By Mary McDevitt, M.D.
Sonoma Valley (Calif.) Sun, October 10, 2023
If you are newly eligible for Medicare, your must choose between Traditional Medicare and a Medicare Advantage program which includes Kaiser. Traditional Medicare was started in 1965 and it pays 80% of most medical services. Most people purchase a supplemental insurance policy to cover the other 20% that is not paid for by Medicare, It’s important to remember that the funding of Medicare comes from our tax dollars by way of a payroll tax during our working career for Medicare part A (Hospital Care) and a monthly deduction from our Social Security for Part B (Physician and other services).
In 1997 at the urging of for-profit insurance companies, Medicare Part C was implemented. This is what is known collectively as Medicare Advantage programs. These programs are formed around a “Network” of Physicians, Hospital(s) and other medical services. Although many of these programs offer a low monthly premium, they usually require “co-pays” for most services, and if you go out of “Network” you may be responsible for the entire bill.
Physicians have problems with these programs in that they often require “Prior Authorization” for expensive procedures.
The Inspector General of Health and Human Services recently found that Medicare Advantage programs improperly denied 13% of prior Authorization requests and 18% of payments. Another problem with the Advantage programs is that they portray their patients as sicker than they are (Upcoding) in order to get greater reimbursement from Medicare. At present the Department of Justice has joined six False Claim cases against Kaiser for overcharging Medicare by one Billion dollars. It is interesting to note that the original six cases were brought by Kaiser employees.
The original goals of the Medicare Advantage programs was to coordinate care and save Medicare money. Multiple studies since their inception by MedPac have shown that they have never saved money. Now, with the extensive use of “Upcoding” by these programs there is concern about the solvency of Medicare for future seniors.
My personal decision to go with Traditional Medicare was based on the facts that I could go to any hospital and see any doctor of my choosing.
As you evaluate your own medical and financial situation, be aware that if you join a Medicare Advantage program you have 12 months to change your mind and enroll in Traditional Medicare without penalty. For unbiased help you can contact Medicare direct at 1-800-Medicare, seven days a week or, the CA State Health Insurance Assistance Program at 1-800-434-0222 or go to their Website at https://www.aging.ca.gov.
Choose wisely.