[HN Gopher] Stop the Medicare "Advantage" Scam Before Medicare I...
___________________________________________________________________
Stop the Medicare "Advantage" Scam Before Medicare Is Dead
Author : MilnerRoute
Score : 99 points
Date : 2023-03-02 20:40 UTC (2 hours ago)
(HTM) web link (hartmannreport.com)
(TXT) w3m dump (hartmannreport.com)
| wankle wrote:
| As someone who will be medicare age in a few years, I was
| following the article until it hit the [drat those darn
| republicans] comment and my attention quickly waned, and not
| because of age.
| nobodyandproud wrote:
| Only several groups are consistently anti-national healthcare:
| Fiscal conservatives, anti-immigrants, and unions.
| more_corn wrote:
| My father in law had Medicare advantage. They denied his claims
| for skilled nursing that was getting him back on his feet. The
| facility just downgraded him from skilled nursing and left him in
| an hallway. He had a cardiac arrest due to low electrolytes ended
| up back in the ER and never recovered. (Pop quiz, how does
| someone on an IV end up with low electrolytes? Only way I can
| think is if they don't fill the bag)
|
| Why did they deny him? No reason. It's just standard procedure.
| They deny, get good justification and approve. They do that every
| 7 days. They prettied up the language but confirmed that this is
| exactly what they do.
|
| They literally killed him as part of standard operating
| procedure.
|
| This country is fucked. Y'all better hope you have enough money
| to go be old somewhere else.
| larrymyers wrote:
| When talk about Medicare they are usually talking about Part A
| (hospital care) and Part B (provider coverage), and sometimes
| Part D (prescription drug coverage). You are on your own for
| everything else, including dental and vision care. Adding dental
| coverage to Medicare continues to die in committee every year in
| congress.
|
| So if you know you'll need continued care from your dentist and
| eye doctor then Medicare Advantage can be a good thing, since
| most of the highly rated plans provide that coverage as part of
| their benefits.
|
| You can also get benefits for things hearing aids, and
| transportation to and from your provider visits, etc.
|
| Yes, if you sign up for Medicare Advantage you'll find yourself
| back in the world of the In-Network and Out-of-Network care
| model.
|
| At the end of the day though it's disingenuous to just label
| Medicare Advantage as solely the privatization of Medicare. The
| only way insurance companies that provide Medicare Advantage stay
| in business is if they provide a high standard of care for their
| members. The payment model set by CMS incentivizes them to do so.
| jpollock wrote:
| I just saw a podcast about a startup that was working with
| Medicare/Medicaid to reduce costs by improving preventative care
| [1].
|
| They look for people at risk, target them and take a cut of the
| overall reduced spend.
|
| If Medicare is requiring the same outcomes and disbursing per-
| person based on the cost to Medicare, then the insurance
| company's profit would have to come from either selecting for
| healthier people on the input side, or keeping them healthier for
| longer. Selecting for healthier people might be hard if it's "all
| signups allowed".
|
| That sounds like a good thing.
|
| [1] https://www.pushkin.fm/podcasts/whats-your-problem/how-to-
| sa...
| mindslight wrote:
| My dad was on a Medicare Advantage plan offered by a traditional
| "insurer", and it seemed to be worthwhile - it covered some drugs
| better than OG Medicare, and had fixed copays rather than
| anything percentage based. Towards end of life (pre-hospice) they
| proactively sent a doctor out a few times for housecalls, with
| the goal of keeping him out of the hospital. And the baseline
| Medicare rules reigned in a lot of the usual "insurance" company
| shenanigans. If he had longer term health issues perhaps Medicare
| plus a Supplement plan would have made sense, but as it was it
| seemed to work out - had two years of paying the drug coverage
| gap (paying a few thousand dollars is essentially table stakes
| for health "care" in this country). I'm not a fan of "insurance"
| companies in general, rather just reporting my experience.
|
| I kept his phone number (VOIP is like $1/mo), and I still get
| spam calls from scammers claiming to be "from Medicare" that
| "have a new card" for him - shamelessly pretending to be part of
| Medicare itself rather than a private company that's trying to
| steal his Medicare payments. Many times I'll ask them if their
| parents know they scam old people all day, or if they would want
| their parents getting scammed in their old age. Most of the time
| they just try to get me back to the script and think they'll
| convert me somehow ("I am not scammer").
