Dear Medicare Beneficiaries

Dear Medicare Beneficiaries,

As we all know, the Annual Enrollment Period (AEP) began yesterday October 15 th. Please be aware that there are 80 million seniors turning 65 over the next 15+ years so call waiting times will be long. Have patience with us, either Medicare, Social Security or your health plan provider. We are doing our best to accommodate and address the concerns you have with your current or prospective health plan. To expedite any inquiry please be prepared with your Medicare card, your health plan card, member ID and a list of any prescriptions you are taking. This will assist us in efficiently answering your concerns.
Also, please be aware that the AEP ends on Dec 7th so if you need any information mailed to you regarding your current or new plan please call at least two weeks before the AEP deadline. By doing this you will have plenty of time to review the information and call back to ask any questions or concerns you may have.
Medicare beneficiaries, I speak to you from the trenches of Medicare warfare. I am on the front lines and deal with seniors and their frustrations everyday. I am providing you with little secrets that will get you the answers you seek in a timely fashion. Take heed however, not everything you hear is gospel. You want to make sure you always confirm the information you receive from another source. If that means calling back then do so. Trust me when I tell you this…” You want to make absolutely sure that the terms and conditions of care provided by your health care provider are what you were expecting.” If it is NOT, then you must contact Medicare because you may have been mislead and this type of Medicare fraud can cost you dearly, both emotionally and financially.



Dear Medicare Beneficiaries,

If you have received a letter from your insurance provider stating that your current MAPD or PDP plan will be discontinued in 2013 you MUST ACT ACCORDINGLY DURING THIS AEP BETWEEN OCT 15th to DEC 7th. Doing nothing will either revert you back to Original Medicare A & B and or no drug coverage. Starting the year without drug coverage can be a hassle so to avoid receiving a Late Enrollment Penalty (for not having Rx coverage) do your due diligence and search for one. Contact your customer service, it’s more than likely they offer a comparable plan to the one you are losing. This also goes for individuals losing their Medicare Advantage (MAPD) plan as well.
Now, for those of you who DO NOT want to replace your MAPD with another one available in your area you have the option of reverting back to Original Medicare and picking up a Rx plan GUARANTEED ISSUE. THIS MUST BE DONE (App completed and submitted) prior to the last day in Feb. 2013. This guaranteed issue provision allows you to enroll into any Medicare Supplement plan without being subject to underwriting. For those beneficiaries who live in the northeast region of the US ( NY, ME, NH, & CT) underwriting is of no concern for you because it is illegal for insurance companies in these states to underwrite a Medicare beneficiary.
However, unfortunately for the rest of you, it is quite legal in other states for insurance companies to weigh the risk of enrolling you as a member. They have the right to deny your enrollment based on the risk you may cost them. Is this fair? Not in my opinion but you have to remember that insurance is a business. As a consumer you must approach the selection process of a plan in the same manner. Do the research and find out which plan offered in your area works best for you.
Retrospectively however this may be an opportunity for you, as a consumer, to seize the moment and take advantage of the loop holes the system has created. What I mean is simply this… For any individual enrolled into Medicare A & B, if your health is where it should be at your age or better (meaning you are quite healthy, and only visit your PCP or a specialist a couple times a year) then enrolling into a MAPD would be beneficial. Your premiums are relatively low and your co-pays for services provided would be minimal because you don’t seek treatment for any issues often. This coincidally keeps your out of pocket expenses (OOPE) low. However if your health is declining and you KNOW that you DO or WILL NEED to seek treatment for conditions that ail you the Medicare Supplement route might be the best path to take. This is where you can take advantage of the system. Normally, any Medicare beneficiary outside of the states I mentioned above looking to enroll into a Medicare supplement plan (outside of their initial enrollment period [IEP]) would be subject to underwriting which may prevent you from being enrolled and getting coverage. Coincidentally however, since your MAPD is being discontinued in 2013 (no longer available) that gives you an SEP or special enrollment period that allows you to enroll into any Medicare Supplement plan guaranteed regardless of your health condition. This is a tremendous benefit because if you can afford the premiums then you will be eligible for the most comprehensive plan (Plan F) out there.
I understand that this situation is annoying and cumbersome but trust me when I tell you this “you are better off doing the research to find a plan similar to what you have or different; it doesn’t matter.” AS LONG AS YOU FIND A PLAN TO REPLACE WHAT YOU ARE LOSING BEFORE THE END OF THE YEAR. If you sit and do nothing, come the new year your OOPE will be drastically higher than what you are used to. My advice is take the time with someone to go over your replacement options so you are aware and can forecast your health care expenses for 2013. There’s nothing more frustrating than looking for financial assistance with your health care costs and being left in the wind to cover it yourself…..unless you “Got it like that!”

