As the year turns over and people start to present into offices with different insurance cards, I wanted to do a brief write up on Medicare Advantage Plans, why patients love them and offices/physicians loath them.

When you turn 65 you get the option as to what kind of Medicare you can sign up for, Traditional Medicare in which you have a deductible of around $250 and then pay 20% of the allowed amount unless you take out a supplemental plan, which most people do.  This is the bulk of your cost is the cost of the premiums on a month to month basis but not a lot of questions are asked about treatment, you get the care that needs to be done.

Medicare Advantage plans are when the patient essentially gives up their traditional Medicare rights and allows a private insurance control the plan. It is much more like what we see in our office as a traditional insurance.  The premium is typically lower, the coverage normally included prescription, dental & vision but the initial burden falls on the patients. A deductible needs to be met, co-pays are normally required at office visits and we have begun to see a trend towards pre-authorization for care.

From a chiropractic perspective, this can be a nightmare for certain plans. As with traditional Medicare, only the adjustment is covered.  Medicare does not cover therapies and exams in a chiropractic office, we can bill for them but the responsibility falls to the patient. The fee schedule for Medicare is stagnant if not declining. So, when someone says you should just raise your price to come in, it doesn’t necessarily work like that, when we agree to accept Medicare patients we are agreeing to a fee schedule and the rules that Medicare sets out, we can’t just “charge more.”

Let me paint you a little picture: a patient presents at the first of the year and gives us a new insurance card; it’s a Medicare Advantage Plan. We bring you back and treat you like you were before the patient selected this particular insurance. When the patient leaves, is when the work actually starts. I, the doctor, sits down at a computer, logs into a website and requests care from a third party conglomerate, which requires constant oversight as we have numerous patients we are watching how much care is allowed and when certain authorizations expire. We may get 10 visits over the first 2 months.  The patient will get a bill for their co-pay amount for each visit. A phone call comes in, it’s the patient saying, why do I owe this amount, it’s the plan you signed up for.

On a side note, this is actually one of the worst parts of the entire process, is that we (the office) have to explain benefits to people (not our job).  The agents that are signing people up for these plans don’t do a good job explaining what is and isn’t covered and what the expectation level will be on the patient end when they present the card to an office.

The first authorization is not normally an issue, it’s the second and third….the “incidents” are not taken into account individually. Let’s say you come in 4 months later, they may only authorize 4 visits over 8 weeks. The year is looked at as a whole, not on an incident by incident explanation.  They are trying to manage cost, for every visit they can “not allow” the more money they save and adds to the bottom line. The more times you try to get pre-authorization, the fewer visits that will be allowed if not flat out denied in some cases.

The plan that you sign up for has a trade off for the cheap premium, which is why most patients love them.  You are responsible for more out-of-pocket expenses, while the doctor and office has to do more background work and paperwork with 3^rd party companies that are going to dictate how much care you are “allowed.” I’m not saying that insurance is perfect, all of them have their quirks and intricacies but the Medicare Advantage plans are crazy in our office because most of the time we are doing paperwork and notes to collect somewhere between $6-15.

While it’s not necessarily in our game plan, don’t be surprised when clinics, hospitals and doctors stop accepting certain plans. We have seen certain hospitals having to hire additional staff just to “babysit” the pre-authorization process while not getting reimbursed more. So try running an office or a business, where you are required to perform more work, can’t raise your prices and your cost of operating a business continues to rise. The math doesn’t math in most offices. There is no perfect solution when it comes to healthcare but the current model doesn’t seem to be working for anyone other than the insurance companies.