|
| I'm ambivalent on medicare advantage as a concept, but the scam
| companies are really what needs to be reigned in. Given that the
| benefits of medicare advantage is supposedly better coverage, I
| think a great way of doing reform would be to make it so people
| could change back to regular medicare at any time, and doing so
| would end up yanking back the premiums from the private company
| for the past year or two, unless they had actually paid them out
| for bona fide services. In addition to a lot more criminal
| enforcement against fraud, of course.
| sicromoft wrote:
| > they proactively sent a doctor out a few times for housecalls
|
| The article talks about these housecalls:
|
| "The home health visits are designed to look for illnesses or
| codings that can increase risk scores. They very much are not
| looking for conditions that require medical intervention. This
| "free home health visit" scam is so profitable that an entire
| industry has sprung up of companies that send nurses out on
| behalf of the insurance companies."
| mindslight wrote:
| If I look at it post-hoc and cynically, maybe their
| motivation was to get him off the "insurance" company's books
| (electing hospice kicks you back onto vanilla Medicare). But
| it was objectively needed and they spent time to do the job,
| on a major holiday even.
|
| I've no idea what the dynamic would have looked like if they
| came to different conclusions than me and we were at odds,
| but all I can say is that the quality of care always heavily
| depends on having an advocate.
| sclarisse wrote:
| So, before the 2028 solvency crisis?
| tedivm wrote:
| The "solvency" crisis is one of the dumbest things that has
| been shoved down our throats.
|
| For decades there wasn't a social security or medicare fund.
| What was there was taxes. Workers paid taxes, and those taxes
| went to retired people. There was no fund. Then people freaked
| out about the boomers and what that would do to retirement. So
| they created a fund- they started collecting more than they
| needed, invested it in government debt so it would grow, and
| used that to get over the bump.
|
| We can easily solve the "solvency" crisis by simply raising
| taxes. Remove the "cap" that says people are only subject to
| the social security tax on the first $160,200 of their income
| and the "solvency crisis" completely disappears. In fact if we
| completely removed the cap, rather than just raising it, we
| could afford to pay out more in social security while still
| extending the life of the "surplus" fund for almost a century.
| sclarisse wrote:
| Nice diatribe.
|
| Anyway, if it is so simple and easy, it raises the question:
| why hasn't anyone legislated this yet? You know, during one
| of those sessions where both houses and the presidency are of
| the same party (two occasions in recent memory, one for each
| party) and put all talk of crisis to rest?
| AlexandrB wrote:
| Probably the same reason the Democrats never legislated
| abortion rights into law: never let a good crisis go to
| waste. The priorities of both major parties are:
|
| 1. Keep the donors happy
|
| 2. Keep getting elected
|
| 3. Line up a cushy position as a lobbyist or other
| government orbiter after retirement
|
| Pretty sure actually serving their constituents is at the
| bottom of the list for most politicians.
| Blammar wrote:
| Perhaps because rich people would pay more, so they tell
| their pet legislators that bill better not pass? It's
| always about the money.
|
| I'm not saying this is actually true -- it's just my
| hypothesis.
| ceejayoz wrote:
| > why hasn't anyone legislated this yet?
|
| Because it's not necessary yet, and the political issue is
| useful to both parties.
|
| Democrats get to go "we should tax the rich more to fix the
| gap".
|
| Republicans get to go "look how badly this is run, we
| should privatize it".
|
| Neither side wants a horde of seniors (who vote, in large
| numbers) _actually_ losing their Medicare /Social Security
| benefits, so when the time comes, they'll vote to add funds
| and celebrate themselves for saving it for another few
| years.
| u801e wrote:
| Probably because the majority in the legislative is not
| filibuster proof, and they're are always a few
| representatives or senators who disagree with the proposal
| and prevent it from going to a floor vote. Recent examples
| of such individuals are Manchin and Sinema. Lieberman was
| another one who managed to get the public option removed
| from the ACA before it was passed.
