New marketing guidance for brokers … this is why we can’t have nice things 😠

[MedicareWAA]

Seriously? Yet another rule/guidance making it harder to sell stuff. A few bad apples ruining it for the rest of us.

OIG's Special Fraud Alert warns about certain marketing schemes involving the Medicare Advantage program. These schemes involve questionable payments and referrals between Medicare Advantage plans, health care professionals, and third-party marketers such as agents and brokers. These schemes can mislead Medicare enrollees into choosing specific health plans or health care providers that may not meet the enrollees' needs.

https://oig.hhs.gov/documents/special-fraud-alerts/10092/Special%20Fraud%20Alert:%20Suspect%20Payments%20in%20Marketing%20Arrangements%20Related%20to%20Medicare%20Advantage%20and%20P.pdf

 

[DonP]

That's the same bs from last yr . It means zip unless dr oz does it .

 

[InsuranceGuy29]

Don't worry....all the loony commie policy is getting scrapped soon.

 

[MedicareWAA]

That's the same bs from last yr . It means zip unless dr oz does it .

This is from the Medicare people who carry guns.

 

[just-a-client]

I considered reporting Sutter Health to Medicare last year. During AEP, they sent marketing letters weekly, and emails, encouraging their patients to call eHealth to choose a plan. Last year these letters barely mentioned Original Medicare, but was filled with ideas like to check if your current plan still met your needs. OM is not a "plan" - though they could argue they mean Medigap and Part D plans. I thought it was misleading communication, and somewhat fear mongering.

Nowhere does it say don't worry, all Sutter doctors accept OM, and so will pretty much any other doctor you see.

This year the communication seemed to mention OM a bit more.

I never reporting them.

Here's the thing: Sutter has a very large presence in Northern California, a monopoly on hospitals in many communities. Outside of San Francisco, they have large numbers of primary care groups (mostly in Family Practice, fairly few internists) in their professional office buildings. As far as I can see, these Sutter health professionals, who work for one of their several medical foundations (with names like Sutter Pacific Medical Foundation) are in exactly one MAPD plan - for 2025, called

Alignment Health Sutter Advantage (HMO) - H3815-023-0

Most MAPD plans available for my zip code are $0 premium, while this one has a $48 premium, $3900 OOP Max, primary care $5/visit, specialist $25/visit, etc. It's more expensive than most plans here.

My PCP is in that plan. But no specialist that I see in other systems is in that plan. That happens - but then, the Sutter doctors aren't in any other MA plan. So there is no way I would be able to get a plan with everyone I see. Or get to use the academic medical center here (UCSF).

And, they don't even cover one very common generic drug I take.

So there is just one MA, plan, it has their name on it, it has no providers outside their system (except in cases where they have gaps and need outside specialists, in which case they include other doctors affiliated with their own hospitals), and they want you to call eHealth where you will certainly be steered into that one plan if you ask about keeping your PCP.

Sutter was poster-boy in Congressional hearings when Congress was talking about the Global and Direct Contracting ACO Model. They dropped out of the program shortly thereafter (maybe kicked out?). (That ACO program morphed into the less controversial ACO Reach Medicare project program, which is better balanced between private equity owners/management vs. health care professionals, and has more requirements for treating underserved communities.)

Sutter has also been sued for upcoding and lost one of the two lawsuits. How did they do the upcoding? It was asserted that they (1) Placed suggested diagnoses into charts based on patient history regardless of whether they were still treating those conditions, and later went a step further and pre-populated actual diagnoses with those extra codes, requiring clinicians to actively delete the diagnoses or they'd be included in the submitted claims. A whistleblower who was on the committees devising all of this testified about the high-level meetings she participated in, and the email communications, which involved setting up, maintaining and encouraging these processes.

But regarding marketing and sales: I don't see how money isn't flowing between Sutter and eHealth. Perhaps this follows the rules, perhaps it's a borderline case, or perhaps it's a blatant violation.

How many such systems have their own dedicated MAPD plans? Usually, providers in plans are at odds with the plans - doesn't it seem like they are in cahoots here?

Kaiser system has its own MAPD plans, its own exclusive medical groups, and its own hospitals. So that is similar. Maybe they try to keep up a firewall between the units.