In a hospital or healthcare facility, once a physician orders a treatment or test, it must be completed, no discussion. However, when a patient has a Medicare Advantage plan, the insurance company will regularly deny a physician’s order. Who is practicing medicine, here? The doctor or the insurance company? After all, if a nurse decides not to carry out an order by a physician, he or she can lose their license.
Medical clinics and facilities are faced with challenges from Medicare Advantage plans on a daily basis. When doctors order procedures based on diagnoses, Medicare Advantage companies are quick to deny coverage, often by a clerk. This sets off a cascade of events, all at added cost to the medical practice or facility. To assist the patient, the provider will send additional documentation to a nurse just to deny coverage again. Next comes a peer-to-peer review where the physician has to spend uncompensated time to try to get the procedure or test covered. Meanwhile, the doctor is behind schedule taking away time from other patients.
Due to provider fatigue, many practitioners simply give up on ordering the additional care a patient may benefit from in recovery. It simply takes too much effort. For what? To have the coverage denied in the end. The result is patients go without the care they deserve due to Medicare Advantage companies refusing to follow physician orders.
The other element of provider fatigue is the added provider costs, primarily staff time, to deal with Medicare Advantage plans and their attempts to avoid paying for care ordered by the physician. The Medicare fee schedule paid to providers is already at a reduced rate, considerably lower than private insurance. Medicare Advantage plans often pay a provider even less than the Medicare fee schedule.
Trying to get paid by Medicare Advantage plans is typically a costly matter, as well. Medicare Advantage often asks for stacks of medical records, even after approving a procedure or course of treatment. Once a claim is submitted, it is often denied; requiring more billing time. To add insult to injury, Medicare Advantage companies often revoke payments months after a claim has been paid. Additionally, the provider has to collect more co-pays and deductibles from the Medicare Advantage patient compared to Traditional Medicare. In particular, if a patient is eligible for Medicare and Medicaid but converts to Medicare Advantage, they likely cannot afford to pay the deductibles or co-pays, anyway — which is why they were on Medicaid to begin with! While the responsibility for payment lies with the patient, you can’t get blood out of a turnip. The burden of collecting (perhaps an uncollectible bill) falls on the provider, not the Medicare Advantage company.
One of the costliest stunts of Medicare Advantage plans is to leave patients in an acute care setting with no additional payment to the hospital. The typical progression of care is to spend only the necessary amount of time in acute care and then discharge the patient to an appropriate level of post-acute care. This may be a Long-Term Acute Care Hospital (LTACH), an Inpatient Rehabilitation Facility (IRF), Skilled Nursing Facility (SNF) or Home Health. Hospitals are paid by a system of Diagnostic Rating Groups (DRG) which is a charge based on the typical expense for the hospital to take care of a patient with that diagnosis. It is not necessarily based on the length of stay. Therefore, Medicare Advantage companies will delay or deny approval of post-acute care options, such as those noted above, forcing hospitals to retain patients. This lack of action by Medicare Advantage companies is responsible for considerable increased costs to hospitals already operating on very thin margins. If that same patient was on Traditional Medicare, he or she would be discharged to the appropriate level of post-acute care for further treatment and recovery. This patient receives proper care and the hospital receives proper payment. If we all want hospitals to be available to us, then we must pay them enough to be sustainable. Medicare Advantage does not pay for the sustainability of our healthcare system!