| PaulHoule wrote:
| It is not a popular opinion but I always thought the tv ads that
| spam the airwaves in the last few months of the year were harmful
| to the legitimacy of institutions. In this day and age most of us
| are so assaulted by spammed scams that we develop a sensitive
| sense of scamminess and like many of the ads aimed at seniors
| these ones scream "get grandma away from the tv!"
|
| Certain day parts on tv are dominated by ads for personal injury
| lawyers and things you can spend government benefits on and are a
| desert for ads for things you might spend your own money on.
|
| One series of ads that promoted getting some free medical
| equipment that ran for years and I thought looked scammy turned
| out to really be a scam.
|
| I've always thought these ads promote the idea that some
| chiselers somewhere are trying to rip off government benefits and
| they drive people, even the pensioners that these are aimed at,
| to vote Republican.
| vharuck wrote:
| >One series of ads that promoted getting some free medical
| equipment that ran for years and I thought looked scammy turned
| out to really be a scam.
|
| Do you mean Hoveround1, or was it something else?
|
| 1https://oig.hhs.gov/oas/reports/region5/51200057.asp
| slackdog wrote:
| Advertising is the business of converting good will and trust
| into cash.
| messe wrote:
| As someone living outside the US, I've rarely, if ever, seen
| any ads like the ones you're describing
| libraryatnight wrote:
| We also have ads in the US where aging actors sell
| questionable reverse mortgages to senors to help them pay for
| their expenses.
| clivestaples wrote:
| I recently saw Tom Selleck as a spokesman for reverse
| mortgages and googled his net worth which came back as
| $45M. Pretty slimy if you ask me.
| Jensson wrote:
| US ads is such a cultural shock when you visit USA. The
| biggest surprise was all the lawyer ads, "Did something
| happen to you? You could get rich by suing them with our
| help!". So ads like this:
|
| https://www.youtube.com/watch?v=Q3wX5pOUIMw
| messe wrote:
| I think the bigger shock is how frequent the ad breaks are.
| In Ireland, an ad-break 4 times an hour is typical, and
| often if a movie is showing, it'd be every half-hour or on
| the hour instead.
|
| In the US it feels like it's every 5 minutes. It's
| especially jarring watching a show that originally aired on
| network television in the US, seeing it cut to black or a
| title card every few minutes where an ad-break would've
| been.
| Arrath wrote:
| Wildest of all to me is that some networks add even more
| ads above and beyond what an older show was produced for,
| leading to running episodes at slightly faster speeds to
| fit in that extra ad break.
|
| TBS was infamous for doing this with episodes of
| Seinfeld, you can find them side-by-side with the
| original speed airings on youtube.
| libraryatnight wrote:
| I've said this before but it was such a perfect moment that I
| share it whenever possible, my mother in law is one of these
| folks and once she said that she'd never support universal
| health care because there was a chance some immigrant might get
| free health care on her dime. She followed that statement up by
| mentioning she was going to Mexico for some dental work she
| couldn't afford.
| zaroth wrote:
| Seems like perfectly congruous statements from what I can
| tell.
| [deleted]
| CalChris wrote:
| When you sign up for Medicare Advantage, and you shouldn't, you
| will still have to apply for and qualify for Medicare (65, 40
| quarters of work, ...). You will generally pay the Medicare Part
| B premium ($164.90/mo this year) and any Medicare Advantage
| premium.
|
| But roughly, the coverage will be the same, anything medically
| necessary. The difference is that with Medicare Advantage you'll
| have an insurance company sitting at the table between you and
| your doctor. Then there are restricted doctor networks, copays,
| coinsurance, deductibles. But when you get expensive, you become
| a cost center, and they can delay and deny coverage.
|
| With Medicare Advantage, you get to spend the rest of your life
| fighting health insurance companies. And for the most part,
| you're stuck on Medicare Advantage. Guaranteed enrollment is only
| in your first year. BTW, brokers are incentivized to sign you up
| for Medicare Advantage. Their commission is much higher for
| Medicare Advantage than for a Medigap plan. Medicare Advantage is
| vulture capitalism.
