Medicare Advantage for Whom?

Healthcare News and Actions June 6, 2023

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Now that the debt crisis is behind us let’s turn our representatives' attention back to reforming healthcare for our benefit.

Medicare Advantage? Advantage for Whom?

We were in a meeting with Wendell Potter last night discussing the history of Medicare and how to provide everyone in the country with access to healthcare. If you don’t know him I recommend his Substack Newsletter Healthcare Un-Covered.

Medicare Advantage has become the most profitable health insurance around. So much so, that at least one company is not going to offer anything but Medicare Advantage next year. It is a cash cow and an example of why we need Improved Medicare for All, not private insurance masquerading as healthcare.

Background

Medicare is a health insurance program run by the the Center for Medicare and Medicaid Services (CMS). Medicare has 2 basic parts. These are A (hospitalization) and B (medical insurance). If you are retired A is paid for has no copay for months of hospitalization. Part B requires a monthly premium payment that depends upon your income. Part B covers doctor visits and is an 80/20 plan. Insurance pays 80%, you pay 20%. One of the residual problems with Medicare is that 20% copay. If you’re medical bill is $1,000,000 then you owe $200,000. There is no cap.

If you want prescription coverage it is a separate part D drug plan, managed by private insurance. Part D is where the government would negotiate with manufacturers to lower prices if we ever got beyond the 10 drugs that can be negotiated now.

In the early days of Medicare the government was considering ways to offload risk and private insurance companies convinced them and Congress that they could help. Congress created an opportunity for private companies to offer a separate insurance plan to replace Medicare for those that chose it, called Part C. It is now called Medicare Advantage.

There are many flavors from which to choose, HMO or PPO, either way you are locked in to a network. Some plans offer additional benefits like vision and dental and a gym membership. Part C buys down the government’s risk because they pay about $1000/month/subscriber to the private insurance company. The subscriber buys down risk of that 20% copay by having a yearly maximum in the plan, paying copays for hospital visits that aren’t in Medicare and having deductibles. Sometimes Medicare Advantage plans charge subscribers a monthly fee in addition to their monthly payment for Medicare Part B. Part C plans can include a part D drug plan.

Recap: You have a yearly maximum, you pay, deductibles and copays for visits and all of that resets every year.

If you subscribe to a Medicare Advantage Plan - you no longer have regular Medicare that year, you have private insurance.

Up-coding - Again?

Do you recall how we discussed how some medical providers game the insurance companies by up-coding patient services to make more money? Essentially, they are billing for more complicated work and reaping the benefits. For example, pregnant women who show up in the ER instead of the hospital front door for a normal delivery are frequently up-coded with ER status to bill an extra $2K.

Anyway, if the Medicare Advantage insurance company can make it appear to Medicare that you are sicker than you are then they can be reimbursed about $196/month more than the nominal $1000/month payment they receive from Medicare. That $1000/month is actually adjusted by zipcode, but is nominal.

Many times the insurer will have someone call you to schedule an in-home visit to evaluate your health. Wendell Potter warned that this technique can be used to collect and interpret data that is used to upcode patients to Medicare and collect that $196/month extra. If you have regular preventive care visits with your doctor, you may want to ask them about it first. Hypertension, depression, diabetes, and more are used to score big paydays for insurance companies. Here is a 30 minute video on the subject by Dr. Ed Weisbart. In it he warns that one of the tests used to upcode can be particularly risky for patients if it is not medically necessary. Profit and healthcare do not make good bedfellows. Even Kaiser Permanente has been accused by the Justice Department of raking in a billion dollars of overpayment by these kinds of schemes. Here is a link to an NPR report on it.

Note that most of these shenanigans don’t occur when there is a single government insurance company responsible for all claims, that’s Improved Medicare for All. It’s worth noting that regular Medicare (Parts & B) don’t have overpayment issues the way Medicare Advantage does. By letting private insurance take over, we the people are overpaying and getting less. Let’s take it back.

ACTION

Use RESISTBOT (text SIGN PQMSOF to 50409) or call or email your congressional representative and senators (their contact info is in the References Section) and tell them something like:

“ Hi. My name is [name] and I live in [zipcode] and I am your constituent. I am so disappointed to read how private insurance companies are cheating the Medicare system by up-coding patients who have private insurance Medicare Advantage plans instead of Medicare.

HR 3421, Improved Medicare for All, will cover all of us, cradle to grave, no copay, deductible, maximum payment, including long term care, reproductive care, gender care, and do it for far less than we pay now. You owe this to all of the businesses in your constituency who will pay less as well as to every student, parent, worker, and retiree. “

References

Find My Elected Officials

Contact the White House  https://www.whitehouse.gov/contact/

Contact State and Federal Representatives

https://www.commoncause.org/find-your-representative/addr/

Important Healthcare Resources

League of Women Voters Healthcare Reform Toolkit

Our Newsletter resources including reproductive healthcare

Healthcare Advocacy Reading List

Organizations to Contact

NARAL - Pro Choice America

Planned Parenthood

Physicians for a National Health Plan

Claims Denials and Appeals & What to Do

Appeal a Healthcare Decision

Appeal/Negotiate a Hospital Bill

Save Democracy

Chop Wood, Carry Water by Jessica Cravens

RESISTBOT

Link to the RESISTBOT site to learn more

Link to Chop Wood, Carry Water Resistbot write up