It’s Finally Here!

It’s here!!! Managed Care Consultants’ inaugural newsletter has just hit the stands!!!….. Just kidding, but it is available to those who want it. And it’s FREE. Inside, we have described for you in detail who we are and what we do. We are ‘THE ‘educational resource guide to understanding Medicare for seniors. We are committed to enlightening those who are willing to learn and help prevent health care fraud. Just click the link below! Check back with us frequently, we’ve always got something new and interesting to share. We ” Tell It Like It Is.” Your opinions and comments on how we can improve are always welcome. Don’t be afraid to share your questions or concerns. We are a community of educators and we learn best from one another’s experiences. Take care and hope to hear from you. Don’t forget to click the MCC Newsletter link below!

Calvert Louden, MCC Newsletter 8-12

Prescription Drugs Don’t Come Cheap

Drug companies are at it again… Not only do they ruthlessly compete for large percentages of the prescription drug market, but now that ‘top-selling’ drug patents are expiring, they are cleverly finding ways to keep some consumers coming back for more. Quick question, “How many of you out there are bargain shoppers?” I would hope all, why waste money when you can get it for cheaper, right? Ok, “How many of you out there use coupons?” I can see thousands of ladies raising their hands right now with coupon clippings in hand, like ” Ooooh, I do, and I’m really good too. Saved myself $34 and some change last time out!” God I love the savvy consumer. Now, try putting those two concepts together and this is what you get…

As current economies, both the US and worldwide, continue to struggle, and health care costs steadily increasing, the price of doing business for prescription drug companies like Pfizer and the like is becoming too much to handle. Research and development for future drugs has become a more scrutinized process by the FDA, costing drug companies billions of dollars before getting final approval. In order to recoup this initial investment, the government has allowed Drug Companies exclusive rights to the market for 10-15 years before a generic equivalent can even be offered as a cost-saving solution to patients. So, after billions in profit and the drug companies’ patent is about to expire, one would think the smaller companies putting out generics can now get a piece of the pie, right? Wrong. Large Rx drug companies aren’t going to just ‘hand over’ a large part of the market like that without kicking and screaming. So, what have they done to offset this? You guessed it! Coupons.

Drug companies are taking a strategic and tactical but simplistic approach to offsetting the loss of billions of dollars in revenue to generic drug makers by offering existing or prospective patients coupons for discounts on monthly brand name prescriptions. I mean think about it, what better way to maintain a small percentage of your clientele base than to offer them incentive to stick around? Times are tough man; we have to save wherever we can, but (and drug companies love this…) we are also creatures of habit. We trust who we trust, who we know, even if that means spending a few extra dollars. This is exactly what large Rx drug companies are banking on. When the patent expires on brand name drugs, generic equivalents flood the market and can be offered for as low as 90% below the cost of brand names. At this point, most consumers usually switch. A massive drop-off of consumer brand loyalty costs drug makers billions, unless they can ‘slow the bleeding.’ In this case, drug companies that offer coupons are effectively killing two birds with one stone. Here’s how…. By offering coupons, consumers are happy to maintain their brand loyalty without having to pay as much as before. And most importantly, they can continue to use a drug that they know works for them versus taking the chance with an unproven generic and its side effects. This is great news!… except for one thing…. “The coupons only work with private insurance, though. Patients with Medicare or other government health insurance are barred from using them.”

