Providers sound off on plans

Saturday, February 28, 2009

YARMOUTH, Maine--With healthcare reform a popular topic these days, even Medicare Advantage Plans are getting a closer look. It’s about time, say some providers.

“Customers come into our store and they will pull out these insurance cards like a deck of cards,” said Kim Lynn, HME operations manager for Reidsville, N.C.-based Carolina Apothecary. “They don’t know what one is current because they don’t get rid of the old ones. It’s a billing nightmare.”

The plans, originally conceived to save Medicare money, have come under fire recently. A report from the Government Accountability Office (GAO) released in late 2008 says the plans made $3.36 billion in profits in 2006, all subsidized by the taxpayer.

Meanwhile, providers get the short end of the stick, they say. One Florida-based provider contracted with an Advantage plan in July 2008, hoping to make up in volume what he would lose in rock-bottom reimbursement rates. He has struggled to get paid.

“The first few months, we got all kind of referrals,” he said. “Then, all of a sudden, we have thousands of dollars out there and we haven’t gotten paid. They guarantee payment, but they are not paying.”

Adding insult to injury, Medicare will pay 14% more this year, on average, to Advantage plans than it does for basic Medicare coverage, according to a report issued in December by the Medicare Payment Advisory Commission.

That doesn’t necessarily mean providers get paid more or beneficiaries get the services they expect, said healthcare attorney Elizabeth Hogue.

“There have been problems where the beneficiary switches to an Advantage plan, and the plan won’t pay for oxygen any longer,” she said. “Nothing has changed in the patient’s clinical condition but all of a sudden they aren’t receiving the services Medicare has been paying for.”

Often, beneficiaries don’t understand what they’ve signed on for, said provider Butch Vanderpool.

“They think they are still in Medicare and I have to explain they’re not,” said Vanderpool, owner of Tampa, Fla.-based Mobility Specialists in Tampa and Auburndale. “They get stuck for a year and can’t do anything about it.”

But the plans have their supporters. All Medical Services does business with 24 major plans and almost as many smaller ones. Most of the contracts are capitated plans - All Med gets paid a fixed dollar amount per month, per beneficiary, said Ruben King-Shaw, CEO of the Miami Lakes, Fla.-based provider.

“We have a contract and we agree on a rate upfront. We know how much we are going to get paid, and it minimizes claims issues,” said King-Shaw.