Tag Archives: Medicare

ATTORNEY GENERAL SWANSON ASKS FEDERAL AGENCY TO INVESTIGATE COMPLAINTS AGAINST HUMANA BY MEDICARE PATIENTS

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Minnesota Attorney General Lori Swanson today asked the federal agency responsible for regulating private Medicare insurance policies to investigate and remedy complaints by Minnesota senior citizens about improper claims handling by Humana, which sells private Medicare policies in Minnesota.

In a letter containing over 25 sworn affidavits from Minnesota patients and medical providers, Attorney General Swanson called on the federal Centers for Medicare & Medicaid Services (“CMS”), which regulates private Medicare plans, to investigate and remedy any violations of federal regulations arising from Humana’s improper claims handling in Minnesota. The United States Congress has determined that states are preempted from regulating benefit determinations of private Medicare Advantage plans and has vested jurisdiction to regulate such plans with CMS.

“Medical bills that aren’t covered or processed properly can hit senior citizens hard in the pocketbook. We are asking the federal agency that has authority over these plans to fully investigate and remedy the problems experienced by Minnesota patients,” said Swanson.

Medicare Advantage plans are private health plans approved by CMS, but sold and administered by private insurance companies as an alternative to traditional Medicare fee-for-service coverage. Medicare Advantage plans may provide prescription drug coverage and include mandatory or optional supplemental benefits such as vision and dental benefits. Minnesota has the highest number of enrollees in Medicare Advantage plans in the nation on a per capita basis, according to a June 2013 report by Kaiser Family Foundation.

In her letter, Attorney General Swanson cites numerous problems reported by Minnesota patients and providers about Humana, including:

  1. Denial of claims involving Medicare-covered services. (Other than hospice care, Medicare Advantage plans must cover anything traditional Medicare would cover.)
  2. Overcharges for co-payments and co-insurance.
  3. Failure to adequately disclose what providers are in network and to update its network provider directories.
  4. Failure to follow the appeal procedures required by federal regulations.

Humana is a publicly traded, for-profit insurance company. It is one of the biggest insurers in the Medicare Advantage market nationwide, offering at least one type of Medicare Advantage plan in all 50 states. About 17 percent of all Medicare beneficiaries nationwide are enrolled in a Humana Medicare Advantage plan, according to a June 2013 report by Kaiser Family Foundation.

The Attorney General’s Office provides this advice to Medicare beneficiaries who are thinking about enrolling in an Medicare Advantage plan:

  1. Determine if your health care providers are in-network.
  2. Identify the copays, deductibles, and out-of-pocket maximum costs for the plan. Plans’ costs will vary, especially for in- versus out-of-network care.
  3. Determine if supplemental benefits are offered by the plan.

People may report complaints against Humana to the Minnesota Attorney General’s Office by calling (651) 296 3353 or (800) 657 3787. Individuals may also download a Complaint Form from the Attorney General’s website by clicking here and mail the completed form to the Attorney General’s Office at: 1400 Bremer Tower, 445 Minnesota Street, St. Paul, MN 55101 2131. People should also contact CMS directly about this problem by calling CMS at 1-800-633-4227 or by writing to its Administrator, Marilyn Tavenner, at Centers for Medicare & Medicaid Services, U.S. Department of Health & Human Services, Hubert H. Humphrey Building, 200 Independence Avenue SW, Washington, DC 20201.

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ATTORNEY GENERAL SWANSON ASKS FEDERAL AGENCY TO INVESTIGATE COMPLAINTS AGAINST HUMANA BY MEDICARE PATIENTS

Minnesota wants CMS to investigate Humana’s Medicare Advantage plans

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AG Lori SwansonMinnesota Attorney General Lori Swanson is asking the CMS to investigate Medicare Advantage plans offered by Humana and has presented regulators with more than 25 affidavits of complaints from beneficiaries.

The affidavits allege, for instance, that Humana denied reimbursement for services that it is required to cover for all Medicare beneficiaries—including diagnostic ultrasounds, mammograms and care in a skilled-nursing facility for a stroke patient.

The letter also said, among other complaints, that the Louisville, Ky.-based insurer created confusion by not adequately disclosing which providers were in-network and does not comply with required appeals processes.

The complaints come at a time when the popularity of Medicare Advantage plans has been escalating. And Minnesota has the highest percentage of Medicare beneficiaries enrolled in an MA plan, at 49%—compared with 28.8% of beneficiaries nationwide, the letter said. Humana has 17% of the Medicare Advantage market in Minnesota, according to Swanson’s office.