Hold on a sec. So, if I understand this correctly, Rx drug companies are only going to incentivize people with private insurance? Isn’t that discriminatory? Yes. And there’s nothing you can do about it. If you are a Medicare beneficiary or qualify for government health insurance, like Medicaid, you do not get to participate in the coupon party. That stinks!!! Medicare/Medicaid beneficiaries who live off of Social Security/Supplemental Security Income (SSI), respectively, are expected to continue to pay the rising costs of Rx drugs or they are forced to switch to generics. Has anyone considered the ramifications of this?! What if seniors or these low-incomed individuals end up worsening their health condition due to the side effects of switching to generics? What happens then? Are we to just look the other way, and tell them to “stick with what works?” Oh, and by the way, in order to safely monitor your condition, you will need to continue to spend hundreds of dollars a year, even though we know you cannot afford it. So much for keeping the consumer’s best interests at heart. Where’s the compassion? Im sorry, I forgot that we were talking about Rx drug companies here. It’s a business and only that. As long as their bottom line doesn’t fall too far too fast that is all they are concerned with.

Not surprisingly, commercial insurers don’t like the coupons, because their share of the cost for a brand-name drug is much higher than for a generic pill. Virtually all prescription plans automatically switch patients to a new generic drug [once available] the next time they refill their prescription. The [Rx] plans also move the drug from the copayment level [usually Tier 2] for most brand-name drugs, usually around $25, to their highest copayment level [usually Tier 3], often $50 to $75 per prescription. [This is to force patients to accept the move to generic drugs because Tier 3 drug cost-sharing for insurance company is more expensive than the cost-sharing for a generic; this method is preferred by the insurance company, regardless of the effect, whether financial or physical, on the beneficiary.] The coupons throw a wrench into insurers’ strategy of getting as many patients as possible to take generic drugs, which account for about 80 percent of all prescriptions filled in the U.S. [To combat this, drug makers are] also signing unprecedented deals with dozens of insurers that lower their (the insurer’s) portion of the cost of [a brand drug] to what a generic would cost them — [as long as] they covered only brand [name ‘X’] for [x amount of time]. That meant both patients and insurers had a big financial incentive to stick with [the brand name drug] for a while.

Drug makers use coupons to fight generics, by Associated Press Aug, 20,2012

So, where do we go from here? I don’t know, it’s tough to say. For right now, it is what it is. Medicare/Medicaid beneficiaries are excluded from the rewards of brand loyalty. I apologize that I unfortunately could not give you any definitive answers as to how to approach or circumnavigate this issue. I hope by asking questions about these incentive ‘kick-backs’ I might be able to raise eyebrows for someone, somewhere, who in a place of power or authority can say ” What are we doing, are we really allowing this to happen?” By generating discussion we can bring to light our concerns. Until then, only time will tell.

EOBs can be SOBs…

Trudy Lieberman, a journalist for more than 40 years, is an adjunct associate professor of public health at Hunter College in New York City. She had a long career at Consumer Reports specializing in insurance, health care, health care financing and long-term care. She is a longtime contributor to the Columbia Journalism Review and blogs for its website,, about media coverage of health care, Social Security and retirement. As a William Ziff Fellow at the Center for Advancing Health, she contributes regularly to the Prepared Patient Forum blog…more.

Prepared Patient Forum

Most importantly however, Trudy Lieberman is a senior, frustrated with Medicare, insurance companies and their efforts to simplify the understanding of coordinating care. In her article, More Confusion about those Insurance EOBs– This Time from Medicare it is quite clear that she has a hard time understanding how Medicare and insurance companies coordinate benefits…..and look what she did for a living! That should be a very powerful statement about how difficult it must be for seniors. Truth be told it seems ridiculous! If Ms. Lieberman is having difficulty than what chance does the average senior have? Why is it so difficult for Medicare and insurance providers to make the explanation of benefits,or EOBs comprehendible?

