A government watchdog report released April 28^th found private insurance Medicare plans routinely rejected claims that should have been paid and denied services that reviewers found to be medically necessary. The report, completed by U.S. Department of Health and Human Services inspector general office, discovered private Medicare plans denied 18% of claims allowed under Medicare coverage rules. The denials often were a result of errors in processing claims. The review also found private Medicare plans turned down 13% of authorizations for medical services that traditional government-run Medicare would have allowed. Private insurance Medicare plans are also called Medicare Advantage and Medicare Part C plans.

The report cited two reasons private Medicare plans rejected authorizations that the watchdog’s agency’s physician reviewers found to be medically necessary. The private plans had coverage formulas beyond what Medicare required – for example, first requiring an X-ray before allowing more complex imaging like an MRI. The plans also claimed the request lacked appropriate documents, but investigators said beneficiaries’ medical records were adequate. Doctors and patients frequently appeal the routine claims and care denials lead to extra work and an increasing administrative burden.

The inspector general concluded that the agency that oversees Medicare should tighten

oversight of Medicare Advantage Plans. This should include new guidance for clinical reviews and fixing vulnerabilities that can lead to review errors. Rosemary Bartholomew, a Medicare Advantage expert who led the team that wrote the report, said beneficiaries may be denied care they need or might have to pay for services that their plans should cover.

 

Listen to the full report below:

 

 

Contact: Dick Needleman, Health reporter, 103.3 AshevilleFM, [email protected]

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The Medicare national health insurance program was passed by Congress in 1965. It provides health insurance for older Americans and some younger people with disabilities. These groups were usually not eligible for employment-linked group coverage. Medicare covers fifty-two million Americans 65 years old and older and 8 million younger people with disabilities and certain chronic diseases including end stage kidney disease and ALS neurologic disease. Working people pay into Medicare through deductions from their paychecks. Medicare Part B insurance (for outpatient care including doctors) bills beneficiaries but does not cover all the bills. There is supplemental Part B insurance available from private insurers for additional coverage. Medicare Part D insurance (helps cover much of the cost of most prescription medicine) is also available through private insurers.

The Equity and Fiscal Responsibility Act, which was passed by Congress in 1985, allowed Medicare beneficiaries to receive healthcare services through private-health plans. These health plans offer the same service coverage as Parts A & B, often with the benefits of Part D, and with an annual out-of-pocket expense limit which traditional Medicare Part A & B lack. The plans receive a predetermined monthly risk-adjusted payment from the federal Medicare program to cover each beneficiary’s care. The beneficiary receives more comprehensive benefits than those provided through traditional Medicare. In theory, Medicare can save money by taking advantage of efficiencies in a managed care health system that the private Medicare plans supply.

Private insurance Medicare plans, also called Medicare Advantage, Managed Medicare and Medicare Part C plans, cover more than 28 million older and disabled Americans. They are an increasingly popular option with total enrollment more than doubling over the past decade. By 2030, the Congressional Budget Office projects more than half of Medicare beneficiaries will be in a private Medicare plan.

Medicare Advantage plans tout perks such as limited out-of-pocket costs, vision and dental benefits not offered by traditional Medicare, and even gym memberships. There have been bills before Congress recently that recommend expanding traditional Medicare by adding these benefits.

Be aware that private insurance Medicare plans restrict networks of doctors that its beneficiaries can use, mandate authorization for some services and require referrals for specialists.

Rosemary Bartholomew, a Medicare Advantage expert with the U.S. Department of Health and Human Services, told U.S.A. Today that private Medicare plans are generally paid a fixed amount per patient, therefore, their profits will be higher if patient care is restricted. Bartholomew said, “There can be an incentive to kind of stint on care a little bit in order to increase profits.” In contrast, traditional Medicare pays doctors and hospitals for each test or procedure.

 

Listen to the full report below:

 

 

Contact: Dick Needleman, Health reporter, 103.3 AshevilleFM, [email protected]

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ASHEVILLE, NC – May 3, 2022 – On May 3rd, the Department of Health and Human Services and Public Health Director Stacie Saunders posted the weekly Buncombe County COVID-19 Community Update. Buncombe County COVID-19 metrics are on the North Carolina COVID Dashboard. Data from the week ending on April 30 indicate:

• There are 164 cases per 100,000 residents in the last 7 days up 21% from the previous week.
• 66% of the total population have received their full primary vaccination series. This is unchanged for about 2 months
• 61% of people with full primary vaccination series have had at least one booster
• The seven-day average of COVID-19 hospitalizations and ICU patients are unchanged over the previous week.
• The CDC reports that the risk level for Buncombe County is low for the week ending May 5.
• Wastewater surveillance may provide an early warning before individual testing shows that COVID-19 is spreading. The state dashboard reports that the 15-day rate of change of viral load for Buncombe County is moderately increasing for the time period ending April 27^th. The CDC website reports that the rate of change is moderately increasing for the time period ending May 3^rd.

The Department of Health and Human Services recommends:

• Get vaccinated and boosted when eligible.
• People with any COVID symptoms or exposure to someone with COVID should get tested
• People who are positive for COVID-19 or do not feel well should stay home

Vaccination sites and testing sites can be located through the North Carolina and Buncombe County Department of Health and Human Services.

Save your face masks:

• The risk level may rise with a new variant
• A person at high risk for severe illness should speak with their health care provider
• Mask wearing is recommended for persons with a positive test, having symptoms, or exposure to someone with COVID-19
• Governor Cooper’s executive order on March 1^st says that agencies may require everyone to wear a mask in “high risk” settings like health care facilities, nursing homes, correctional facilities and homeless shelters.

 

Listen to the full report below:

 

 

Contact: Dick Needleman, Health reporter, 103.3 AshevilleFM, [email protected]

More Posts for Show: Asheville FM News Hour