UHC Violates CMS Rules

[LostDollar]

Red letters mine.

4. MAPD can deny your claims (obviously). Med supps do not. Wanna roll the dice? Be my guest. I generate 20X more MAPD traffic as a marketer than I do Med Supp. I happily send it off to my partners and bank with both.
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I have enjoyed seeing your posts about Medigap sales.

I am not trying to create conflict with my following statement.
Just a random fact that might indicate there are rare exceptions to the generally accepted rule.

Last year I had health services that caused creation of over 60 MEOB's by Medicare.
(Maybe just 45-50 if you remove physical therapy ones.)

---I had a claim with Medicare approved services.

---It did not meet whatever the requirements are for automatic submission of the claim by Medicare to the Medigap carrier.

---The provider submitted the claim to my Medigap carrier. The carrier refused to accept the claim, even after multiple re-submissions. While this may not have technically been a denial, the non-payment effect to the provider was the same.

So, my personal experience suggests that there must be some unusual or uncommon situations in which a Medigap carrier can deny or refuse to process a claim.

 

[Bevo]

Red letters mine.


I have enjoyed seeing your posts about Medigap sales.

I am not trying to create conflict with my following statement.
Just a random fact that might indicate there are rare exceptions to the generally accepted rule.

Last year I had health services that caused creation of over 60 MEOB's by Medicare.
(Maybe just 45-50 if you remove physical therapy ones.)

---I had a claim with Medicare approved services.

---It did not meet whatever the requirements are for automatic submission of the claim by Medicare to the Medigap carrier.

---The provider submitted the claim to my Medigap carrier. The carrier refused to accept the claim, even after multiple re-submissions. While this may not have technically been a denial, the non-payment effect on the provider was the same.

So, my personal experience suggests that there must be some unusual or uncommon situations in which a Medigap carrier can deny or refuse to process a claim.

And I appreciate you sharing this.

As an experienced broker, I'll be the first to say that none of us have "seen it all", most certainly myself included. And I'll see even less as the very near future approaches as I bow out of engaging in sales and shift over to marketing nearly 100%.

In your example and your own experience, I think you hit the nail on the head...

There are "rare and uncommon exceptions".

So rare, in fact, that compared to the massive number of denials and refusals of MAPDs, it's even clearer that the two are almost night and day in the case of those denials and refusals.

But great knowledge to have, so thank you.

 

[somarco]

4. MAPD can deny your claims (obviously). Med supps do not

Med supps do not adjudicate and approve/deny claims . . . only Medicare performs that function

 

[Packerland]

Several hundred on MA? Let me know when you become a big producer and get to a 1000? Then the law of #'s and denials will hit you

Let me chirp in here I currently the AOR of 3000+ Medicare Advantage Prescription Drug (MAPD) clients alongside around 600 Medicare Supplement (Med Supp) clients, and I haven't encountered the same level of issues that you have reported regarding Medicare Advantage plans. Perhaps it's partly due to my location and the specific plans available in my area, or it could be attributed to my approach in providing clients with clear expectations during our consultations.

It's worth noting that I haven't converted any of my MAPD clients to Med Supp plans this year, but interestingly, I've successfully transitioned 28 Medicare Supplement clients to MAPD plans. This shows that clients do appreciate the benefits that MAPD plans can offer.

I do find it somewhat challenging to believe that individuals are randomly reaching to you out with complaints about Medicare Advantage plans, as my experience has been quite different. However, I understand that experiences can vary, and I respect your perspective on this matter.

 

[LostDollar]

Let me chirp in here I currently the AOR of 3000+ Medicare Advantage Prescription Drug (MAPD) clients alongside around 600 Medicare Supplement (Med Supp) clients, and I haven't encountered the same level of issues that you have reported regarding Medicare Advantage plans. Perhaps it's partly due to my location and the specific plans available in my area, or it could be attributed to my approach in providing clients with clear expectations during our consultations.

It's worth noting that I haven't converted any of my MAPD clients to Med Supp plans this year, but interestingly, I've successfully transitioned 28 Medicare Supplement clients to MAPD plans. This shows that clients do appreciate the benefits that MAPD plans can offer.

I do find it somewhat challenging to believe that individuals are randomly reaching to you out with complaints about Medicare Advantage plans, as my experience has been quite different. However, I understand that experiences can vary, and I respect your perspective on this matter.