In case you’re new to Managed Care Consultants, here is a little information about us. We are a group of qualified health care professionals that take a lot of pride in educating seniors about Medicare and how they coordinate benefits with their current health plan. We host seminars, consultations, public speaking events and the like at retirement communities, senior centers and pretty much wherever seniors congregate. During my time working as a quality development specialist at a health insurance consulting firm I came up with the idea of starting my own educational resource guide for seniors when I began to notice a disturbing trend – More seniors, than I realized, were knowingly enrolling into health care plans due to lower premiums without understanding how benefits were coordinated with Medicare or what they would be financially responsible for. Health insurance agents didn’t take enough time to carefully explain what seniors were signing up for and why, they would simply send out the EOBs and wipe their hands clean. Insurance companies and agents are more concerned with enrolling a new member than they are in making sure the plan selected is in the best interests of the individual. This is a very big problem, not to mention extremely careless. Here’s a thought for you though….what other choice do seniors have? Many rely on income from Social Security which can be very limited and often puts them between a rock and a hard place when deciding between paying bills and buying food or continuing to pay rising health care premiums. This doesn’t leave them with much of an option. So they mull over countless pages of information regarding available health care plans in their area, and they try and compare them to the plans they currently have. They struggle to understand how they are similar, but more importantly how they’re different. Now, of course, if the premium is lower it looks more attractive, but why? Is there something that they are missing? Truth be told, yes. Well then what is it? This is what Managed Care Consultants strives to offer to the senior community. Knowledge and understanding.

As alluded to by Trudy in her article (which, if you haven’t please read) Medicare and insurance companies are a pain to deal with. When claims forms are delivered to the member, coordination between the insurance provider and Medicare is almost non-existant. There are separate forms for each which makes understanding who paid what more difficult. Whenever you as a consumer reach out to clarify this issue they either put you on hold, answer your question in a way that is still confusing, transfer you to another agent or refer you to your insurance company to answer your questions. This is time consuming and extremely annoying. All consumers want is clarification for a product they are paying for and they cannot even get that without jumping through hoops! Where is the customer service?!!! It’s no wonder seniors are fed up and angry. I don’t blame them, they have every right to be. They don’t have the time or the patience to deal with this….they are retired. They should be spending their time with grand children, their loved ones, traveling or enjoying life at this point in their lives. Instead, they are compounded with confusing claims statements about their health insurance plan and Medicare (which is a social insurance protection plan established for them!) Oh, by the way, did I mention that this was an EOB that was delivered after the ACA and Medicare made extensive efforts to simplify the wording? And yes, I did hold that piece of information on purpose. Here’s why….

Even after CMS and Medicare have made the effort to reach out to insurance companies in hopes of getting them to simplify the terminology used to explain benefit structure and financial responsibility in health care plans, their efforts have bore little fruit. It’s still a hassle to deal with. Most seniors wish they don’t have to, however, when living on Social Security seniors are pigeon-holed into forecasting their out of pocket expenses for the year regarding their health care. This requires an understanding of coordination of benefits: who pays what and how much. Seniors obviously aren’t getting this understanding from Medicare or their respective insurance company, which begs one to ask ” how do they find out, how do they educate themselves and where?”

I wish there were an easier way, and I will try my best to make it as simple as possible, but the only avenue I see as being effective is to educate yourself or those who manage your health care. As consumers nowadays, we are much more savvy than in the past. We do our homework….but to what degree, ever heard of buyers remorse? With regards to health care, key factors such as premiums, provider accessibility, and your provider’s relationship with the insurance company you are considering should be major determining factors when choosing a plan. This is extremely important because the ACA has allowed Medicare and CMS to monitor and regulate Medicare Fraud Waste and Abuse and in the short term they have saved Medicare beneficiaries billions of dollars. That could have been money out of your pocket. The more aware we as beneficiaries are about our financial responsibilities for senior health plans, the less likely the chance of being taken advantage of. This can only be achieved by educating yourselves about your entitlement rights and what you are responsible for financially. Managed Care Consultants has written a very informative piece titled, “Are You a Part of the Growing Trend?,” that does a fantastic job of highlighting different avenues for seniors to do just that: educate themselves about Medicare and take responsibility in simplifying their health care management.

