Switching from Advantage Plan (which left my area, creating a qualifying event) to Original Medicare. Here's Why

[Silent Type]

39. Not exactly true. Traditional Medicare has very detailed coverage rules that prevent some questionable claims.

Further, Medicare audits providers exhibiting a billing pattern that is questionable, often 3, 4, 5 years after services rendered, prompting providers to be careful.

Every few days, one reads of Medicare audits where a provider billed millions of dollar over 4 years, when no patient was even seen. Medicare doesn't catch it and we get ripped off.

MA on the other hand often has only 12 to 18 months to recoup questionable services. So they deny upfront. Most denials are overturned quickly once the doc send in records. If you don't think providers -- including Marcus Welby -- don't cheat, you are mistaken.

And, home health gets audited too.

KFF:

Key Takeaways:
"Medicare Advantage insurers made nearly 50 million prior authorization determinations in 2023, reflecting steady year-over-year increases since 2021 (37 million) and 2022 (46 million) as the number of people enrolled in Medicare Advantage has grown. The determinations represent requests for approval that providers are required to submit before providing a service. Substantially fewer prior authorization reviews for traditional Medicare beneficiaries were submitted to CMS – just under 400,000 in fiscal year 2023 – though the number of people enrolled in Medicare Advantage and traditional Medicare were similar in these years.

"In 2023, there were nearly 2 prior authorization determinations on average per Medicare Advantage enrollee, similar to the amount in 2019. In contrast, in 2023, about 1 prior authorization review was submitted per 100 traditional Medicare beneficiaries – a rate of about 0.01 per person — which reflects the limited set of services subject to prior authorization in traditional Medicare.

"In 2023, insurers fully or partially denied 3.2 million prior authorization requests, which is a somewhat smaller share (6.4%) of all requests than in 2022 (7.4%). Though there were substantially fewer prior authorization reviews for traditional Medicare beneficiaries, a larger share was denied – 28.8% in 2023. Denial rates varied across the limited set of services subject to prior authorization in traditional Medicare.

"A small share of denied prior authorization requests was appealed in Medicare Advantage (11.7% in 2023). That represents an increase since 2019, when 7.5% of denied prior authorization requests in Medicare Advantage were appealed. A relatively small share of denied prior authorization reviews was appealed in traditional Medicare (6.4% in 2022) as well.

"Though a small share of prior authorization denials were appealed to Medicare Advantage insurers, most appeals (81.7%) were partially or fully overturned in 2023. That compares to less than one-third (29%) of appeals overturned in traditional Medicare in 2022. These requests represent medical care that was ordered by a health care provider and ultimately deemed necessary but was potentially delayed because of the additional step of appealing the initial prior authorization decision. Such delays may have negative effects on a person’s health."

https://www.kff.org/medicare/nearly-50-million-prior-authorization-requests-were-sent-to-medicare-advantage-insurers-in-2023/