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October 30, 2024 (Update 7)
About Those Aetna Home Visits
The Wall Street Journal has published two investigative reports (August 4 and October 24) that confirm that the real purpose of home visits is to enable Medicare Advantage companies to find, exaggerate, or invent new medical conditions to justify higher payments from the federal government. The more medical conditions a person has, the more Medicare and the federal government pays the Medicare Advantage company, including Aetna, to insure her or him. Both reports are behind paywalls.
The October 24 report began, “Private Medicare insurers got about $4.2 billion in extra federal payments in 2023 for diagnoses from home visits the companies initiated, even though they led to no treatment, a new inspector general’s report says.”
Erin Bliss from the Inspector General Office stated, “Profiting off enrollees’ medical conditions without providing treatment for those conditions is wrong.”
The Office of the Inspector General recommended that Medicare stop making extra payments for diagnoses resulting from home visits.
The Justice Department has begun to pursue cases of such diagnosis inflation. Last year Cigna Group paid a fine of $172 million.
When privatized Medicare Advantage programs were established as an alternative to traditional Medicare, the argument made on their behalf was that they would deliver the same services for less cost. In fact, the opposite has occurred. Medicare Advantage plans are much more expensive to the federal government and taxpayers, in large part because of the home visits gaming of the system.
To stop receiving Aetna’s multiple phone calls promoting home visits, you can contact Kevin Sullivan (ksullivan@csea760.com) at the Connecticut State Employees Association/SEIU if you are a member. He will contact Aetna to put you on a Do Not Call list.
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October 25, 2024 (Update 6)
State’s Health Care Advocate Responds to Aetna Problems
“Good Retiree Healthcare Coverage—A Moving Target”
By Kathleen Holt
CT Mirror
October 24, 2024
A response to Medicare or Medicare Advantage – CT employees want a choice by James W. Russell:
I agree with Russell’s frustration over the increasing privatization of Medicare. The health care eco-system, in Connectiut and nationally, is ever-changing and is now very different today than it was in 2018 when the State of Connecticut implemented a private, customized Medicare Employer Group Waiver (EGWP – pronounced “egg-whip”) plan for its’ retirees.
At that time, providers were generally accepting EGWP Medicare beneficiaries nationwide. Today, in-state and beyond, more providers are rejecting private Medicare, both EGWP plans and individual Medicare Advantage (MA) plans, for all the reasons Russell articulated – high claim denials, delayed payments, and crushing administrative requirements – plus, increasingly, extremely low provider reimbursement rates.
Unlike State of Connecticut retirees, Connecticut teacher retirees are not limited to one Medicare plan. Retired Connecticut teachers may choose between a customized EGWP plan (different from state retirees), or original Medicare with a supplement for out-of-pocket costs.
To continue reading, click here.
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October 24, 2024 (Update 5)
Blumenthal Report Slams Medicare Advantage Plans, Including Aetna
“New Senate Report on Prior Authorization in Medicare Advantage Plans Begs a Question: Can Big Insurance Ever Be Regulated Adequately to Ensure Patient Care?”
By Rachel Madley
Health Care Un-Covered Substack
October 24, 2024
Last week, the Senate Permanent Subcommittee on Investigations, led by Sen. Richard Blumenthal (D-Connecticut), released a Majority Staff Report on rampant prior authorization (PA) abuses in Medicare Advantage (MA). The report offers unique insight into recent trends in the use of prior authorization by Medicare Advantage plans and the strategy and motives behind insurance corporations’ use of it.
While the findings won’t surprise those who’ve been following health policy trends, it is immensely concerning that between 2019 and 2022, the prior authorization denial rate for post-acute care in UnitedHealth’s Medicare Advantage plans doubled. The denial rate for long-term acute care hospitals in Humana’s Medicare Advantage plans increased by 54% from 2020 to 2022. During this time, UnitedHealth, CVS/Aetna, and Humana increased their use of artificial intelligence (AI) for prior authorization reviews, often resulting in increasing denial numbers and decreasing (or absent) review time by human beings.
To continue reading, click here.
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October 15, 2024 (Update 4)
Feel free to forward to others who may be interested.
“Medicare or Medicare Advantage—CT Employees Want a Choice”
One man’s experience with the deterioration of healthcare insurance for CT state retirees
By James W. Russell
CT Mirror
October 14, 2024
In September 2021 an X-ray for shoulder pain inadvertently found a mass in my right lung. The radiologist wrote in her report that it was highly likely cancer. Because I had never smoked and had no symptoms, I went through a lot of denial. What I did not know at the time was that ten to twenty percent of lung cancer sufferers are never smokers. A CT scan later confirmed the suspicion of cancer.