The economy of this great nation has thrived off of a capitalistic approach to running business for decades, however, at a severe price (as our current economic status has clearly shown). America’s ‘business’ mantra, if you will, was to produce profit at any cost….even at the expense of those driving it. That approach has come back to bite us, you know where!… and unfortunately the ones suffering the most are the very ones who helped navigate this nation’s success and position it as a world power. Now, we can barely afford to care for their health. Pretty sad right? I know. Trying to find a solution to reduce health care costs is going to take time, something our current seniors don’t have too much of. So, in the meantime, to help contain costs and prevent unnecessary submission of claims, what is needed is the motivation to self educate. The more informed we are as consumers, the less likely the chances of being hoodwinked by insurance providers.

Medicaid Providers, Where Are They?

Medicaid.  A highly publicized and scrutinized social insurance program established for those with low income has seen a wavering sense of support recently, especially with the decision of the Affordable Care Act.  Sarah Kliff, a writer for the Washington Post, has written about Medicaid and the gleaming show of support by its enrollees in California, stating that more beneficiaries than expected actually like their health coverage offered by the program.

Here’s the thing….  Medicaid has been known to offer low reimbursement rates to physicians across the country, causing many providers to not accept new Medicaid patients.  Not only is this a major concern for the social insurance program, but accessibility to care as well.  Here is where this article, Actually, Medicaid enrollees really like their coveragecan be a little misleading to the uninformed.  It is true that out of the 1,083 Medicaid enrollees that were surveyed, 9 in 10 said that Medi-Cal (Dual eligible individuals who have Medicare and Medicaid) services were “very good” or “pretty good.”  Not to sound callus, but any type of ‘free’ insurance should be considered “very or pretty good.”  I mean, lets be honest here.  If an individual cannot afford to pay for insurance to manage their’s or the  well-being of their loved ones, can they really be critical of they type of care they receive?   I, for one, believe that regardless of an individual’s economic or social standing, the care provided to them from a professional should be of the upmost quality (within means of course).  If the nation’s hard earned tax-payer dollars are going to do something, then it might as well be to get these individuals healthy and back working again.  Unfortunately, not every Medicaid beneficiary is experiencing this quality of care.

This was kind of what I was eluding to earlier when I made mention of the uninformed.  You see, a large population of Medicaid beneficiaries reside in the geographical areas of the the Southern United States, where rural, not urban, culture holds reign.  It is here where more Medicaid beneficiaries struggle to receive the type of care that would get them back on their feet.  Access to quality care in these states suffers because there are few doctors in these areas to provide care for the millions of enrollees in the social insurance program.  This unfortunately creates discontent for the program for many individuals.  They do not have accessible means to receive the care they need; that they are entitled to as Americans.  Hence spawning the viral, infectious perspective that this country does not care for or has forgotten about them.  Did I forget to mention that a lot of these individuals are seniors, they’ve fought for this country and helped America become the “Land of the Free and the Home of the Brave?”

Ooops, my bad.  (Yes, I admit I did that on purpose, …but for a reason).  Not all is what it seems.  The point I am trying to make here is that Medicaid and its struggles are affecting more individuals than we think.    It could be your mother or father, your grand parents or aunts and uncles, brothers and sisters.  And it expands across generation gaps and racial divides.  These tribulations are felt by beneficiaries across the nation.  Quality and accessibility in California, for instance, can and must improve.  However, due to population density, accessibility isn’t much of an issue there, where as in more rural areas of the south, accessibility is of major concern.  How can you grade the quality of care provided when patients have no means of access?  The ACA is looking to change this but in order to do so the federal government needs help from individual states.

The “Benefit Period.”

Benefit Period. What is it exactly? Medicare beneficiaries are aware that it exists but do they actually understand how it works?  From my experience with seniors, most that are enrolled don’t.

