As I have discussed, Medicare Advantage insurers have an incentive to deny individuals healthcare coverage when it is needed most. That's because a Medicare Advantage insurer gets paid a flat rate by the federal government and profits more the less medical services an insured uses.
Thus, as a Medicare consumer advocate and an attorney, I am not just concerned about how much an individual will pay for medical services. I am equally concerned that an individual will be wrongly denied medical services altogether when he or she needs it the most. Even if he or she eventually gets the medical services, appealing is a burdensome (and sometimes expensive) experience at an emotional time.
On this measure, Blue Cross Blue Shield of Michigan's Medicare Advantage PPO plans rate "Below Average." [1] Specifically, the Centers of Medicare & Medicaid Services ("CMS") rates the BCBSM Medicare Advantage PPO plans "2 Stars" on the "Fairness of Health Plan's Denials to Member Appeals, Based on an Independent Reviewer."
What does this mean? BCBSM is denying more people medical services under its PPO plans than it should. Those inappropriately denied have had to go through bureaucratic hoops to ultimately get that wrong decision overturned. What really concerns me are the individuals that have been denied coverage by BCBSM, but did not go though the burdensome process of appealing that coverage decision.
How many stars would Medigap plans get? 5 stars. Why? Because with these plans, there is no private insurer standing between an individual and his or her medical provider when making medical coverage decisions. Additionally, unlike a Medicare Advantage plan, an individual can immediately appeal all decisions to an independent entity.
I have talked with BCBSM and suggested that they create an ombudsman or similar program to work on this critical measure. BCBSM seemed open to the idea, but I have yet to receive any commitments. Until this rating gets to at least four (and ideally five) stars, this remains yet another reason why Medigap remains the gold standard.
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[1] BCBSM's HMO plans do not fair much better at an "Average" 3-star rating.
Thus, as a Medicare consumer advocate and an attorney, I am not just concerned about how much an individual will pay for medical services. I am equally concerned that an individual will be wrongly denied medical services altogether when he or she needs it the most. Even if he or she eventually gets the medical services, appealing is a burdensome (and sometimes expensive) experience at an emotional time.
On this measure, Blue Cross Blue Shield of Michigan's Medicare Advantage PPO plans rate "Below Average." [1] Specifically, the Centers of Medicare & Medicaid Services ("CMS") rates the BCBSM Medicare Advantage PPO plans "2 Stars" on the "Fairness of Health Plan's Denials to Member Appeals, Based on an Independent Reviewer."
What does this mean? BCBSM is denying more people medical services under its PPO plans than it should. Those inappropriately denied have had to go through bureaucratic hoops to ultimately get that wrong decision overturned. What really concerns me are the individuals that have been denied coverage by BCBSM, but did not go though the burdensome process of appealing that coverage decision.
How many stars would Medigap plans get? 5 stars. Why? Because with these plans, there is no private insurer standing between an individual and his or her medical provider when making medical coverage decisions. Additionally, unlike a Medicare Advantage plan, an individual can immediately appeal all decisions to an independent entity.
I have talked with BCBSM and suggested that they create an ombudsman or similar program to work on this critical measure. BCBSM seemed open to the idea, but I have yet to receive any commitments. Until this rating gets to at least four (and ideally five) stars, this remains yet another reason why Medigap remains the gold standard.
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[1] BCBSM's HMO plans do not fair much better at an "Average" 3-star rating.
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