Where’s the Advantage?

On a semi-regular basis, Editor Liz Beaulieu asks me: “Are HME providers for or against prior auths?” 

I then try to remember where things stand on that particular issue before helpfully responding: “Both, I think?” 

So, we went directly to the source. Our October HME Newspoll (See story page 3) asked: “How do you feel about prior auths?”  

Results were mixed, with 58% of respondents saying, “No thanks!” due to the heavy burden they place, with no guarantee of payment. However, the other 42% feel prior auths provide some sort of safety net, as long as everyone follows the rules. 

When it comes to Medicare Advantage plans, however, it’s crystal clear where providers fall. 

Our November Newspoll found that 75% of providers accept Medicare Advantage and 78% say that the plans have become a bigger part of their payer mix in the past year (See results on page 21). 

And they aren’t happy about it. You know why? Because, by and large, the Medicare Advantage plans aren’t playing by the rules, or at least not any of the rules everyone else follows. 

“It has become a nuisance, as each Medicare Advantage plan has different rules,” wrote one respondent. “None of them follow Medicare guidelines or allowables.” 

We saw this recently with non-invasive ventilators, with at least one large payer denying 86% of claims for the life-sustaining technology even though patients meet Medicare coverage criteria. If they follow Medicare guidelines, the plans shouldn’t be denying the claims. 

Providers also say the plans are deceptive, and that beneficiaries often don’t understand what they are getting (or not getting, as is often the case). That places an additional burden on the provider, who is then tasked with explaining what their plan does and doesn’t cover. And we all know what they say about the messenger. 

But with nearly one-third of all Medicare beneficiaries projected to be enrolled in Advantage plans in the next 10 years, it doesn’t look like things are going to improve on that front any time soon. 

Our friend Craig Rae at Penrod Medical Equipment summed up the issues with Medicare Advantage plans quite succinctly: “Slower pay, higher denial rates of both prior approvals and claims, and access issues for patients.” 

Where’s the advantage?