Medicare defines the Benefit Period as “ The way thatOriginal Medicare measures your use of hospital and skilled nursing facility (SNF) services.  A benefit period begins the day you’re admitted as an inpatient in a hospital or skilled nursing facility.  The benefit period ends when you haven’t received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row.  If you go into a hospital or skilled nursing facility after one benefit period has ended, a new benefit period begins.  You must pay the inpatient hospital deductible for each benefit period.  There is no limit to the number of benefit periods.”

Confusing?… I know, I agree.  Do not worry though, I will explain further so you understand what your rights and entitlements are.  This is one of the few problems I have with the insurance industry; the use of unclear terminology that is communicated and misunderstood by consumers for whom the product is meant to benefit.  If you do not work in the insurance industry, it becomes foreign language to you.  Unfortunately, that is the point.  The less you understand, the better chances an insurance company has of taking advantage of you.  It is quite heartbreaking and pathetic.  It still frustrates me that insurance companies, not all of them mind you (but most), prey off of the uninformed. Yes, they do provide members with what is called the Summary of Benefits (SOB) but it is comprised of nothing but insurance jargon.  If you don’t comprehend the lingo, then the explanation of benefits that you are paying for become confusing to understand.  (Because of this widespread issue, Medicare has called for the use of general terminology in explaining benefits of the SOB)   This misunderstanding can lead to a variety of problems down the line that can have devastating financial consequences for the beneficiary.

Now, let’s start from the beginning.  Medicare is comprised of two parts, A & B.  Part A covers your hospital (inpatient care), skilled nursing facility (SNF), hospice (a special way of caring for individuals who are terminally ill) and home health care (only covered by Medicare on a limited basis as ordered by your doctor).  Part B covers your Medical, like primary care physicians/specialists, outpatient services, etc. The benefit period only applies to Part A of Medicare.  This is how it works….

Say in January you are hospitalized for a couple of days overnight for a condition; your benefit period doesn’t begin until you are released from the hospital. Now, since you stayed overnight, you would be responsible for Medicare’s Part A deductible of $1152, and all other expenses regarding your stay are paid for by Medicare.  However, this is where things get confusing.  Medicare uses the terminology of ‘benefit period’ to explain hospital stay and what the beneficiary is responsible for financially.  Disregard that.  It only makes things more confusing and you won’t get a clear picture as to what the benefit period is and how it works.  So, that being said… Medicare Part A will cover all costs except for $1152 of your first 60 (consecutive) days in the hospital.  After that, days 61-90 you, the beneficiary are responsible for $289/day and Medicare covers the rest.  Days 91-150 you are responsible for $578/day and Medicare covers the rest. However, be aware that days 91-150 are your lifetime reserve days (60) WHICH YOU ONLY GET ONCE.  THESE DAYS CANNOT BE RESET, UNLIKE THE BENEFIT PERIOD.

So, again, what exactly is the benefit period?  Well, the benefit period is the time (60 days) in which a beneficiary can be released from an overnight stay in the hospital and be re-admitted without having to pay the Part A deductible.  What that means is simply this…. As I stated earlier, for example, you are hospitalized for a few days in January.  You pay your Part A deductible.  When you are released you have 60 days in which for any reason, whether it be the same or different cause for your first hospital stay, if you are admitted you will not be subjected to pay the Part A deductible.  If you go for more than 60 days consecutively (from your initial release) without being admitted overnight, the next hospital stay you have you will need to pay the Part A deductible again.

This unfortunately is where forecasting one’s own medical expenses for the year can be very difficult.  We cannot predict the future, and because of this uncertainty, we need to be fully knowledgeable of what expenses we could incur in an ‘off, or health-wise’ drastic year.   It is quite possible for a beneficiary to pay the Part A deductible 3 times in a year. That’s $3,456.  Have you planned for the worst-case scenario?  If you haven’t, I suggest you take a look at what type of plan you currently have because outside of the deductible, you may have other expenses you need to be aware of.  (There are a few Medicare plans out there that do take care of the deductible for you)  If you have to dip into those allocated funds, how are you going to supplement the other facets of your health care management, like prescription drugs or copayments, etc?