|
| Traditional Medicare generally pays 80% and you get a Medigap
| plan for the other 20%. My UHC Plan G costs $139.28/mo with a
| $226/yr deductible, no copays, no coinsurance, no restricted
| network. And you'll need a Part D drug plan. My SilverScript
| SmartRX PDP costs $4.50/mo.
|
| Bernie is right. Medicare for all would be awesome.
| toast0 wrote:
| > But roughly, the coverage will be the same, anything
| medically necessary. The difference is that with Medicare
| Advantage you'll have an insurance company sitting at the table
| between you and your doctor. Then there are restricted doctor
| networks, copays, coinsurance, deductibles. But when you get
| expensive, you become a cost center, and they can delay and
| deny coverage.
|
| I'm much too young to figure this stuff out now, because it
| will be drastically different by the time I would need to use
| it, but ...
|
| If you're in regular medicare, don't you have a government
| agency filling the same role at the table with you and your
| doctor? Or does medicare not deny or delay coverage? Not all
| doctors take Medicare either, but I do understand it's pretty
| widely accepted. I've also heard something that if a doctor
| accepts Medicare and Medicare won't pay for a procedure, you
| can't pay for it out of pocket; is that accurate, or something
| misleading I picked up?
|
| And doesn't the patient have to pay some portion of some
| procedures etc? You could get Medigap insurance for the patient
| pays portion, but does that have limits or judgement, or are
| they compelled to follow Medicare's decisions?
| CalChris wrote:
| > If you're in regular medicare, don't you have a government
| agency filling the same role at the table with you and your
| doctor?
|
| There are no death panels.
|
| If Medicare covers the procedure (you can look the procedure
| up in the What's Covered app) and the doctor deems it
| medically necessary, Medicare pays and then your Medigap plan
| pays. So cosmetic surgery isn't covered but removing skin
| cancers is.
|
| In the Medicare Advantage case, you are an account and when
| your account gets expensive, Allison Janey's company gets
| very passive aggressive.
|
| Traditional Medicare sets a policy. Medicare Advantage sets a
| policy AND manages a cost (you're the cost).
|
| > Not all doctors take Medicare either
|
| The vast majority of doctors take Medicare and accept
| Medicare Assignment, the standard amount that Medicare pays
| for a procedure. Cedars Sinai takes Medicare.
|
| > I've also heard something that if a doctor accepts Medicare
| and Medicare won't pay for a procedure, you can't pay for it
| out of pocket; is that accurate, or something misleading I
| picked up?
|
| Yeah, that's nonsense.
|
| > And doesn't the patient have to pay some portion of some
| procedures etc?
|
| Medicare pays 80% (except for preventatives where it pays
| 100%). You get a Medigap plan for the 20%. Mine is UHC Plan G
| which costs $134/mo and includes some extra benefits.
|
| There is no logical way that Blue Cross or Kaiser can sit
| between you and Medicare (they get paid by Medicare to take
| your risk) make billions and still provide the standard of
| coverage that Traditional Medicare offers. That's a shell
| game.
| mindslight wrote:
| > _There are no death panels._
|
| The overall function of private "insurance" is
| appropriately labeled a "death panel". In general I find it
| very odd how so much scare propaganda against changing
| things is based on describing the actual current dynamic.
| dragonwriter wrote:
| > If you're in regular medicare, don't you have a government
| agency filling the same role at the table with you and your
| doctor?
|
| Well, no, you have...a private insurance company, who has a
| contract with the government.
|
| Just with a different contract with the government than the
| Medicare Advantage ones have.
|
| https://www.cms.gov/Medicare/Medicare-
| Contracting/Medicare-A...
| ThePowerOfFuet wrote:
| >Bernie is right.
|
| Yes, but you don't even need to listen to him: the rest of the
| civilized world figured this out years ago.
| tstrimple wrote:
| This country's obsession with NIH can be maddening.
| jewayne wrote:
| Not Invented Here? That's too kind. More like "the universe
| ends at our borders, and anything done outside it can be
| dismissed offhand".
