Any idea with MA companies are the best? I currently have BCBS MA. As long as I get authorizations nailed down it has been ok.Denying claims: The insurance companies do love to deny claims. APlans do so frequently, and only about 9 percent of such denials are appealed, even though about 80% of the appeals are successful. Either way the insurance company wins by getting free use of your premiums until the approval, and of course they know that many invalid denials will not be appealed.You may or may not care about this, but from the provider side of the equation Original Medicare with a supplement just works well. What is or is not covered is pretty well understood and prior auths are limited. Claims go to Medicare who pays what they're supposed to then forwards the crossover claim to the supplement who pays what Medicare says they're supposed to.
Medicare advantage introduces all the pitfalls of commercial insurance. Every plan has different rules for what is or isn't covered and what needs prior authorization and they love to deny claims.
Anecdotal story time feel free to stop here if you like. We once had a direct admit from ER to inpatient. The Medicare Advantage plan took all 14 days allowed by the contract to determine if an inpatient stay was necessary, and ultimately denied it as an inpatient stay saying the patient had to be in observation status. The patient died in our bed over a week before the Medicare Advantage plan responded that their situation didn't warrant an inpatient stay.
Incentives to sell Aplans, per a broker that I spoke to: Brokers in my state get paid about 800 dollars to sell an APlan, and about 400 to sell a Medigap plan the first year. APlans also pay about 50% of the origination commission for renewals for a year or so even if the broker is not part of that transaction.
Underwriting for a Medigap plan: The broker I spoke to noted that she has had only one underwriting that allowed the applicant to go to a Medigap plan, and that person was a world class athlete. I have known one female who tried to get a Medigap plan after the APlan and she was denied for taking a statin medication for prophylaxis, and a medication to prevent osteoporosis because her 90 year old mother had osteoporosis. The person who was denied was very healthy, with no history of surgery other than a fracture open reduction/fixation from years earlier, and no sig medical problems of any sort. The underwriting is pretty somewhat of a scam because the insurance companies consider APlans to be much better for them and the underwriting criteria is very unreasonable. and effectively very confining to say the least.
Aplan you sign up for is not exactly the same plan next year. They can change your plan, and the do so annually. If you are not happy with the plan you are now usually stuck with it...or some other Aplan.
Aplan's Fraud investigations: Aplans from many (perhaps all?) are harvesting more money from the feds by scouring your chart/billings to find ways to tag you with diagnoses that are not really applying to you... and did/do not result in any treatments. This results in the insurance companies harvesting huge sums of funds that for labels that make you appear to be a higher risk patient than you are. The fraud investigations have been going on for a few years, and appear to be ongoing. The results and hard data of those investigations don't seem to be easy to find and read but are very real.
Statistics: Posted by bogles the mind — Wed Nov 20, 2024 4:56 am — Replies 9 — Views 847