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Old 02-24-2016, 11:04 AM
 
Location: louisville
4,754 posts, read 2,013,522 times
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Quote:
Originally Posted by Weichert View Post
I think the key as to whether to go with Advantage plans depends on the popularity of them in a particular location. Why they have wide acceptance in some areas and not others is a mystery to me. These plans don't seem to be very popular in Jacksonville yet in other parts of Florida everyone (including providers) seems to be happy with them. Why is that?

I recently read an article about their acceptance in Portland. There the Advantage plans have generally become the plans of choice. They pay more than Medicare (for both doctors and hospitals) with fewer hassles and the associated problems of Medicare (so they say). Maybe its the variability of Medicare in Oregon. Who knows?

But there are other large metro areas than Portland where close to half of those eligible for Medicare are in Advantage plans and like them. Just so strange.

And it could be that Medicare is finally dealing with the bad/poor practices of companies like UHC. They have also banned Cigna-Healthspring from offering Advantage plans to new enrollees until they clean up their act and conform to regulations.
I would concur. Depending on an MA plans penetration, market presence, often coincides with their group coverage (employer) reputation. In an area that does good business with the employer based side, the MA plan side often operates very well. However, if the employer based plans have 'quirky' contracts, which often leads to 'they denied my claim', the MA plan will often fall prey to that mindset.

There is a whole administrative side that seems 'schmarmy' to the public. That is where the 'devils in the details' results. Who a provider has their PMS (practice management system), their billers, their AR posters, their clearinghouses... which publications for correct coding they utilize, whether they stay current, all play a part. On the payor side, commercial or MA, do they have favorable contracts/relationships with clearinghouses, how is their file/translator set up (basically, to what level do they even let a claim 'in' to the system'), provider contracts, networks, nurse outreach, etc.. those also play a huge part.

The part about the government, and this usually falls down the political aisle.... one side would like to end subsidies to MA plans, resulting in higher premiums, resulting in members staying on traditional medicare. One side believes the trust fund is broken, keeping subsidies and lower premiums to MA plans, to help sustain the current broken system. Neither side is totally wrong, but neither side is even close to right. So they play their constituents off... meanwhile, CBO numbers get manipulated in the 'media' sector because, although CBO reports are public information, who wants to read 150 pages of methodology when they can look at a chart that gives only the partial picture?

Medicaid and MCOs (the medicaid version of MA plans) is in even dire straights as there are federal and state layers of red tape, the state medicaid regulations are often using 4 or 5 year old reimbursement methodologies and or rates....

How or why is that important? Take a provider for an example that sees 33% commercial/33% traditional medicare (leave out MA in this instance), 33% medicaid. Either they will have 1 biller, 1 coder, and 1 AR poster who is familiar with all their contracts, all the regulations for each type of plan, or 1 person doing all. It is very easy to see, say a colonoscopy come through, with expected reimbursement of $500. But for which type of plan? The commercial may reimburse that at $600 for ppo/$575 for hmo, medicare at $500, and medicaid at $375. One simple mistake and a whole storm of 'the claim was paid wrong' is set off, first to the member, then between provider and payor... and a whole lot of investigation that isn't always easy for a person making $14 an hour on the phone to determine. Those are simplistic examples of a very complex industry and I made those numbers up from generalities from 2010. But that is the sort of stuff the media and politicians pick up on to then demonize the entire industry, all 'looking out' for 'our' best interest. They aren't interested in the reality. Why? They don't understand it, quite frankly. (and none of that even takes into account things like preauthorization, the proper coding of the claim for services that are mutually incompatible, etc..., etc...).
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Old 02-24-2016, 04:11 PM
 
Location: Ponte Vedra Beach FL
14,628 posts, read 17,935,948 times
Reputation: 6716
Quote:
Originally Posted by Weichert View Post
I think the key as to whether to go with Advantage plans depends on the popularity of them in a particular location. Why they have wide acceptance in some areas and not others is a mystery to me. These plans don't seem to be very popular in Jacksonville yet in other parts of Florida everyone (including providers) seems to be happy with them. Why is that?

I recently read an article about their acceptance in Portland. There the Advantage plans have generally become the plans of choice. They pay more than Medicare (for both doctors and hospitals) with fewer hassles and the associated problems of Medicare (so they say). Maybe its the variability of Medicare in Oregon. Who knows?

But there are other large metro areas than Portland where close to half of those eligible for Medicare are in Advantage plans and like them. Just so strange.

And it could be that Medicare is finally dealing with the bad/poor practices of companies like UHC. They have also banned Cigna-Healthspring from offering Advantage plans to new enrollees until they clean up their act and conform to regulations.
We lived in Miami for 20+ years and have lived here for 20+ years. And I can tell you there is a world of difference between the 2 places. MA plans are very popular in Miami - especially at so-called Clinicas Cubanas for lower income Hispanic people. Where the emphasis is on a lot of nonsense. E.g., they'll pick you up at home - drop you off at the clinic - where you'll get a massage and a pedicure "for free" in addition to medical care (often rendered by fairly substandard providers). My husband was a plaintiff's medical malpractice lawyer in Miami - and these clinics are often a good source of income for malpractice lawyers.

OTOH - the uninsured/underinsured black community (both domestic and increasingly the immigrant Haitian community) turned the main public hospital - Jackson Memorial Hospital - which used to be affiliated with the University of Miami Medical School (UM bought Cedars Hospital a while back and - to the best of my knowledge - has limited or no affiliation with JMH these days) - from a place where everyone could get good care into a place where no one with any money cares to go today. My GYN (a talented cancer surgeon) left UM/JMH to come to Mayo here a year after we moved here. After JMH almost lost its accreditation as a teaching hospital because all residents were doing was mostly delivering Haitian babies - not learning how to do surgery (especially complicated surgery). Needless to say - none of our (upper middle class professional) friends in Miami get their medical care at Cuban Clinics or JMH these days. Many are in concierge plans as well.

Up here in JAX - we don't have a large number of Hispanics. Hence - no Cuban Clinics. Poor black/white people (uninsured/underinsured/on Medicaid) tend to go to Shands. Medicaid black and white people go to Memorial Hospital too.

This is a very cursory and perhaps in parts slightly incorrect overview. But the bottom line is people in Miami tend to be rich or poor. Here - perhaps we have more of a middle class who can and do buy Medigap policies? I am sure there are other things that come into play when it comes to other parts of the US (like Kaiser in California seems to be a much much better than average place to be a MA patient). And - if you can do a MA plan with Mayo in Rochester - why not? I suspect this is very very area specific.

Also - it is very hard to evaluate things from far away. Up here in NE Florida - I know hardly anything about plans/providers in Orlando or Tampa or Tallahassee - even though they're just a few driving hours away. What could I possibly know about Portland (Maine or Oregon)?

Overall - I think the best solution for anyone just going on Medicare is to go on traditional Medicare with Medigap first. Especially if you might be making a move to a place you don't know anything about. It is much easier to go from Medicare/Medigap to MA than the other way around. Best to keep options open - as opposed to closing them - if at all possible.

Note that everyone in our families has been happy with UHC Medigap policies. Robyn
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