they have.”

Stephenson also cautions people to at least look at any piece of mail that talks about insurance coverage. He relayed a story about his late father, whose former employer switched him to a Medicare Advantage plan without his knowledge, let alone his understanding of what the new plan did and did not cover. “When my dad retired, part of his benefits package was insurance for his lifetime,” he said. “At some point, the company switched all their retired people over from original Medicare to a Medicare Advantage plan. Everything rocked along great until he was 95 years old and got really sick and we had to take him to the hospital. “When he needed to move out of the hospital to an acute rehab center I said, ‘Where do y’all recommend?’ They said, ‘We recommend Baxter Regional in Mountain Home. That’s the best acute rehab center in your area.’ But when we called over there and gave them the information they promptly said, ‘I’m sorry. We do not accept his plan.’ I just was shocked.

”Stephenson’s case had a happy ending—he managed to get his father untangled from the Medicare Advantage plan, and his new insurance was accepted by Baxter Regional where the care was, in his words, “outstanding, and their willingness to work with me was amazing.” But there was also an ironic twist awaiting him back in Shiloh one morning. “About a month ago, I got a letter in the mail from Arkansas State Employee Benefits, and guess what? AR Benefits has signed on with a Medicare Advantage plan for all state and retired employees, of which I am one,” he said, the heat rising in his voice. “I went ballistic. I had just gone through this absolutely horrible time with my dad’s situation, and they are doing the exact same thing to my insurance. “Now, you can opt out, but it’s on you, the consumer or the beneficiary, to take action or it happens automatically. In other words, if you throw it in the trash, they’re going to change your benefits without you fully understanding what that means. If I could advise someone else on this, I’d tell them, ‘Remain vigilant.’ ”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 recent report.

To read more about this report please visit:https://www.nytimes.com/2022/04/28/health/medicare-advantage-plans-report.html