My sister who had worked in top-rated MD Anderson Cancer Center in Houston for many years. told me to come to Houston for a diagnostic workup. When I called MD Anderson about whether the diagnostic workup could be done there, I was told that there were just two criteria for admission: a suspicion of cancer diagnosis and having insurance to pay for treatment.
I sent the CT scan results and the back and front of my insurance card to them. I had no worries on either count. The CT scan interpretation clearly stated that there was a suspicion of cancer, and I thought I had excellent retiree insurance, much better than most.
I had retired after 29 years as a State of Connecticut employee. Like most state employees, I had very good benefits, including a life pension and medical insurance. The insurance, negotiated between the state and a coalition of state employee unions, had recently been changed from traditional Medicare plus a medigap plan to a Medicare Advantage Preferred Provider Organizations (PPO) plan. We were assured that the Medicare Advantage PPO plan allowed us to see any of the 98 percent of providers nationwide who took traditional Medicare.
To continue reading, click here.
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October 3, 2024 (Update 3)
“’Inhumane,’ ‘Hazardous’: Legislators, Advocates Sound Alarm on Medicare Advantage”
By Katy Golvala
CT Mirror
October 2, 2024
In the spring of 2022, Gary Bent underwent surgery to remove a bleeding lesion in his brain resulting from melanoma. The procedure left him with severe mobility and cognitive impairments — he couldn’t walk or remember how to read a calendar.
Bent’s physicians said he needed intensive rehabilitation. Luckily, there was a spot available at one of only three facilities in the state that provide that level of care. Then, Bent’s Medicare Advantage plan denied the prior authorization.
To continue reading, click here.
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October 2, 2024 (Update 2)
“Blumenthal, Anwar Speak Out Against Medicare Advantage”
By Brandon Whiting
Connecticut Inside Investigator (October 2, 2024)
Earlier today, Connecticut’s U.S. Senator Richard Blumenthal (D), State Senator Saud Anwar (D- South Windsor) and State Representative Susan Johnson (D-Windham) held a press conference calling for greater consumer awareness surrounding Medicare Advantage, and greater accountability for insurance companies’ administration of the program.
“What we have found is, essentially, there is no advantage for patients in Medicare Advantage all too often,” said Blumenthal. “There’s a distinct disadvantage too often, and for taxpayers, there is definitely a waste of money that borders on scandal.”
The two were joined by a group of other speakers, who were either healthcare reform advocates, healthcare providers, or state residents that had been negatively impacted by Medicare Advantage. The group argued that the plan, which is required under state law to provide coverage equal to traditional Medicare plans, more often than not ends up costing policyholders more while providing them with less coverage, greater numbers of denials to care and requirements to preauthorize treatments, and a smaller network of providers that accept their insurance than traditional Medicare.
To continue reading, click here. [Discussion of the state retiree’s Medicare Advantage plans is further down in the article.]
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September 6, 2024 (Update 1)
Good morning. We are a new organization of Connecticut state employee, retirees, and their dependents dedicated to obtaining a choice in our retiree health insurance benefit between traditional Medicare plus supplemental insurance, as we had before 2018, and the current privatized Aetna Medicare Advantage plan that we have. The state and the State Employees Bargaining Agent Coalition (SEBAC) will be renegotiating the retiree healthcare benefit in 2025. Right now, Connecticut is one of only thirteen states that do not give their retirees a choice between health insurance plans.
While many retirees may be currently satisfied with the Aetna and, before it, United Healthcare Medicare Advantage plans, there are members, especially those with serious and chronic illnesses, who would be better served by traditional Medicare that has access to far more providers and requires far fewer treatment preauthorizations.
A full ninety-eight percent of doctors, hospitals, nursing homes, and other providers accept traditional Medicare insurance. Despite the claims made to us when the Medicare Advantage model was adopted and still being made that we could see any provider that accepted traditional Medicare, that is not true. We can only see providers that are willing to accept Aetna Medicare Advantage insurance and many do not. The far lower proportion of providers nationwide that will take Aetna Medicare Advantage is unknown or unpublished. Members have had their Aetna insurance rejected for chemotherapy treatment and would have gotten it if they had had traditional Medicare instead.
Medicare Advantage plans such as Aetna and United require and reject far more treatment preauthorizations than traditional Medicare. The Guardian newspaper recently reported the terrible experience that a retired member of the UConn Physics Department had with our plan rejecting his doctor-ordered skilled nursing care after cancer brain surgery. That treatment would have been routinely authorized under traditional Medicare. That experience was the subject of a heart-rending video made by More Perfect Union.
What we are calling for is that Connecticut join the great majority of states and allow its retirees during Open Enrollment periods to choose the health insurance plan that serves them best, whether that is traditional Medicare or a privatized Medicare Advantage plan. If you agree, please contact your union and state legislator. We will keep you informed. Check our website for more information. Join us in this campaign!