Affordable Care Act Continues to Benefit Seniors — for Now

In response to the Healthcare Leadership Council (HLC) article regarding Medicare Advantage Continues To Benefit Seniors — for Now, there are a few things left unsaid that may have a great impact and change the perception that some may think the Affordable Care Act (ACA) will diminish these options that benefit seniors.

If you haven’t read the hyperlink I have attached,….. Read it. Ok,…..that’s a little harsh. No one is “Forcing” seniors out of popular MA-PD plans. That is not the “true” issue here. What is, however, is the result of individual agents/brokers convincing Medicare beneficiaries of enrolling into a plan that unfortunately doesn’t meet their health care needs specifically; thus leading to financial responsibility that, one, the beneficiary was unaware they had, or two, were under they impression that their current provider would cover. The idea that “it is wrong to disrupt the elderly’s existing health coverage” would be a good argument to adjust the current health care reform bill, if Medicare beneficiaries’ health coverage were working effectively and efficiently. It, however, is not.

Medicare MA plans are designed to include all of the same benefits as Medicare A+B, and may include Rx drugs. The only difference, however, is that the beneficiaries’ health care management is administered by the insurance provider. Not to mention, even though Medicare no longer is the administrator of the beneficiary’s health care, they still pay the independent provider for overseeing the provision of care for that same beneficiary. This, HLC, neglected to mention continues to draw from the federal budget allocated for Medicare beneficiaries nation wide causing even more stress on the government funded social insurance. That being said, the beneficiary is responsible for cost-sharing/co-payments for Medicare covered services provided. These programs, as the previous article has conveyed, can be cost effective for seniors who are still relatively healthy and see a physician only a couple times a year. Enrollment into MA-PD plans saves these beneficiaries the cost of spending hundreds a month on supplemental coverage, Rx drug plan premiums and their Medicare Part B Premium/and or deductible. Hence the appeal to these plans, however, there is a downside….

Attorney General Eric Holder and Department of Health and Human Services (HHS) Secretary Kathleen Sebelius recently released a new report showing that the government’s health care fraud prevention and enforcement efforts in taxpayer dollars in the 2011 Fiscal year. This is the highest annual amount ever recovered from individuals and companies who attempted to defraud seniors and taxpayers or who sought payments to which they were not entitled.”

– HHS.Gov,

Due to the cost-sharing/co-payments beneficiaries are responsible for, there is still some responsibility borne to the insurer to coordinate benefits (entitled to the beneficiary) with Medicare. When the responsibility of submitting claims forms are left to the provider of these services, for example primary care physicians or specialists, this CAN and HAS been the result; Seniors being taking advantage of and in many cases overcharged for services they might be entitled to. Because of the ACA the Department of Human Health Services (HHS) has diligently overseen the government’s administration on fraud, waste and prevention which is now being closely monitored. Theoretically, this should improve a beneficiaries’ overall experience in an MA plan, and allow for more distribution of Medicare/Medicaid funding to those who really need it.

By no means is the quality of coverage going to be decreased if a Medicare beneficiary opts to enroll back into Original Medicare A+B, unless the provider of services is taking shortcuts to cut costs for providing care. The Affordable Care Act has been implemented to increase care across the senior population, not diminish its quality. That would not make any sense. The essence of this reform is to improve quality by cutting down on fraud and putting back into the Medicare funding program what was taken from it illegally and with reckless abandon…..beneficiaries’ and taxpayers hard earned dollars. Access to more funds can lead to a variety of improvements within the Medicare/Medicaid programs such as increased reimbursement rates, quicker access to patient records by sharing of private health information (PHI) within a secured virtual database, etc.

What we need to understand, and respect is that health care is an ever-changing environment that constantly requires innovative and effective implementation to improve the quality and efficiency of providing care. To be honest, its mainly a trial and error process that we must be patient with. Im not saying we are to drag our feet in coming up with useful solutions, but we must allow some time to analyze the “ripple effect” of what we are trying to accomplish. With regards to the patient experience, we will get a better understanding of what works and what doesn’t, and use this vital information to improve the entire process holistically from initial contact to final disposition.