| [deleted]
| PopAlongKid wrote:
| For a contrasting viewpoint, I have MA plan with Kaiser
| Permanente (HMO). As far as I can tell, it is essentially the
| same as what I previously had under employer group coverage,
| which was satisfactory to me for many years. Fortunately I have
| no major medical issues requiring expensive treatment, but if I
| do, I'm pretty confident that my coverage won't be so scant
| that it leads to bankruptcy or anything. The monthly total
| premium for both Part C (MA) and Part D (drugs) is $70, and the
| only co-pay I've seen is $10 for each office visit after the
| first one of the year.
| jewayne wrote:
| For a contrasting viewpoint to _your_ contrasting viewpoint,
| I took over my parents ' finances as my father was dying from
| emphysema. He had a number of comorbidities that led him to
| see a number of specialists, so he was definitely using a
| large number of health services. After he died, I steeled
| myself for the dreaded slow drip of medical bills in the
| ensuing weeks and months. They never came.
|
| Because my father had Medicare and a Medigap plan.
| skrowl wrote:
| [dead]
| Blammar wrote:
| I can speak about an apparently non-scam Medicare Advantage plan
| that my wife and I are on.
|
| It is effectively a PPO (similar to the Kaiser plan someone else
| mentioned), so we have access to exactly the same physicians that
| we had already where we were paying for private insurance. Our
| annual premiums went from about $85k a year (on the private
| insurance) to around $10k out of pocket.
|
| We are fairly healthy, though my wife is going to have some major
| joint surgery. What was interesting is that it was our PRIVATE
| insurance that stalled and stalled over approving the surgery.
| When she switched to the MA plan, it was approved immediately.
| (That stalling finally motivated my wife to make the switch out
| of the private insurance.)
|
| The downside of our MA plan is that we are not going to be able
| to move out of the area easily. But you always have that issue
| regardless -- finding a whole new set of doctors and dentists
| when you move...
|
| I do get these phone calls asking to schedule a "wellness" check
| that the article writer mentions. Oddly enough, my wife didn't
| get any (so far.)
| asah wrote:
| She's probably already high risk, so the visit would be an
| additional cost to the insurance company.
| [deleted]
| Trisell wrote:
| That call is because Health Plans are rated by CMS on if you
| get certain types of services, or skip them. By skipping those
| checkups you are reducing your health insurance plans STARS
| rating, which means they lose significant monies from the
| government. Each .1 of a start equals around 1 million US in
| government funding to a health plan doing MA.
| 88913527 wrote:
| Is $85k annual premiums a typo? That's about an order of
| magnitude higher than my expectations would have been for near
| retirement age health care.
| DiggyJohnson wrote:
| Do you have some sort of special private insurance? 85k /yr is
| unbelievable to me.
| cool_dude85 wrote:
| >What was interesting is that it was our PRIVATE insurance that
| stalled and stalled over approving the surgery. When she
| switched to the MA plan, it was approved immediately.
|
| At least one part of the scam seems to have worked here: you
| use "private" to describe your old plan, to contrast with MA.
| In reality, both your old and new plans are private.
| SoftTalker wrote:
| The entire health care system for seniors is a scam to drain them
| of their wealth and/or government benefits until they are broke
| or dead.
| digianarchist wrote:
| Looting the state is a core tenet of contemporary conservatism.
| OrvalWintermute wrote:
| I always thought that Medicare & Medicaid are a scam to drain
| the nation of their wealth, until the nation is dead AND
| healthcare used to be a great deal more affordable before
| Medicare & Medicaid got involved in it.
|
| Now, senior folks get on Medicare until they've tapped out its
| lifetime benefits and then they go onto Medicaid.
|
| This is part of what has created the upteen millions of
| Medicare scams.
| arrosenberg wrote:
| The programs only exist because health insurance became
| unaffordable for seniors. Healthcare is expensive for the
| old! I'm not arguing against the idea that the program has
| fraud issues (Rick Scott made a fortune off of it), but its
| not going to be cheaper or better for the elderly if we let
| private companies exploit them individually instead of
| forcing them to defraud the government.
| OrvalWintermute wrote:
| Medical insurance in general is a scam.
|
| Profitability of the insurer is tied specifically to claim
| denial and reducing expenses.
