'Heavy handed' Medicare Advantage tests providers

YARMOUTH, Maine – The majority of respondents to the HME Newspoll say the number of patients they care for that are covered by Medicare Advantage plans has increased more than 10% in the past year – and they’re worried. 

The trend is no surprise, with more than half of eligible Medicare beneficiaries enrolled in these plans this year, with a projected 62% by 2033. 

“Medicare Advantage plans have disrupted the health care sector,” wrote one respondent. “They are marketed as a great alternative to traditional Medicare; however, they are misleading patients to think they still have traditional Medicare. Yes, (MA plans) save the patient more out-of-pocket expenses; however, when they need to use their insurance for DME, they then realize the limitations.” 

Seventy-five percent of respondents say they accept Medicare Advantage and about 78% say the plans have become a bigger part of their payer mix in the past year. 

The list of complaints against MA plans is long, but chief among them, respondents say, is reimbursement that’s lower than traditional Medicare – and, often, more difficult to hold on to. 

“Medicare Advantage, specifically UnitedHealthcare, has continued to target DME suppliers with a barrage of pre- and post-payment audits, overwhelming our audit and appeals staff,” wrote David Soblick of Specialty Medical Supplies. “In many cases, Medicare LCD guidelines are not followed. Audit requests include demand for medical records having no bearing on a patient’s diagnosis. What relevance does a patient’s surgical records have on diabetic testing supplies? Advantage plans use these heavy-handed tactics to enrich their record profits.” 

But because MA plans are where patients are moving, respondents say it’s a necessary part of doing business – that’s when they can get the business. 

“With limited networks, the continued transition to MA, which is incorrectly named ‘Advantage,’ harms patients by limiting their access to providers,” wrote one respondent. “This is especially true in rural areas where MA plans are aggressively marketing to patients, but then the patients are surprised to discover that their providers are not ‘in network.’ This is wrong.” 

Other responses 

Erin Dolan of Med-Essentials summarized the disadvantages of MA plans this way: “Lower reimbursement, exclusions due to very limited and/or closed provider networks, horrendous customer service, delays in prior authorization decisions, incorrect claims processing requiring time-consuming follow up.” 

Cheryl Ward of RestorixHealth wrote: “The increasing enrollments in Medicare Advantage, which has significantly lower reimbursement, erodes profitability and is a threat to sustainability.” 

One respondent wrote: “It would be fine if they followed Medicare guidelines, but I see more of them, one, not paying Medicare allowable and, two, giving prior auths and then auditing them a year or two years later and denying what they approved.”