By the end of the decade, Medicare Advantage plans are projected to cover nearly half of eligible beneficiaries. This author examines the impact of Medicare Advantage plans, what the plans cover, and how the preauthorization appeals process works.
Medicare for all” will soon become “Medicare for us.” The spectre of universal health coverage has made me look at the various Medicare options with a more critical eye. Even though Medicare looms as a constant in my clinical practice, the implication for me as a potential patient is a somewhat greater unknown. A little research was warranted.
Medicare became a reality in 1965. Since that time, the rising cost of paying for the benefits promised to seniors and the disabled has become increasingly evident. Medicare has evolved over the years to consist of Part A (hospital), Part B (physician and hospital outpatient services), Part C (Medicare Advantage, or MA), and Part D (prescription drugs). Medicare pays for these services under two separate trust funds, the Hospital Insurance (HI) Trust Fund and the Supplementary Medical Insurance (SMI) Trust Fund. When articles are written concerning the looming insolvency of Medicare by 2026, they are referring to the HI trust fund, impacting hospital reimbursement, not the SMI trust fund. Part C or Medicare Advantage plans are funded by the premiums/out of pocket costs that enrollees are responsible for as well as the portion from both the HI and SMI funds.
For clinicians, this should be reassuring, but is it? For patients, there are options for coverage. MA plans have a capitated payment model based on the Hierarchical Condition Category (HCC) score of their members. The higher your HCC score, the more comorbidities you have and the higher your projected medical costs will be. That means you bring more dollars to the plan. The question is, does the plan spend those dollars on your care?
A Closer Look at How Medicare Advantage Plans Function
Historically, MA plans offer more than traditional Medicare. More than 80% of plans provide the additional benefits of eyeglasses, vision benefits, hearing aids, and prescription drugs. These plans are administrated by commercial insurance companies. Most traditional Medicare beneficiaries carry a secondary insurance plan to cover the 20% copayments. MA beneficiaries cannot carry a secondary plan.
Looking more closely at MA plans, they attract a younger, healthier population. In 2019, more than 34% of Medicare-eligible recipients chose a MA plan.1 The MA plans are legally limited to a maximum of $6,700 out of pocket expenses for their members. If you become ill, your monthly premium is actually about $558. Because the plans are advertised as “no monthly premium” in most cases, this may be a false economy if you do become ill.
How do MA plans work? Medicare Advantage plans are supposed to offer the same benefits as traditional Medicare, using the same National Coverage Decisions and Local Coverage Decision policies. They are allowed to limit the number of available providers and may restrict what hospitals and facilities the beneficiary may use. Since plans are run by commercial insurance carriers such as UnitedHealthcare, Humana, BlueCross BlueShield, etc., these carriers have already developed prior authorization models for many services. They are implementing them to lower their costs across all lines of service, and potentially reducing coverage in their Medicare Advantage products.
A report by the Office of Inspector General in 2018 found a very high number of preauthorization and payment denials were overturned on first and second level appeals in Medicare Advantage plans.2 More than 75% of the denials were overturned on the first round of appeals, and even more were overturned when independent reviewers looked at these claims. This raises significant concerns that beneficiaries were being denied services and payments when they should not have been. The OIG found that only 1% (that is not a typo) of beneficiaries and providers went through the first level of appeal. In 2015, CMS cited over half of the MA plans for inappropriate denials of care and payment.2
Hyperbaric oxygen therapy (HBOT), as well as certain advanced wound care modalities such as cellular- and tissue-based products (CTPs), have been under scrutiny by all insurance providers, regardless of whether they are commercial or governmental plans. These modalities are costly, and since the MA payment model is a pre-set amount per patient, denials translate into profits. This has resulted in a greater than expected number of denials for advanced wound care modalities; in many instances, CTPs that are covered by the traditional Medicare are not being covered in the MA plans in the same jurisdiction.
The Appeals Process for Medicare Advantage
Many providers are under the impression that denial at the initial level of preauthorization in a MA plan cannot be appealed. In traditional Medicare, you submit a claim. If it is denied, then you can appeal through five levels of appeals: redetermination, reconsideration, administrative law judge, the Medicare Appeals Council and then finally a judicial review in federal district court. Most providers are aware that the process starts with redetermination.
However, this is not the case with MA plans. You begin at reconsideration. And there are only three levels that are identified. The result is confusing terminology that impedes your ability to search for the correct forms.
For example, on the Humana website, if you search for “redetermination,” it comes up blank.3 Once again, we need to know the terminology that is being used to be the most effective in appealing our case. On the United Healthcare website, under “Appeals, Coverage Determinations and Grievances,” if you click on “Medicare complaint form,” you get a “page not found” error.
So, appealing Medicare Advantage decisions is not for the faint of heart. You need to bookmark the Medicare.gov website and then find the provider payment integrity medical record review dispute request form for the insurance carrier you are appealing to.4
Be prepared to continue your appeals. Your chances of success are very high, according to the OIG.
Medicare Advantage plans are predicted to cover more than 47% of eligible beneficiaries by 2029.5 To best serve our patients as well as ourselves, we must educate ourselves on the processes that are being used by these plans. Sharing of experiences and outcomes is also valuable, so I invite you to post comments and let us know how you are doing. n
Helen B. Gelly is emeritus medical director of Hyperbaric Physicians of Georgia and chief executive officer of HyperbaRXs, Marietta, GA.
1. KFF. A dozen facts about Medicare Advantage in 2019. Available at https://www.kff.org/medicare/issue-brief/a-dozen-facts-about-medicare-advantage-in-2019/ . Published June 6, 2019.
2. U.S. Department of Health and Human Services Office of Inspector General. Medicare Advantage appeal outcomes and audit findings raise concerns about service and payment denials. Available at https://oig.hhs.gov/oei/reports/oei-09-16-00410.pdf. Published Sept. 25, 2018.
3. Humana. Available at https://resolutions.humana.com/grievances-appeals-forms/step-two?pageId=65894463-7453-4aae-9e6f-4668b708731b
4. Medicare. Available at https://www.medicare.gov/claims-appeals/file-an-appeal/appeals-if-you-have-a-medicare-health-plan
5. Congress of the United States Congressional Budget Office. The budget and economic outlook: 2019 to 2029. Available at https://www.cbo.gov/system/files?file=2019-01/54918-Outlook.pdf . Published January 2019.