“Not Medically Necessary”: Inside the Company Helping America’s Biggest Health Insurers Deny Coverage for Care

[annon123]

No the main reason the medical profession hates Medicare advantage is money . I bet 80% of Medicare advantage clients are lower middle income to low income . With routine $200-$300 copays for mri’s , X-rays etc and hospital stays of $400 a night . You think 90% of these copays are ever paid ? Heck no . You walk in with a fat sup and the dr orders all the tests he wants and he’s paid 100% of what his contract speculates . No question the biggest question I get is why am I billed for this and that ? Mrs Walters id be glad to sell you a sup and pdp at $230 a month but you rx’s will also cost you $1000 more got the yr . No question if you can afford it a plan n much better medically than a mapd .

That is not true. There is also a lot of bitching about OM reimbursements as well, cuts, failure to take inflation into account... This really affects private practices - not to mention hospital systems are reimbursed at a higher rate for what their employees do, the tests done there, etc than the private practice doctors.

1) The medical professionals I know (and a lot has been written about this in that profession as well on Becker, etc.) hate MAPs because of all the denials of referrals, denial of tests, enough rehab, etc. and number of appeals it takes to overturn that... and so as a result how much longer and how much work it takes to get something done.

2) Most of the denials are done using AI in 15 seconds or less and with quotas the medical people who are supposed to review them have a minute or less to do so. Never mind a lot of this is done by NP's and PA's and not MD's with a speciality in that area. Many poor decisions are made that way. Not a problem with OM with respect to referrals as no referrals are needed. Saves the MD/office/system some time and the patient gets more timely care.

3) By the time the denials are overturned the patient may have gotten worse. Around here pretty much any residential rehab is denied for MAP patients even if they could really use it. Meanwhile waiting for the appeal the patient is sent home and needs more help than they have.

4) So many systems, once you get sent to collection, they cut of care for you in the entire system and then sue you (which is an increasing problems as health care systems are buying other systems and growing exponentially, reducing local choices with respect to number of different systems). That helps minimize losses with respect to continuing failure to pay in a health system. Of course in an area with few choices you may end up with no heath care with a MAP.

Add to that the for profit (and sometimes the Venture Capital owners - they make their money by selling what they invest in within 10 years which means the new owners often have a large debt that needs paid off) ownership and yes, even though they get more money (not to mention MAP's get more to begin with than OM), but they have less left for patient care because they need to have shareholders to take into consideration. In for profit companies generally they tend to view their obligation to the shareholder as the highest priority (eg return on their investment; if they didn't their stock would drop) and not the other stakeholders (eg patients, medical system/employees, etc.). That doesn't end well for patients, hospitals, private practices...

There is no one simple explanation for what is going on.

 

[Midlevel]

What I'd like to know is the name of that hospital that only charges $400 a night.

I know I’m always defending DonP but I bet he meant 400.00/night copay on the MAPD plan.