Health Care Collector - Kluwer Law International

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AUGUST 2010
insurance) and Part B (medical insurance) coverage
to that beneficiary. MA plans must cover all
the services that traditional Medicare covers except
hospice care.
The lure for many beneficiaries is the “advantage”
that MA plans can offer extra coverage, such as
vision, hearing, dental, and/or health and wellness
programs. Almost all MA plans include Medicare
prescription drug coverage. Because patients pay
one monthly premium (in addition to their Part B
premium), they often view the program as a simplified
alternative requiring less paperwork.
But MA plans bring an element of risk to the
marketplace. These plans often seek to balance their
risk by passing extra costs on to the provider and
indirectly to the patient. Unlike traditional Medicare,
MA plans add additional levels of authorizations and
medical records requests that delay payment. In one
survey, some providers reported that they can expect
payment from Medicare within 25 days while MA
plans take over 50 days to pay the same claim.
While MA contractors will see cuts in premium
levels from CMS, MA plans will remain a choice for
beneficiaries under health care reform. Regardless of
premium amounts, the contractors cannot cut core
benefits to the beneficiaries. The risk for providers is
that the MA plans will continue to balance their budgets
by taking their “savings” from providers.
Beneficiary Choice and Consequence
Patients often think that an MA plan will administer
their benefits while simplifying the paperwork.
When patients choose an MA plan, they don’t factor
into their decision the restrictive policies that exist
under these plans. But CMS makes it very clear in
their official beneficiary handbook, Medicare & You
2010 , when they state:
Medicare pays a fixed amount for your
care every month. These companies follow
the rules set by Medicare. However, each
Medicare Advantage Plan can charge different
out of pocket costs and have different
rules for how you get services (like whether
you need a referral to see a specialist or if
you have to go to only doctors, facilities, or
suppliers that belong to the plan). . . .
If you get health care outside the plan’s network,
you may have to pay the full cost. . . .
Make sure you understand how a plan works
before you join. Not all plans work the same
way, so before you join, find out the plan’s
rules, what your costs will be, and whether
the plan will meet your needs. . . .
It is important that you follow the plan’s
rules, like getting prior approval for certain
services when needed. . . .
It is questionable how many patients have conducted
a thorough review of their MA plan, and
whether they fully understand that they have given
up the flexibility of a full choice of providers. For
more mobile beneficiaries, they may not realize the
financial impact of seeking care outside their service
area. This is often a big shock to patients who travel
or who split their time between summer and winter
homes. While emergent services are covered, the routine
care is not. It falls upon the provider to inform
patients that they may not be covered for the services
they need.
MA plans often seek to balance their
risk by passing extra costs on to the
provider and indirectly to the patient.
When patients are unprepared for the additional
responsibility they take on when they sign up for an
MA plan, the provider must take an active role in
advocating for their patients so that their patients get
the most out of their benefits. Part of this is about
educating the patient. If the patient was not fully
informed about the risks and limits of the MA plan,
the patient can request to un-enroll in the plan. In
the Medicare & You 2010 handbook there are instructions
for patients who are already in MA plans who
need to switch to traditional Medicare.
Risk Points
Indeed, gaps in provider documentation have
promoted the image that MA plan savings come
from preventing what they deem to be unnecessary
care. In most cases, despite these documentation
gaps, the care follows the standard courses
of treatment. However, much of the payer savings
are recouped in other risk points. The provider
is vulnerable in a number of areas and these are
the very points that the MA plan claims processor
exploits to gain profits. Some examples of these
risk points are:
• The point of service. Providers have difficulty identifying
MA plan coverage vs. Medicare coverage,
authorization requirements, notification requirements,
and care management requirements.
(Utilization review nurses and doctor intervention
is needed to prevent gaps.)
HEALTH CARE COLLECTOR