Don't Allow Medicare Advantage Plans and MCOs Take Advantage of YOU!

Published in Complex Rehab on June 22, 2021

By Dan Fedor, Director of Reimbursement and Education, U.S. Rehab

The HME supplier has always had challenges in getting paid timely and accurately for the items and services they provide to their customers. This is an assumed cost of doing business but the HME supplier still does this because of the reward of taking care of their customers. But nothing has challenged the supplier as much as when a customer has a Medicare Advantage Plan (private insurance companies replacement to original Medicare) or an MCO (outsourcing of state Medicaid programs to private insurance companies). These private for-profit insurance companies have infiltrated the once sacred protection of health care for seniors through original Medicare and the Medicaid program with health care for low income adults, children, and people with disabilities.

The common theme here is the two major government healthcare programs (Medicare and Medicaid) that are supposed to safeguard healthcare for seniors and low-income adults, children, and people with disabilities are allowing private insurance companies to administer healthcare for this demographic.  

Seniors today are being bombarded with TV commercials from these private insurance companies often posing as Medicare and they often use likable celebrities to sell their Medicare “Advantage” Plan. But read the fine print: Not affiliated with any government program or agency. 

This is a screenshot of the commercial and it’s still difficult to read the fine print, so does anyone think a senior is able to read this while Joe is cheerfully talking and it’s a moving video? No, so senior believes they are calling a real Medicare representative with their best interest in mind. We all know their target audience is the Medicare aged (65 +) and their goal is to convince them to select their “Advantage Plan” over Original Medicare by touting that they offer all the standard benefits of Medicare plus additional benefits with a lower out of pocket cost. But many HME suppliers are finding out just how these private health insurance companies pay for all these celebrity-filled commercials and additional benefits and that is by making suppliers fight for every claim with delay tactics or simply denying claims and many reimburse at unsustainable rates when they do pay.   

These ads are very misleading and some (me) would say deceptive, especially when they are targeting seniors. How can these healthcare insurance companies get away with this type of misleading advertising to seniors and what can you do to combat it?

First, if there is a contract to be in-network, review it thoroughly and make sure the coverage criteria, rates, and payment processing is acceptable. Don’t just accept it if they say “We Follow Medicare.” Ask to see details in writing. If there is no contract and a customer comes to you for HME, verify these details. If you can’t accept what they offer, don’t. Try to negotiate a fair contract and if they won’t, don’t accept it and inform the customer specifically the reason why you can provide them with the items they need.  They are only hearing from celebrities promoting their plans of how great they are but not how they negatively impact their true medically necessary benefits with unsustainable prices and payment methods.

Second, assist your customers (current and new) of where they can obtain unbiased information on the differences between Original Medicare and these Advantage Private Plans. With the MA plan, the customer may be able to get a gym membership and eyeglasses, but they may not be able to obtain the wheelchair, hospital bed, oxygen they need because their insurance makes the supplier jump through hoops to get paid for their services. Educate them that they CAN select Original Medicare FFS (or switch back) if they find that the MA plan isn’t as good as the celebrities made it appear. 

Please notify Medicare recipients struggling with making sense of all these plans and the sales pitch from insurance companies that they can call 1-800-633-4227 (1-800-Medicare) to speak an ACTUAL Medicare representative for accurate unbiased information about selecting the best plan for them.  

As far as the Medicaid patients that are moved to an MCO, it’s actually a more difficult position as they weren’t manipulated by a celebrity to select this for their health insurance, they were placed here by the state. And they can’t switch back to the state's Medicaid program since the state outsourced this function to the MCO. So what can you do when you want to help the patient but the MCOs is using delay tactics, outright denying inappropriately, or paying at a rate that you can’t accept?

Contact the MCO to express the concerns and let them know you can’t continue servicing these patients and if these issues are not corrected. However, from what I hear don’t care about the patient and won’t change anything. Remember, they are for-profit insurance companies not for-patient insurance companies, which is what they should be. If that doesn’t work then contact your state's insurance commissioner, your state representatives, and your congressional representatives. But before you do, have your case prepared as to the details of how their actions are negatively affecting your business and in turn, how it is negatively affecting patient care. They will ask for examples, so have them ready with how long claims are delayed, incorrect denials and their payment rates (40% of Medicare, etc.).

If suppliers keep accepting delays in payment, incorrect denials, and unsustainable rates the Medicare Advantage Plans and MCOs will continue taking Advantage of suppliers. It’s easier said than done but suppliers must stand up to the bully to initiate the changes needed to ensure timely, accurate and sustainable reimbursement rates so they can continue taking care of their customers. 

This article was originally featured in HomeCare's June 2021 issue.