Swanson wrote that she was asking the CMS to pursue an investigation because states do not have the authority to enforce Medicare Advantage plan rules and make benefit determinations.

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Minnesota wants CMS to investigate Humana’s Medicare Advantage plans

Medicare Advantage? or DISAdvantage?

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signing 2The following article appeared originally on the healthinsurance.org Blog.

If you’re being courted by a private insurance company to enroll in one of its Medicare Advantage plans, don’t sign on the bottom line until you’ve read a recent report by a researcher at the Center for Medicare and Medicaid Services (CMS). The real bottom line you need to understand is that the insurer might want to keep you enrolled only as long as you’re relatively healthy. When that changes, you just might find that you’re no longer considered a valued member and that the traditional Medicare program is a much better deal for you.

The study, published recently in the Medicare and Medicaid Research Review, confirmed what some who are familiar with the Medicare Advantage program, including me, have suspected: when people enrolled in MA plans become critically ill, many realize that the only way they will get coverage for the care they need – and at a facility of their choice – is to return to the traditional Medicare program.

It may come as a surprise, but one of the reasons the Medicare program costs taxpayers more than it should is that the federal government has for years been overpaying insurance companies to participate in the Medicare Advantage program. (Medicare Advantage plans – typically HMOs and PPOs – are private alternatives to traditional Medicare.) Congress created the program after private insurers insisted that not only could they meet the medical needs of senior citizens and the disabled more cost effectively than the government, they could do so and still make a profit.

Many of the first insurance companies to participate in the program (previously known as Medicare+Choice) found out they couldn’t deliver on that promise. According to Health Affairs, 44 percent of the insurers that tried it between 1987 and 1990 threw in the towel and dropped out of the program. To entice them back, the federal government began paying insurers a bonus every year in the form of overpayments. Those overpayments have been sizable enough to keep most of them in the game and to keep investors of for-profit insurers happy.

You’re helping to keep those investors happy In 2009, the Medicare Payment Advisory Commission (MedPAC), which advises Congress, reported that those bonuses were costing Medicare (read: taxpayers) billions of dollars every year. It estimated that in 2009 alone, Medicare paid private insurers 14 percent more per beneficiary than it would cost the government to cover those beneficiaries in traditional Medicare. Between 2004 and 2008, according to MedPAC, the overpayments totaled nearly $33 billion.

During the debate on health care reform, the Congressional Budget Office estimated those overpayments would cost the government $157 billion over the coming decade. As a consequence of these overpayments, according to CMS, premiums for all Medicare beneficiaries, including those enrolled in traditional Medicare, are higher than they otherwise would be. That’s more than just an annoyance: the Medicare Hospital Insurance Trust Fund will become insolvent 18 months earlier than it would otherwise because of those overpayments, according to Congressional testimony by CMS’ chief actuary. That’s why, despite intense lobbying by the insurance industry, Congress inserted a provision in the Affordable Care Act to eventually phase out those overpayments.

It turns out, though, that those overpayments are not the only reason for MA insurers’ healthy profits. Many MA enrollees are finding that their plans – which offered discounts on gym memberships and hearing aids as an enticement to enroll – are not so willing to cover things like skilled nursing care when they get critically ill.

To see if that might be happening on a large scale, CMS researcher Gerald Riley looked at 240,000 people who dropped out of their MA plans in 2007 and compared them to Medicare beneficiaries who had always been enrolled in traditional Medicare. He found that those who had left their MA plans had used an average of $1,021 a month in medical services during the first six months after returning to traditional Medicare, compared to $710 a month for those who had never been in an MA plan.

Sicker MA enrollees may be less satisfied with program Citing his own findings and previous research that found more problems getting needed care among MA enrollees than beneficiaries in traditional Medicare, Riley wrote that, “Disenrollment of high-cost individuals may be related to persistent lower levels of satisfaction among sicker MA enrollees.”

My own mother will attest to that.

Back when my mother was much younger and healthier – and when I still worked in the insurance industry – I encouraged her to enroll in an MA plan. At the time it was especially appealing because it covered prescriptions medicines. The traditional Medicare program didn’t provide drug coverage until 2006.

Although Mom saw her MA premiums increase significantly over the years, she didn’t have any real motivation to disenroll until after she broke her hip and required skilled care in a nursing facility. After a few days, the nursing home administrator told her that if she stayed there, she would have to pay for everything out of her own pocket. Why? Because a utilization review nurse at her MA plan, who had never seen or examined her, decided that the care she was receiving was no longer “medically necessary.”

