Inspector general report on Medicaid advantage plans

Crushed

note the thread title is wrong it's MEDICARE 
there is no such thing as Medicaid advantage
There is also no way to edit a thread title

New report

 Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care


https://oig.hhs.gov/oei/reports/OEI-09-18-00260.pdf

Our case file reviews determined that MAOs sometimes delayed or
denied Medicare Advantage beneficiaries’ access to services,
even though the requests met Medicare coverage rules. MAOs
also denied payments to providers or some services that met both
Medicare coverage rules and MAO billing rules.

  
 A central concern about the capitated payment model used in
Medicare Advantage is the potential incentive for Medicare
Advantage Organizations (MAOs) to deny beneficiary access to
services and deny payments to providers in an attempt to increase
profits. Although MAOs approve the vast majority of requests for
services and payment, they issue millions of denials each year, and
CMS’s annual audits of MAOs have highlighted widespread and
persistent problems related to inappropriate denials of services
and payment. As enrollment in Medicare Advantage continues to
grow, MAOs play an increasingly critical role in ensuring that
Medicare beneficiaries have access to medically necessary covered
services and that providers are reimbursed appropriately.

toolbeltexpert

Caveat emptor

Ed1937

Good info. Thanks.

Quilting brings calm

Crushed -  I notice that the report refers to MediCARE while the thread title shows MediCAID.  I didn’t go through all 61 pages to confirm. Of course, the issues highlighted probably apply to both. 

I am so glad you posted this. As I think I posted in another thread,  my spouse will be 65 this summer.  We( me, he leaves this stuff up to me) have been trying to decide whether to switch him from my retiree insurance to Medicare part G and part D.  My insurance will automatically turn into a Medicare Advantage plan once we are both 65 in 18 months or so.  This report just highlights my concerns about an Advantage plan.  Even though my plan is a group plan for state employee retirees, I just don’t trust it to be any better than Medicare Advantage plans  offered to everyone.  My stomach has been in knots trying to decide what to do ( pay more in prescriptions with the part D in return for less authorization issues and claim headaches).  

Crushed

Quilting brings calm wrote:

Crushed -  I notice that the report refers to MediCARE while the thread title shows MediCAID.  I didn’t go through all 61 pages to confirm. Of course, the issues highlighted probably apply to both. 

thanks for the pick up  I edited the post to put a note in

Crushed

Quilting brings calm wrote:

I am so glad you posted this. As I think I posted in another thread,  my spouse will be 65 this summer.  We( me, he leaves this stuff up to me) have been trying to decide whether to switch him from my retiree insurance to Medicare part G and part D.  My insurance will automatically turn into a Medicare Advantage plan once we are both 65 in 18 months or so.  This report just highlights my concerns about an Advantage plan.  Even though my plan is a group plan for state employee retirees, I just don’t trust it to be any better than Medicare Advantage plans  offered to everyone.  My stomach has been in knots trying to decide what to do ( pay more in prescriptions with the part D in return for less authorization issues and claim headaches).  

I know. it's crazy 

DW and I don't have medicare part B Because we have 

Federal employee health benefits and would have to pay IRMA on  Medicare  DWs care costs $150,000 a year.  That comes out of pensions and IRA  but its all income for IRMA

  

Jo C.

This has been a serious problem issue since the Advantage Programs started in 1997.  As an RN, Administrator of Patient Care Management, at various medical centers as well as a consultant, I have seen what can be done well; but also have seen plenty of bad practice and bad faith. 

When profit can be made from holding back on patient care in a variety of ways, and annual bonuses in the five to six figures can be made by practitioners who have annual "good utilization," things can slide sideways pretty fast.

I saw so much and actually found myself advocating for patients caught in a bad place.  Equipment refused to be ordered for the Advantage patient, BUT ordered for same symptoms/needs for private pay patients by the very same physicians.

I saw bonus checks for both the primary MDs and specialists at a large Advantage Program group for a very large med center that I was consulting for . . . the checks were extremely "generous."  This was coming from holding down admissions, getting the patients out quicker and sicker, and not authorizing the more expensive tests and scans.  I also found that hospital readmission rates for the group was high as well as were those patients who got sicker and needed more care.

In one large med center Advantage group I was consulting at, I literally saw what happened to Quality Improvement with patient response questionaires.  QI is important and mandated to be reported for the Advantage Groups . . well; this huge group had their QI Director with a very large number of highly negative returns.  She was speaking to the physician director and said, "Well; we know what we do with these, " and promptly threw them in the trash and both of them laughed.  Stunned me.  I decided to leave.

Another such group, I sat on the MD committee that met weekly to discuss high end patients.  It again stunned me in how they were trying to find ways to have such patients actually disenrolled from their plan and some of it was not so nice. 

Then there was the horrible day; I was consulting at an acute med center and was on a patient care unit going over something in a record.  An excellent Neurologist had been in to see a female patient. She had had severe symptoms for months - won't describe them, but she got worse and worse and lost much function. She had asked for a CT Scan or MRI several times, but was denied authorization.   The Neurologist, a nice man, actually threw the hard copy record at the wall.  He angrily said, "If they had authorized a scan months ago, this patient could have had that tumor removed and lived a normal life.  It is now too late and she is dying."  He was furious and walked away cursing.  Again, stunned.

These are some instances of terrible practice; but there are those groups who practice ethically and well; it is just hard to know. That can also be variable depending on how well the group is doing as well as instances in who is heading the group and applying pressure.

How the feds did not realize that personal profit would not just hold down Medicare's costs which was what the Advantage programs were supposed to do, but would also cause harm secondary to greed and avarice, I do not know. 

My feeling is; personal profit in such a way is a negative, and bonuses for holding down care should be illegal.  Here we are anyway.

Still; similar problem issues have existed for a long time now since hospitals have been paid on the Diagnosis Related Group dynamics.  One flat fee for the admitting diagnosis no matter what.  Hospitals need to hold down lengths of stay and expensive testing as much as they can and use their own physician hospitalists to follow and manage inpatients, as well as their utilization staff to do it so they can make a profit and not a loss on Medicare patients and other insurance groups.

Medicare realizing oh; uh-oh, patients are being discharged too early and being redmitted sicker . . . SO they decide to penalize hospitals for too many early readmissions . . . BUT . . . then they decided to let hospitals turn the inpatients into outpatients; and  they can do that retrospectively even post discharge.  Gee; guess what happens . . . outpatients are NOT considered readmissions, so it is healthier for the hospitals to have outpatients so there is no readmission concern re penalities, etc.  

I do not think we will find an answer, it is the industry's dynamics.  Let's not forget the dark  political aspect of deep pockets and lobbyists paying out to candidates, etc., in all of this.

No answer that I can find.

J.

sandwichone123

QBC, while it means nothing really, and we're probably in different states, I did want to say that my parents have been very, very happy with their state employees Medicare advantage plan here in NM. I'd suggest talking with other people that use various plans, if you know any. It's hard to trust the reported data, since so much is self-reported by the corporations.