The Medicare Advantage SCAM
An elderly and weakened patient was released from a hospital admission after a series of falls, appearing in our office six days later. He was still wrapped in the same dressings for his arm and leg wounds. The gauze was totally encrusted to him and we had to do a lot of cleanup to remove all of the debris. No one at the hospital had set up Home Health for him, which he desperately needed. He was going to need help with dressing changes. Home Health might have been at least a start.
“What the heck?! How could the hospital have been so negligent?”
Then, we learned more. None of the Home Health agencies in our region would even consider taking his particular Aetna brand of Medicare Advantage. Zero! Zip! We have a lot of Home Health agencies in our region and there were NONE willing to take his case! We called them all. It was not debatable.
Here we have an Aetna Medicare Advantage plan which promises all sorts of services. Except….those services are imaginary and do not exist for him.
Important report about fraud and over-billing in Medicare Advantage plans:
https://www.nytimes.com/2022/10/08/upshot/medicare-advantage-fraud-allegations.html
Most State Insurance Commissions have Network Adequacy rules, or some wording equivalent to Network Adequacy. They should be able to offer these services to insured living in a certain area.
I encountered this with Suboxone, early days of the treatment. A large employer, where workers can choose among different plans. Workers sometimes pick cheap mental health-substance abuse coverage. You know, the thinking that “it can never happen in this family” [mental health-substance abuse problems]……”it can never happen in this family” until it does.
An insurance that usually is pretty good around here, had a psych-substance abuse sub-plan that was horrible. I saw lawsuits across the map on Internet searches.
I have the usual buprenorphine certification, perfectly legal to prescribe. This plan took the position that the only physician qualified to prescribe the drug was an addiction psychiatrist. They did not give a damn about my qualifications. And they meant addiction PSYCHIATRIST. Addiction medicine physicians did not count. And of course, it was an addiction psychiatrist crazy enough to sign a contract with this plan.
So, in a three-county area, with a population just shy of four million, there was precisely one addiction psychiatrist where I could send a suboxone patient.
One. And that doc was on the other side of a major city. So it would take the better part of a day to drive to and from the addiction psychiatrist, driving across town..
Next appointment opening Lord only knows how far in the future.
I find AMA useless, and County Medical Society is a social club. I find State Medical Association helpful in my area. Brought problem to Chief Operating Officer. He wrote a letter to President of Large Company. Very nice letter, quite cordial, I think they socialized together, golf or some such. “By the way”, pointing out the company might be violating State Insurance law.
Problem was fixed. Only thing that concerned me, I never knew if they just fixed it for me, to shut me up, or if they fixed for everyong.
All that said, I agree with what I am sure is your first objection. We shouldn’t have to fight for this shit.
For me, it was the principle of the thing, and I’m a stubborn bastard.
We deal with this issue all the time There are regional plans…..the snowbirds in Michigan have insurance that cover everything (they say). Then they winter with us in Florida and we KNOW there plans offer limited coverage- Michigan Blue Cross is one continuous problem). Regional plans should be outlawed!!!
I actually don’t think Medicare beneficiaries should be allowed to cross state lines. That’s why I already live in Florida.