Because there are no commonly used criteria as to what constitutes medical necessity, insurers have wide discretion in determining what they will pay for and when they will stop paying for services like skilled nursing care by decreeing it “custodial.”

After doing considerable research, I learned that another highly regarded nursing facility nearby would take Mom and provide her with the skilled care she needed, but not if she stayed in the MA plan. That facility had years ago decided not to participate in MA plans like the one my mother was in because what happened to Mom was happening to other patients. Utilization review nurses at MA plans – not the patients’ treating physicians – where making the ultimate decisions as to whether nursing care was medically necessary. They still do.

I’m confident that Mom is alive today – and not completely broke – because she disenrolled from her MA plan and returned to traditional Medicare with a Medicare supplement plan to cover out-of-pocket expenses. And I’m confident after reading Riley’s study that there are hundreds of thousands of other people just like Mom who had similar experiences. And that the traditional Medicare program is paying more than it should because of the practices of many MA plans.

Your chance to leave MA is limited

At the beginning of the MA program, people could disenroll at any time. That’s no longer possible. If you’re in an MA plan and don’t like it, you have a relatively brief window of opportunity each year to go back to traditional Medicare. Keep that in mind as you’re trying to decide whether an MA plan is right for you, either now or later. It very well could be right for you. Some studies have indicated that people in MA plans are less likely to end up in the hospital or emergency room. But you might not know that enrolling in a private plan was not a great idea until you’re critically ill.

Following a 20-year career as a corporate insurance executive, Wendell Potter left his position as head of communications for Cigna in 2008 to advocate for comprehensive health care reform. He is now an analyst at the The Center for Public Integrity and president of Wendell Potter Consulting. He has also served as a consumer representative to the National Association of Insurance Commissioners. His book, Deadly Spin: An Insurance Company Insider Speaks Out on How Corporate PR Is Killing Health Care and Deceiving Americans, was awarded the Ridenhour Book Prize for “outstanding work of social significance” in 2011. In March, he testified before Congress about the affordability of Obamacare. Potter also provided his perspective on the nation’s broken health care system when he was interviewed for a documentary that aired nationally.

 

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Medicare Advantage? or DISAdvantage?

Taking Advantage of Medicare Advantage

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Federal government has been overpaying private insurers.

cash cowFacing government cuts to one of their cash cows—private Medicare plans—health insurance companies have launched a multi-pronged campaign, financed by the customer premiums, to persuade Congress to keep the cuts from going into effect next month.

The industry’s big PR and lobbying group, America’s Health Insurance Plans, is deploying the tactics I described in Deadly Spin to scare seniors into believing that if the federal government stops overpaying insurers that offer Medicare Advantage plans (the private alternative to the traditional government-run Medicare program) seniors will “pay more, get less and lose choices.”

“U.S. Health Insurers Launch TV War Over Medicare Advantage Cuts,” read the headline of a Reuters story last week when AHIP’s ads started running.

At issue is a 2.3 percent cut in payments to Medicare Advantage plans by the Centers for Medicare and Medicaid Services (CMS) that are scheduled to go into effect on April 1.

The industry’s campaign, of course, conveniently leaves out the fact that the government has been overpaying private insurers for years and that the cuts being proposed starting next month are part of a broader effort to put a stop to those overpayments.

Members of Congress inserted a provision in the Affordable Care Act to reduce the overpayments by $200 billion over the next several years.  The 2.3 percent cut would be in addition to that.

It makes little sense for the government to overpay private insurers in the first place, but that is exactly what’s been going on for several years. During the administration of George W. Bush, which supported the privatization of the Medicare program, Congress passed legislation to provide incentives to insurers to offer private plans to compete with traditional Medicare. This enabled the plans to offer richer benefits than traditional Medicare at little or no additional cost to beneficiaries while also making a tidy profit.

It’s little wonder that the number of people enrolled in Medicare Advantage plans has increased rapidly. About one of every five Medicare beneficiaries are now enrolled in private plans. When the government enables you to offer plans with vision and dental benefits, lower copayments and discounts on gym memberships, all at no additional cost, you’re going to be able to lure a lot of seniors from traditional Medicare.

An agent for Humana Inc., one of the biggest Medicare Advantage companies, told me a few years ago that, thanks to the sweet deal insurers have been getting from the government, his job of enrolling healthy seniors in Humana plans was “like shooting fish in a barrel.”

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Taking Advantage of Medicare Advantage