"Prior Authorization" roadblock to Medicare Advantage

Investment Analysis Clubs Macro Economic Trends and Risks
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Medicare Advantage premiums are much lower than standard Medicare premiums. Medicare Advantage also provides benefits (such as glasses) that Medicare doesn’t cover. Millions of American seniors choose Medicare Advantage so it has a truly Macro impact. What’s not to like?

When ‘Prior Authorization’ Becomes a Medical Roadblock

Medicare Advantage plans say it reduces waste and inappropriate care. Critics say it often restricts coverage unnecessarily.
By Paula Span, The New York Times, May 25, 2024

…

Traditional Medicare rarely requires so-called prior authorization for services. But virtually all Medicare Advantage plans invoke it before agreeing to cover certain services, particularly those carrying high price tags, such as chemotherapy, hospital stays, nursing home care and home health…

After years of steep growth, more than half of Medicare beneficiaries are now enrolled in Advantage plans, which are administered by private insurance companies.

In 2021, those plans received more than 35 million prior authorization requests, according to a KFF analysis, and turned down about two million, or 6 percent, in whole or in part…

Insurers can save money by restricting coverage; they’ve also learned that few beneficiaries challenge denials, even though they are entitled to and usually win when they do.

Medicare Advantage plans are capitated, meaning they receive a fixed amount of public dollars per patient each month and can keep more of those dollars if prior authorization reduces expensive services…

… the proportion of prior authorization denials overturned on appeal had reached 82 percent…[end quote]

The government is aware of this problem.

I heard about this and chose traditional Medicare for myself and my husband (along with Medigap Part G to cover the 20% that Medicare doesn’t cover).

Health care costs can be astronomical. My bilateral mastectomy surgery including one night in the hospital (but not including testing and other treatments) cost $150,000.

The last thing I need when dealing with a serious health problem is a denial of authorization at the worst possible time. Even if it might be reversed on appeal that takes time and mental energy. Meanwhile the bills would be arriving.

Wendy

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Where does plan B fit into this? Aren’t we supposed to sign up for plan B when we reach a certain age or otherwise face penalties down the road when we try?

I am no expert.

I pay $254 for plan B out of my SSI check and I also pay $89 a month for Providence Medicare Advantage + RX.
Recently they said prior referrals for any in-network are not required.

My plan B is twice the normal $174 because my bottom line on my taxes for the year amounted to allot.

I am happy with my coverage. $43k new robo knee was $300 for out of pocket. $30 co-pay for PT sessions after that.

Kind regards,
MS

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iirc, A and B are hospitalization and Dr office services covered by traditional Medicare. Part C is MA. Part D is the pharmacy program. I know there is a penalty for not enrolling in Part D as soon as you go on Medicare.

Steve

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@MoneySlob since Medicare is such an important part of retirement planning you would benefit from reading a book like “Get What’s Yours for Medicare” which is available from the library.

If you are enrolled in traditional Medicare you will get Part A and Part B included. You need to sign up for Part D to get prescription drug coverage. (This can be inexpensive – we pay $11 per month.)

Traditional Medicare only pays 80% so you need separate Medigap insurance to cover the remaining 20%. There are many Medigap choices for different prices.

Do yourself a favor and read about it so you understand what you are paying for.

Wendy

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We get this all the time. Wife’s med’s for monthly shot in the eye. You need to use the cheap stuff. Doesn’t matter that you will take double the amount of shots. My cellulitis meds. Oh, use this other cheap stuff. You will only be in pain twice as long. You’re a big boy tough it out.

Believe me, Express Scripts and Aetna suck big time.

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Yep.

{{ The panel upheld Melgen’s conviction on all 67 counts. It deemed his 17-year-sentence to be even-handed, noting that the trial judge factored in Melgen’s advanced age and lack of criminal history.

A jury in the Southern District of Florida convicted Melgen in April 2017 of carrying out a systemic billing fraud at his South Florida medical offices. Melgen stood accused of routinely administering unnecessary, invasive treatments and profiteering off the macular-degeneration drug Lucentis.