Since you are talking about less than 5% of you Medigap client base, let's make a small modification to your statement to make it more clear and more accurate:

This shows that some clients do appreciate the benefits that MAPD plans can offer.

 

[MedSuppPro]

Just moved a lady off of her $5,600.00 / year MedSupp into a $390 / year MAPS PPO. She will have a $3400 in and out of network MOOP. I will educate my people why I want them in a PPO and why they need to avoid HMOs. I’m a MedSupp agent and wish everybody could afford them. Many can’t. All that MAPD agents have at the point of sales are confusing Enrollment Guides or Enrollment Books that CMS needs to standardize. CMS needs to be standardized them to the point where the consumer can lay two competing plans side by side and coherently compare line by line. The point of sales material need to list ALL the procedures that require prior notifications, prior approvals, and prior authorizations. Nobody knows what these plans restrict because it is not listed up front like a MedSupp that has a page of Limitation and Exclusions in their outline of coverage. Why CMS turns a blind eye on this fundamental disclosure requirement is beyond me.

 

[somarco]

The point of sales material need to list ALL the procedures that require prior notifications, prior approvals, and prior authorizations. Nobody knows what these plans restrict because it is not listed up front

Sounds nice, but almost no one, consumer or agent, reads the "fine print"

Most of my clients don't even read the ANOC to know their 2024 premium is 2x what they currently pay.

I sent out newsletters in Oct, Nov and Dec letting clients know about premium increases yet some called me as late as yesterday asking to change their PDP because they "just found out" about the new premium.

The last 2 newsletters let them know Elixir would not be offered in 2024, and the Dec notice about discontinued ClearSpring plans. BOLD PRINT!!!!

 

[LostDollar]

Just moved a lady off of her $5,600.00 / year MedSupp into a $390 / year MAPS PPO. She will have a $3400 in and out of network MOOP. I will educate my people why I want them in a PPO and why they need to avoid HMOs. I’m a MedSupp agent and wish everybody could afford them. Many can’t. All that MAPD agents have at the point of sales are confusing Enrollment Guides or Enrollment Books that CMS needs to standardize. CMS needs to be standardized them to the point where the consumer can lay two competing plans side by side and coherently compare line by line. The point of sales material need to list ALL the procedures that require prior notifications, prior approvals, and prior authorizations. Nobody knows what these plans restrict because it is not listed up front like a MedSupp that has a page of Limitation and Exclusions in their outline of coverage. Why CMS turns a blind eye on this fundamental disclosure requirement is beyond me.

Caveat, not an agent.

Wouldn't this be one of the results of turning over administration of health care insurance administration to a third party in order to reduce effort and save money?

Seems to me like the essence of your comments is that CMS should drop MA coverage options and go back to only Medigap and PDP.

 

[LostDollar]

Med supps do not adjudicate and approve/deny claims . . . only Medicare performs that function

Well ...
As I told another poster, I would consider this to be a rare and unusual circumstance,
but I just checked my Medigap EOB history for last year on the carrier's website. I did not use the word denied in my discussion with the other person, but the specific verbiage the carrier uses in the online claims recap is "DENIED" (vs PAID).

I have 5 EOB lines that come up with a status of "denied".
Claim A was denied 3 times.
Claim B was denied 2 times.

These claims were processed by the CMS Part B contractor for Kansas and both contain Medicare approved services. On one claim not all services were approved by Medicare. The claims were not automatically transferred to the Medigap carrier by Medicare. The Part B provider seems to be unable or unwilling to submit the claims to the Medigap carrier in a manner that will lead to the Medigap carrier approving the claim.

 

[MedSuppPro]

Sounds nice, but almost no one, consumer or agent, reads the "fine print"

Most of my clients don't even read the ANOC to know their 2024 premium is 2x what they currently pay.

I sent out newsletters in Oct, Nov and Dec letting clients know about premium increases yet some called me as late as yesterday asking to change their PDP because they "just found out" about the new premium.

The last 2 newsletters let them know Elixir would not be offered in 2024, and the Dec notice about discontinued ClearSpring plans. BOLD PRINT!!!!

True… but I always read to them the Exclusions and Limitations found in the MedSupp Outline of Coverage. It's usually a very short list. The MA plans point of sale summaries lack these consumer disclosures.