so there's an article in the new york times today that i think is absolutely worth
talking about the article is titled medicare advantage plans often deny
needed care federal reports show so they've done an investigation into managed care plans and
how they function within the medicare world and primarily pre-authorization so something i find
very important going to go through that right now i'm keith armbrack founder of medicare on video
i help people across the country make the right medicare choices can absolutely help you as well
the best part is there's no cost to allow me to help you so hopefully you'll take advantage of
all my information that i have available right now we're going to talk about this article that's in
the new york times i have the link below the video if you want to take a look at the article yourself
but it's pretty damning and it's pretty concerning and with medicare advantage plans if you're just
coming into medicare you're just becoming kind of exposed to medicare advantage and most people
only see all the commercials on tv telling you how wonderful it is and how many free things
they're going to give you and how easy they make it and obviously they're selling they're selling
medicare advantage because there's big money in medicare advantage so what to understand about
it i'm gonna go through this article but if you choose a medicare advantage plan it takes you
from medicare to a private insurer so all those medicare advantage plans are owned by
private insurance companies and it takes your claims responsibility away from medicare
and gives it to the private insurance company so they now are in charge of your claims so it's in
their best interest to limit the amount of money they spend on your claims the less they spend
the more they make so let's take a look inside this article and see exactly what they found
and this is no real secret but just most people don't ever get to hear about it so the article
starts off every year tens of thousands of people enroll in private medicare advantage plans are
denied necessary care that should be covered under the program federal investigators concluded in a
report published on thursday the investigators urge medicare officials to strengthen oversight
of these private insurance plans which provide benefits to 28 million older americans and called
for increased enforcement against plans with a pattern of inappropriate denials
so in the long and the short of it if you're familiar with my channel i recently did a video
that was entitled why i would never choose medicare advantage and you can find that video
right here you can click on it i highly recommend that you watch it right now it's got over 700
000 views so at least it's getting out there and people are watching and understanding the
difference between original medicare and medicare advantage but that's one of the main reasons why i
personally would never choose medicare advantage is i don't want to ask for permission if you're
having something done especially something serious why in the world do you want to ask for permission
from a private insurance company if it's okay will they authorize it for you to be able to have it
done your doctor says you need it but guess what that's not enough you have to ask permission from
the medicare advantage company so back to this article the industry's main trade group claims
people choose medicare advantage because quote it delivers better services better access to care and
better value that's certainly what you hear from joe namath and william shatner and jimmy walker
on all those television commercials but federal investigators say there's troubling evidence that
these plans are delaying or even preventing medicare beneficiaries from getting medically
necessary care why because it's financially in their best interest is the primary reason again
they get x amount of money from medicare to take your claims responsibility away from medicare
and then however much they spend on you goes to your care they're required to spend 85 percent
on medical care but the more they don't spend the better it is for the medicare advantage plan so
it's just a very difficult situation you have no recourse so there are appeals process we'll
talk about that in just a second but what are you going to do you know if they say no what
are you going to do tens of millions of denials are issued each year for both authorization and
reimbursements and audits of the private insurers show evidence of widespread persistent problems
related to inappropriate denials of services and payments the investigators found so this is not
somebody you know in my other video i have agents that sell medicare advantage accusing
me of misleading people and not giving a straight story this is coming from federal investigators so
this is not my investigation into medicare advantage it just kind of solidifies the way
i feel about medicare advantage and again asking permission investigators estimated as many as 85
000 beneficiary requests for prior authorization of medical care were potentially improperly denied
2019 85 000 requests now doesn't mean a whole lot to you unless it's your request and unless
you have something significant in your life going on whether it's cancer or whether it's something
terminal or major and your doctor says you need this and the medicare advantage company says
we're not paying for it so it's a huge huge issue that you need to understand when you make this
choice that you need to be comfortable with and i absolutely understand cost is an issue coming
in so medicare supplements have a monthly premium medicare advantage plans a lot of times do not but
the ones that do not will have a whole lot more of this denial than ones that do and they'll also
have a smaller network of doctors and hospitals things of that nature so back to the article the
healthcare lawyer so they they show an example in the article and by all means read the article
they talk very specifically about one person's scenario and what was denied
and how it was denied and the healthcare lawyer for the family in the article says
people should know what they're giving up if they go into medicare advantage and he's a healthcare
lawyer and he's also the son-in-law of the person that is the example in the article people signing
up for medicare advantage are surrendering their right to have a doctor determine what is medically
necessary he said rather than have the insurer to say so when you go into medicare advantage
so if you're on original medicare let's back up to that so original medicare a and b and you have a
supplement you go to the doctor doctor says you need this you need that you need whatever it is
if it is medically necessary that's it medicare does not play a role in determining whether
or not it's going to be approved there's no pre-authorization there's no
asking for permission so if it is medically necessary and your doctor says you need it
you do it and medicare pays for it other side of the coin medicare advantage
completely different scenario if your doctor says and i can tell you if it's something significant
and i've been into the situation most of us probably have on our regular insurance
before medicare if you are in a managed care hmo point of service type situation the doctor says
we need to do this but uh first we gotta see if we can get it approved
