Roadblock to Medical Care? Medicare Advantage Plans

Posted by Helen, Volunteer Mentor @naturegirl5, May 27 8:58am

Here at Mayo Clinic Connect we often discuss Medicare Advantage Plans vs. Traditional Medicare. The New York Times published an article recently that takes up the prior authorization required by Medicare Advantage Plans and how some critics say that Medicare Advantage unnecessarily restricts coverage. I have no conflicts of interest. I never worked in the insurance industry in the U.S.

Personally, I have Traditional Medicare (Plans A, B, D and Supplement G)

When ‘Prior Authorization’ Becomes a Medical Roadblock (read the comments too and these are illuminating).


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What is described in this article is exactly what happened to my cousin, a retired RN, last month in Texas. After an auto accident in March, and a bout of pneumonia, she had used 26 days of her 30 day "rehab" allotment according to her Advantage Plan. In April she was found unresponsive at home and was hospitalized again by ambulance.

It took 5 days for the hospital to get permission to conduct all the diagnostics to prove it she had a stroke and not just a recurrence of pneumonia. Her Advantage plan was only going to allow 4 days of rehab in spite of the new diagnosis and in-hospital therapy already showing progress. The insurance carrier insisted they were "powerless to change this Medicare rule" but gave the family 3 days to find a place for her. The kids didn't know what to do and were about to place her in palliative care as suggested by the hospital social worker who told them "this happens all the time." No suggestion of an appeal was made.

Her sisters and I, realizing she was also a Vietnam era Veteran, insisted they contact the VA. Today she is receiving full rehab (PT & OT) services through them, and will soon get a small financial supplement to her Social Security that will improve her life. As a result she is regaining her mobility and independence so she will be able to be in a residential Assisted Living facility instead of skilled care.

This story has a happy ending, but is another example of unwarranted denial of care, and a family with no idea they could appeal. All communications between the family and the Advantage plan were by phone or relayed by hospital staff.

Just a side note - in this electronic era, we have found that the documents regarding patient rights (like the right to appeal) are frequently presented to patient and family to sign at admission, and paper copies are not always provided. I am sure that in those stressful moments, it never occurs to people to ask for a hard copy.

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