|
| Medical insurance transfers onto Doctor's Offices and
| Hospitals all the expenses of billing & coding which then
| also requires the doctor / medical provider spend 20-40% of
| their time doing billing & coding, and dedicated personnel
| to interface with the insurance companies and be involved
| in tracking down outstanding bills, getting pre-authed,
| negotiating settlements with insurance, getting "in
| network" etc.
|
| The whole insurance thing is a racket that has massively
| enlarged the costs of doing medicine.
| nobodyandproud wrote:
| You know what gets rid of paperwork? Nationalized health
| services.
|
| Look at South Korea for a palatable (to conservatives)
| example.
| smaudet wrote:
| The whole private insurance is a racket, because private
| companies don't have many incentives to offer reasonable
| insurance.
|
| Public insurance, or community driven, is a different
| matter. Sure, someone can have a non profit racket, but
| if the insurance pool is communal with relatively low
| overhead, it can function much better.
|
| Universal care has different issues, but at least it is
| closer to communal in this sense, so better in that sense
| at least.
| girvo wrote:
| Why did you always think that? Doesn't seem true at all to
| me. Seems kind of wild that a country as rich and privileged
| as America struggles to provide healthcare to its citizens
| without going broke?
| jewayne wrote:
| What? You're talking about two different things: Health
| insurance vs Long Term Care.
|
| There are no maximum lifetime benefits for Medicare Part A &
| B (health insurance) that I'm aware of. When you hear about a
| "Medicaid spend-down", it's all about reducing an elderly
| persons assets so that the state sees them as poor and
| Medicaid will pay their Long Term Care (nursing home)
| expenses. Medicare has almost nothing to do with the Medicaid
| spend-down strategy that I know of.
| ceejayoz wrote:
| A/B definitely have some lifetime limits.
|
| https://www.aarp.org/health/medicare-
| insurance/info-02-2009/...
|
| > Medicare Part A covers a stay in the hospital for any
| single spell of illness or injury within a time frame of 90
| days. This is known as a benefit period, and there's no
| limit to the number of benefit periods you can have. But if
| you need to stay in the hospital for more than 90 days with
| the same illness or injury, you have the option of using
| some of your 60 lifetime reserve days. These allow you to
| extend your hospital stay for a higher copayment ($608 a
| day in 2014). You can use these days--one or more at a
| time, or as you need them--over the rest of your life. Once
| the 60 reserve days are exhausted, you would pay the
| hospital's full daily charge (except for services covered
| under Medicare Part B, such as physician visits) if you
| need to stay in the hospital for more than 90 days in a
| benefit period.
|
| > Medicare covers only 190 days of inpatient care in a
| psychiatric hospital in your lifetime.
|
| > Medicare limits the amount of coverage you can get as an
| outpatient for physical or occupational therapy and speech-
| language pathology in any given year. In 2014 the limits
| are $1,920 for occupational therapy and $1,920 for physical
| therapy and speech-language pathology combined.
| jewayne wrote:
| The first two are interesting, but last one you mention
| is not a lifetime limit, and so doesn't really belong in
| the discussion.
|
| And the first one is interesting, because that 60 day
| "limit" is actually 60 days of extra benefits. If those
| 60 days didn't exist, if Medicare Part A _always_ ended
| their coverage for an incident at 90 days (which would be
| perfectly reasonable), then there wouldn 't be a lifetime
| limit, but I think we can safely say that the coverage is
| better _with_ those 60 days than without them.
|
| Which is to say, you kinda had to reach to come up with
| examples of lifetime limits.
| dragonwriter wrote:
| > When you hear about a "Medicaid spend-down", it's all
| about reducing an elderly persons assets so that the state
| sees them as poor and Medicaid will pay their Long Term
| Care (nursing home) expenses.
|
| Correct.
|
| > Medicare has almost nothing to do with the Medicaid
| spend-down strategy that I know of.
|
| Basically. Medicaid will pay Medicare premiums for dual-
| eligible beneficiaries, and many states have special
| coverage plans for the dual-eligible population, so there
| is a Medicare-related impact of the spend-down, but it has
| nothing to do with exhausting Medicare lifetime benefit
| limits (which do not exist, also, under the ACA, do not
| exist for other insurance, either.)
| [deleted]
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