KFF Report on MAPD Prior Authorization

[somarco]

Nearly all Medicare Advantage enrollees are in plans that require prior authorization for some services



https://www.kff.org/medicare/issue-...enefits-prior-authorization-and-star-ratings/

 

[Tscholar]

Nearly all Medicare Advantage enrollees are in plans that require prior authorization for some services

View attachment 9154

https://www.kff.org/medicare/issue-...enefits-prior-authorization-and-star-ratings/

I believe this too, had my client the other day complain about this; she really wanted a Medigap plan, but she's under 65 and the rate would be too high. This is a good selling point for people selling Medigap plans.

 

[somarco]

I was surprised at the number of services in the 80 - 90% range requiring PA.

When you click through and read the article you get more granularity about the services requiring PA. I do mention the PA requirement when someone asks about comparing MAPD to Medigap, but I just make a general statement that "PA typically applies to high dollar care such as radiology and surgery, typically outpatient". I take it for granted that Part B drugs, which often include chemo, would be subject to PA in an MAPD plan.

There is no PA with Medicare for chemo, only MAPD.

While I am aware of PA requirements in stand alone dental plans I only discuss that, and the par provider limitation that applies to nearly ALL dental plans. I never get questions about MAPD dental plans other than "they are "free" with MAPD, how about Medicare/Medigap". I don't promote dental or DVH plans because of the hassle factor for clients.

Agents that heavily promote MAPD either are unaware of how often PA comes into play or they don't care. My block is 100% Medigap so I never get client questions about PA because, other than DME, PA is not a requirement. Most of the client questions are pre-emptive such as "Does Medicare cover this".

Even the post claim questions about "Why wasn't this paid?" are usually countered by "Have you satisfied your Part B deductible?". If they haven't the question does not require furthe explanation.

I tell prospects up front that one of the reasons for considering Medigap is the low hassle factor . . . "When you have problems with coverage those problems become my problems and neither of us need to be spending time fighting insurance carriers to get claims paid".

If you have not read the linked article yet, you should. It is quite eye opening about the contrast with the MAPD world. I am convinced many MAPD policyholders don't ask questions, of the agent or carrier, because they feel it is a waste of time. Or maybe they just don't want to take the time to appeal.

Of course the burden for PA falls on the provider, not the policyholder.

Post claim appeals rest on the policyholder for the most part. I wonder how many MAPD claims are denied because PA rules were not followed?

That is not a rhetorical question but one that requires something other than anecdotal responses "my clients never complain" kind of stuff.

 

[rhcbp]

I would think for the first 65 years of our lives we were also in plans that required prior authorization. In NJ the MAPD plan is a lot better than the plan I was paying $915 a month for. If someone can afford the $915 a month plus the $3000 deductible, I am pretty sure they can afford the $6700 maximum out of pocket. MAPD's are not for everyone, but neither are Med Supps. In 15 years while some people complained to me about the prior authorizations, no one has told me their procedure was not approved.

 

[Packerland]

I had a client that went to her Dr and was told she needed back surgery fusion on her spine. She was denied the surgery by her MA carrier and she called me upset. I suggested she appeal the decision which she did and she was denied again. She went on to get two additional second opinions on our own. In both cases those doctors told her there's no way she needed to have her back fusion. Needless to say she was beyond happy back fusion was avoided.

I think we all know why preauthorization is important in the medical industry.

I do think that any services requiring pre authorization be handled in a timely manner 48 to 72 hours.

I understand that it can be a time-consuming and often frustrating process for the patients alike, there are several reasons why getting a prior authorization for a medical procedure can be a good thing.

By ensuring that a procedure is medically necessary and appropriate, insurance companies can avoid unnecessary expenses and reduce the overall cost of healthcare. By requiring authorization, insurance companies can help ensure that these procedures are performed by experienced and qualified healthcare providers who can deliver high-quality care.
Prior authorization can also help prevent fraud and abuse in the healthcare system. By requiring authorization, insurance companies can ensure that procedures and treatments are not being performed unnecessarily or fraudulently.
Finally, prior authorization can help ensure patient safety. By requiring approval for certain procedures or treatments, insurance companies can help prevent patients from receiving treatments that may be unsafe or inappropriate for their specific medical condition.
Overall, while the prior authorization process can be challenging, it can ultimately help control costs, ensure quality care, prevent fraud, and promote patient safety.

I just returned from Costa Rica from a Sales Incentive trip for selling Med Supps. I sell both MA and Med Supp be sure to present both options. Give your clients the pro and cons of both and ultimately it is their decision.

 

[somarco]

I would think for the first 65 years of our lives we were also in plans that required prior authorization. In NJ the MAPD plan is a lot better than the plan I was paying $915 a month for. If someone can afford the $915 a month plus the $3000 deductible, I am pretty sure they can afford the $6700 maximum out of pocket. MAPD's are not for everyone, but neither are Med Supps. In 15 years while some people complained to me about the prior authorizations, no one has told me their procedure was not approved.

PA's with MAPD seem to be more prevalent than U65 health insurance . . . EGH or Obamacare. Part of that may be because folks 65+ generally have more ailments than before. Most of the large claims experienced with U65 are childbirth or accidents. Not a lot of cancer or cardiac issues.

A blanket statement that those with coverage prior to 65 encountered the PA issue ignores utilization pre-65 vs post-65.

Also, pre-65 "large claims" are not as frightening when you have an income stream. Post 65 is where a large number are living off SSA almost exclusively with very little in savings and many do not have a retirement plan. Perspectives change when you are living month to month on a fixed income.

PA's with MAPD are denied and often require an appeal plus a peer to peer consult. Just because YOU don't hear about them doesn't mean they don't exist. There are plenty of DOCUMENTED research articles including the KFF post linked above that disprove the anecdotal comments that PA is not an issue.

 

[DonP]

Somarco uses fear and no first hand knowledge when discrediting Mapd . My mapd active is near 1000. YET TO THIS DAY IVE NEVER GOT ONE CLIENT THATS TOLD ME A PROCEDURE HAS BEEN DENIED .Now admittingly I’ve not been doing 2 1/2 yrs .Sure ive gotten some clients who had to appeal first denials but ultimately got the procedure done . Even on very expensive drugs .Most mapd carriers have clinical pharmacy fax #’s for rx exclusion lists to appeal Bottom line is most carriers have approved drugs not on their formulary when appealed

 

[Midlevel]

I guarantee you every Med Sup company in the United States wishes Medicare would implement PA. It would be the smartest thing Medicare could do so all these procedures such as running nursing home patients through rehab like cattle could be cut back. Can't imagine how much $$$ is wasted every year because providers know they can do whatever they want to someone on OM and no questions will be asked. Poor Med Sup companies have no say whether something is medically necessary or not, hence why their premiums go up yearly and MA plans tend to get better each and every year. What a great scare tactic though for the Med Sup only crowd even though us that sell MAPD's don't run into PA problems often.

 

[Midlevel]

. "When you have problems with coverage those problems become my problems and neither of us need to be spending time fighting insurance carriers to get claims paid".

Could this be part of the reason some refuse to give their clients all their options? Too much of a hassle for only $601.00?

 

[somarco]

Not unexpected, but a number of ANECDOTAL responses. How about evidentiary citations to support your theory? Bueller?