He was also charged with running millions of dollars’ worth of dubious diagnostic tests, often using old technology that allowed him to bill higher rates. }}

11th Circuit Upholds Doctor’s Massive Fraud Conviction | Courthouse News Service

intercst

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Are you sure you have Medicare Advantage and not a supplemental plan? Medicare Advantage is designed (pretends?) to replace traditional Medicare…parts A, B and D…but can’t be used concurrently since the insurance company you’re signed up with has grabbed the funds earmarked for the traditional Medicare coverage

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That was the objective of Part C. Insurance companies have offered Medicare supplements for years, to cover things Medicare does not cover. Part C funnels the money for the things Medicare does cover through the insurance company hands so it can be skimmed.

Steve

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I have the card here in my hand:
“Providence Medicare Choice + Rx(HMO-POS)”

$116 monthly includes dental.

And I am very happy with my out of pocket and all the services the in-network system doctors have provided.

Here is a rough history of my costs over the last several years:

$30 copay for Sleep Doctor appointments(they aren’t cheap)
$30 copay for Sleep Test (all night)

$1,200 out of pocket for $16k fractured pelvis stay in hospital and rehab
$15 copay for Orthopedic Surgeon X-ray and followup visit

$300 out of pocket for $43k robo titanium knee.

On and on.
I have kept same GP I had when I was working and pre-medicare age.

All the snide comments about medicare scams can go somewhere else. Not saying they might have some sort of validity, but I am sticking with my system.

This whole topic is probably OT, I wonder who started it :thinking:

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The out-of-pocket maximum (MOOP) for Medicare Advantage plans is a government-mandated amount that varies by plan and changes every year. The MOOP is intended to protect enrollees from excessive costs if they have high medical expenses due to illness or injury. In 2024, the maximum MOOP is $8,850, but some plans may have lower limits.

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It’s absolutely great that you’ve had no problems with Medicare Advantage but remember, you asked the question about Medicare part B and seemed unsure of what it was, no?

Criticisms of Medicare Advantage are absolutely not snide comments or remotely OT…and should stay right here because, for a good many, denials and patchy coverage are a reality.

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I want want my own Swiss chalet rather than buying one for a health insurance CEO.

Minimizing the “skim” – the Key to Retiring Early.

intercst

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I started it. The whole topic is definitely on topic because it involves millions of people and many billions of dollars – affecting the medical and insurance industries and the spending power of half the retirees in the U.S. which directly impacts the Macro economy.

Wendy

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As the denial appreals pile up, a lot of MA providers are pulling out of the market.

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This is the reality. The practical implication moving forward is that, once enough providers and even facilities drop MA, folk who can no longer get adequate care are going to try moving back to trad Medicare with supplemental. Depending upon age and medical status, that might not be an easy proposition, given that those insurance company underwriters are going to make sure the company is well protected.

I’m pretty sure that if husband and I had gone the MA route as healthy seniors at age 65 , we’d be paying heavily in supplemental premiums now if we tried to switch to trad Medicare…even if we would get coverage…and for as long as we stay above ground given the surprises we’ve both had over the past few years.

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The only time insurance companies are forced to write supplemental insurance policies without underwriting is when the insured begins Medicare at age 65. After that, all bets are off. Denial of coverage is a real possibility.
Wendy

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Seeing as my date with Medicare is getting scarily close, let me ask a question.

If you get a supplement at age 65, can you continue to get a supplement without underwriting after that? Or is the guaranteed issue only for that one year?

And what about the premiums. Assuming you start at 65, do they increase with age? Inflation? Health condition?

—Peter

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Some states have guaranteed issue laws that expand when you can switch.

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@ptheland once you have a supplement insurance you can continue and even change companies without additional underwriting. But make sure you keep continuous coverage.

The premiums do rise every year but it hasn’t been bad. The government stipulates that each tier of coverage costs the same from all the companies.

Wendy

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