Tag: Medicare reimbursement

With special thanks to Dr. Brent Schillinger

The open enrollment period for Medicare Advantage plans runs from October 15 through December 7, 2012.  That is precisely the reason why every form of communication—– be it internet, television, radio or your mailbox is loaded with recruitment messages from the big and not so big companies.  Medicare Advantage Plans is the contemporary name given to the old Medicare HMO insurance programs.  The difference is that today the marketing is particularly intense and slick because under current federal legislation, passed several presidential administrations back, the profits for the commercial insurers is huge.  When the first Medicare HMOs appeared on the scene, they were providing care to seniors at an average cost savings (to the federal Medicare budget) of 5% less than traditional Medicare.  Today, they provide care at upwards of 115% of the average cost per patient per year for traditional Medicare.

The plans market themselves to seniors offering more services for less money than a person would have to pay under traditional Medicare.  In most cases there are savings in terms of reduced monthly out of pocket costs.  And there may be extra services I such as a gym membership or a low-priced pair of eyeglasses.  But there are many tradeoffs for patients tradeoffs that are not referenced in the marketing material.  Patients are limited to doctors who are specifically contracted with the plan, specialist referrals are generally rationed, and it may be difficult, should a person desire care in a specific hospital if that facility is not contracted.

Seniors have options. They can choose from many different Medicare Advantage Plans and probably save some money, but they  need to understand that they are giving up many of the choices they have with the other option, keeping traditional Medicare and adding supplemental medical and pharmaceutical insurance. Identified problems include:

1. Care can cost more than  it would under original Medicare
2. Private plans may not be stable and may suddenly cease coverage
3. Members may experience difficulty in getting emergency care
4. Continuity of care may be broken if the plan drops a provider
5. Members have to follow plan rules to get covered,
6. Members are restricted in their choices of doctors, hospitals, and other providers
7. It can be difficult to get care away from home
8. The extra benefits offered often turn out to be less than promised.

Physicians will be approached by patients about the confusion in the choice of the Medicare Advantage plans vs. traditional Medicare.  As your patients’ advocate you should become knowledgeable about the different plans so you can give reasonable guidance to your patients.   This would also be a good time to review your contracts and reimbursement schedules as well the ability to obtain authorizations for prescription drugs and specialist referrals.

From an economic point of view, most physicians, in our area who participate in these Medicare Advantage plans receive reimbursements that are substantially lower than traditional Medicare.   Take the United Health Care product for example.  While United is paid by the government upwards of 115% of the average traditional Medicare cost, many specialists receive less than 70% of the normal Medicare allowable.   Some of the Blue Cross plans work with a number of tightly restricted capitated networks so patients may not be able to see the doctor of their choice, individual physicians may not be able to join these restricted networks,  and the same time the reimbursements through the capitated networks are pathetically low, often less than half of the traditional Medicare allowable.

Doctors need to take all of these factors into consideration in order to give their patients good advice.  For additional information and patient resources you can visit www.pbcms.org or email Dr. Schillinger at [email protected].