and that's gonna probably take a couple weeks so we're gonna have to submit it for approval
and then if it gets approved then we can go ahead and do it that's a crazy way to run
health care if your doctor thinks you need it and obviously there could be financial incentive on
the doctor's side but most of the time they are trying to get you where you need to be
on figuring out whatever your scenario might be so difference between original medicare
medicare advantage pre-authorization with medicare advantage no pre-authorization with
original medicare number one reason that i would never choose a medicare advantage plan personally
myself now back in the article the federal government pays private insurers a fixed amount
per medicare advantage patient usually it's about a thousand dollars a month so medicare pays about
a thousand dollars a month to a medicare advantage plan to take your claim responsibility away
that's a lot of money so that is when you get thousands and hundreds of thousands of people
going into a plan thousand dollars per month every month is a lot of money if the patient
choice of hospital or doctor is limited and if he or she is encouraged to get services that are less
expensive but effective then the insurer stands a profit so in other words so if they tighten up a
network and have fewer doctors fewer hospitals so they don't pay out as much money in that scenario
and you're encouraged to get less expensive treatment you know generic drugs versus brand name
drugs things like that or physical therapy versus actually doing something to correct the problem
it just benefits the profit of that private insurance company under traditional medicare
in the article there may be an incentive for hospitals and doctors to over treat patients
because they are paid for each service and test performed so where medicare original pays a doctor
to do their stuff and do their stuff well i mean it could lead to doctors doing too much stuff but
if i'm in a medical situation i'm looking for too much stuff i'm not looking for cutting
costs cutting corners saving money but the fixed payments given to plan to private plans
provides the potential incentive for insurers to deny access to services and payment
in an attempt to increase their profits the report concluded so this federal report concluded that
the way things are paid and you know a lot of times in a medicare advantage plan they pay a
doctor x amount of money per patient per month so if he gets so many patients per month he makes x
amount of money whether you come in or whether you don't and that's also problematic because
they'd really rather you not come in because they're getting paid no matter what so if you
go to make appointments you end up finding wow what two months that's the first availability
is two months down the road because they're capitated they're getting paid per person per
month because that's your primary care physician uh another crazy way that things work with
managed care so i wanted to give this article some light and absolutely download it read it share it
but it's important to understand the differences in medicare because we have a choice you know when
you had your work insurance you probably didn't have a choice you pretty much had an hmo plan
or you could upgrade to the point of service or ppo that gave you a little more doctor
hospital choices but still had the private insurance company making the decision whether
they're going to pay for it or not pay for it and there's very little ramification there is
talk in here you know dr jack resnick the president-elect of the american medical
association said the plans denials had become widespread the organization has been aggressively
lobbying lawmakers to impose stricter rules prior authorization intended to limit very expensive uh
or unproven treatment has spread way beyond its original purpose when patients cannot get approved
for a new prescription many do not fill it and then they don't even tell their doctor about it so
it just something that falls through the cracks it could have been really important appeals end
up unfairly burdening patients and often take precious time some some doctors said we are
able to reserve to reverse this some of the time said dr patel a cancer specialist who serves as a
chief executive carolina blood cancer care and president of the community oncology alliance
but his efforts to fight like a hawk to get approvals take him away from many other things
so they have to go through hoops and ladders and jumps and file paperwork and appeals
to get something that they have said is necessary especially again if it's something significant
it's just crazy that they have to do what they have to do to get it approved so anyway i wanted
to make sure that we understand the differences between original medicare and again original
medicare a and b with a supplement super low out of pocket all the freedom flexibility do anything
you want go to any hospital any doctor anywhere in the country manage care most of those plans
especially the ones you see on tv are hmo based plans with your very small networks localized area
have to ask for permission have to get a referral in many cases there are options of ppo plans
that cost more but for the most part people get pushed into these hmo plans
and they don't know until it's time to have something significant going on so i hope you
found this helpful stay tuned i'll show you how to download my book medicare made clear can help you
figure out all the other parts of medicare and then we're super happy to help with any of it so
hope you found this helpful have a fantastic day thank you for taking the time to watch my video
hope you found it very helpful here are a couple other things that you'll also find helpful as you
go through medicare the first one is a copy of my book medicare made clear you can download it right
now for free i've put a lot of time and effort into this book and you'll see i covered just about
every piece of medicare and i've written it in a way that makes it pretty easy to understand
now i also have videos throughout the book so if you don't want to read through all the information
click on the video and i'll explain it all to you right there you'll also find all the links that
you need to either sign up for medicare or things that you're going to need now or in the future
when things come up related to medicare so take just a minute go to medicareonvideo.com forward
slash free book and you can download it right now now also make sure once you're in medicare
that every year you come back and visit medicare price check this is my other website
where i make it super easy for us to compare our current coverage against new plans that may be
less expensive and remember that medicare supplements are standardized so it doesn't
matter which insurance company we use we'll still have the same plan g or the plan n
that we have now but hopefully we can get it at a lower price so visit medicarepricecheck.com
real easy we'll email you the quote if it makes sense then we'll do it from there
so hope you found all this helpful have a fantastic day hey don't go anywhere these
are some of my most recent videos right here you can also find the link right below this video to
download my book medicare made clear absolutely free you can also subscribe to my channel
right here so please download my book watch some videos subscribe to the channel have a great day