Great article written by a friend on the many slimy aspects of Medicare Advantage plans Concord Monitor - Opinion: The siren call of Medicare Advantage
Upcoding is not unique to Medicare Advantage, but also occurs in traditional Medicare and non-Medicare plans. I recall some instances of tests of dubious value being ordered (looked up later to find that they were only indicated under certain symptoms or conditions, which I did not have), seemingly to run up the bill against (employer provided private) insurance (part of why I left that primary care physician).
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Upcoding is typically coding (billing) for a more complex level of service than was provided, or for a longer timed service (eg coding for a 30 minute consultation when only a 15 minute consultation was provided). In the case of MA, some doctors may feel certain tests should be run on their patient, but the insurer will only pay for it if the diagnosis is “X” . So guess what diagnosis they use for their patient. It’s not only running up bills, but it’s a CYA if the Dr. feels the patient should have the test. Running up bills with possibly unnecessary tests to generate billing for private insurance is not exactly the same as upcoding, IMO.
Oh, and as an aside, @ucbalumnus, Rob’s middle initial is S, not F. Not sure if you mistyped or if somehow copying the quote made the error!
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Thanks for sharing!
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As I’ve said year after year when this subject comes up…
All Medicare Advantage plans are not the same. I’m a member of a very large group and I have an Advantage Plan. It’s a PPO with a lot of extra features wrapped into it. It’s not a bargain priced one, but it is very robust.
There is no in/out of network at all. Any doctor who takes Medicare is required to take this plan. Same with hospitals, labs, etc.
Believe me, I keep a careful eye on the benefits.
So, as with most health insurance plans, YMMV…so please don’t cast a broad brush on all advantage plans, because they all are not the same.
The other benefit I have as a member of my large group…I can switch back to regular Medicare with supplement during any open enrollment period without underwriting. This is not the case with many who choose to switch to the advantage plans.
I am not saying everyone should sign up for an advantage plan. But there are some advantage plans that really are good.
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Please read the article. Much of what he addresses is behind the scenes shenanigans for these private providers, not just the services the patients see.
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I read the opinion article.
Most individuals are not able to access large contracted MA retiree plans.
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There are surely those who are fortunate to have access to a good contracted large group retiree healthcare plan. And they are fortunate. And surely some are happy with their coverage. But for the vast majority of folks, most MA plans are cheap for a reason- you get what you pay for. Most notably the HMO plans (which the majority of MA plans are), and more and more hospitals are dropping them, due to excessive pre authorizations, denials, delays in payment, etc. sure this is true for many insurers (Especially HMO’s), but lying to senior citizens to lure them into plans that won’t provide decent care is unacceptable. I spoke to a colleague yesterday who had this happen to a potential patient who she could not see because of the plan (UHC Wellmed) some salesman sold her. As mentioned previously, Mayo Clinics will accept no MA plans. Hospitals are dropping Medicare Advantage plans left and right
Like my old friend, the retired physician and author of the article in the OP, and many other of us former providers who have experienced the hassles and nightmare of many MA plans, I will encourage those who can afford to select traditional Medicare to do so.
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I despise this company…but they are really the only viable option in much of northern CA. They are also the reason we are the most expensive healthcare market in the nation…at least they got a slap on the wrist. I am not yet Medicare and this provider does the upcoding in the private insurance market too.
Mention that ‘hey, I’d like like to lose those five lbs’ and the coding reflects ‘counseling on weigh management and discussion of BMI’. Mention that I saw an DO for hip pain which is RESOLVED and it gets coded as ‘discussion of hip pain’. By the end of a session - where I’m just checking in to remain an active patient - I get a bill with a surprising number of diagnostic codes.
Oh well, I’m on Medicare in August and then they will just have to keep me as a patient.
‘Sutter Health, a California-based health care services provider, and several affiliated entities including Sutter Bay Medical Foundation (dba Palo Alto Medical Foundation, Sutter East Bay Medical Foundation, and Sutter Pacific Medical Foundation) and Sutter Valley Medical Foundation (dba Sutter Gould Medical Foundation and Sutter Medical Foundation) (collectively, “Sutter Health”), have agreed to pay $90 million to resolve allegations that Sutter Health violated the False Claims Act by knowingly submitting inaccurate information about the health status of beneficiaries enrolled in Medicare Advantage Plans.’
Thanks for posting this article, jym. H recently went on Medicare and I was encouraging him to sign up for MA. Now I’m not so sure if that’s a great idea. He definitely needs drug coverage.
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my nephew lived in Pennsylvania. He has UPMC health care through his employer. UPMC Health also has MA plans in the area. All UPMC owned and affiliated providers are in network as are many other providers. Some health systems have their own MA plans.
In contrast, it looks like one major medical group* around here seemingly prefers Medicare Advantage plans, based on its Medicare pages encouraging people to use them, with no mention of traditional Medicare (which it does accept, according to the government Medicare pages). Perhaps it is because traditional Medicare’s reimbursements tend to be smaller (in exchange for less questioning of claims), while the medical group already knows how to work the system with the usual insurance companies whom it has to make claims on for their non-Medicare business.
*Not referring to Kaiser, which accepts only Kaiser plans, including its Medicare Advantage plans.
It’s a good point that not all doctors accept traditional Medicare. Something people have to research when looking at their options.
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“Mayo Clinic and UnitedHealthcare also have established a new relationship that will give members enrolled in UnitedHealthcare Medicare Advantage plans in-network access to Mayo Clinic Rochester and Mayo Clinic Health System sites in the Midwest for the first time, effective Jan. 1, 2023.”
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I recently enrolled in Medicare. The pros and cons of MA plans are hotly debated on r/medicare. Personally, I never seriously considered a MA plan despite the relentless onslaught of marketing materials and TV ads promoting them. It was important ot me to maintain maximum flexibility to go where I want for treatment, and fortunately I can afford the premiums for B + supp G + D. I certainly know lots of people who have opted for MA plans, though, and anecdotally none of those friends are unhappy with them.
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What’s unfortunate for some patients with MA plans is that they don’t know if there are things they can’t get or will have to pay for. Some had charged a copay for every single chemo treatment. Don’t know if they still do.
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Glad to hear Mayo now accepts one MA plan. The letter they sent to patients was vague about which they accepted, but said most are not accepted and a patient with OON MA will not be scheduled at mayo.
MA can be fine for people who are generally healthy. Just steer clear of the HMO ones if one must get a MA plan.
TV ads are expensive. Yet many MA plans pay famous actors to hawk these plans I’ll over the airwaves. Wonder where they get the $$ . Hmmm…
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