U.S. Finds Many Failures in Medicare Health Plans
http://www.nytimes.com/2014/10/13/us/us-finds-many-failures-in-medicare-health-plans-.html?_r=3
You never let a serious crisis go to waste. And what I mean by that it’s an opportunity to do things you think you could not do before.
This is Pres Obama’s first Chief of Staff… who apparently knows how to play the political game …
WASHINGTON — Federal officials say they have repeatedly criticized, and in many cases penalized, Medicare health plans for serious deficiencies, including the improper rejection of claims for medical services and unjustified limits on coverage of prescription drugs.
Medicare officials impose civil fines and take other enforcement actions when they see practices that could harm beneficiaries by delaying or denying access to care. Insurers usually do not dispute the audit findings, but say the care they provide is superior to that in the traditional fee-for-service Medicare program.
The Centers for Medicare and Medicaid Services reported these findings:
In more than half of all audits, “beneficiaries and providers did not receive an adequate or accurate rationale for the denial” of coverage when insurers refused to provide or pay for care.
When making decisions, insurers often failed to consider clinical information provided by doctors and failed to inform patients of their appeal rights.
In 61 percent of audits, insurers “inappropriately rejected claims” for prescription drugs. Insurers enforced “unapproved quantity limits” and required patients to get permission before filling prescriptions when such “prior authorization” was not allowed.
Medicare plans frequently missed deadlines for making decisions about coverage of medical care, drugs and devices requested by doctors and patients.
These companies are receiving premiums to provide Medicare folks with products/services.. they advertise that they have 60 K pharmacies to fill the needed prescription. If these Pharmacies are declining to fill legit/on time/medically necessary Rxs… then they are in violation of their contractual obligations with the Medicare Part D… and if the Part D provider doesn’t require their contracted pharmacies to honor their contract.. then they are accepting premiums and not providing promised covered services/products and accepting money and not provide what is required by the contract .. then they are defrauding Medicare and the patient.
This fact may not being investigated… and since CMS is already focusing on abuses by these Part D providers… complaints by pts… may get more attention… CMS already has these Part D providers under the microscope…
Here is the ON LINE Medicare complaint page… https://www.medicare.gov/medicarecomplaintform/home.aspx?AspxAutoDetectCookieSupport=1 YOU DO NOTHING…. YOU GET NOTHING !
Filed under: General Problems
I hope lots of people use this complaint form or at least call the number the listed on the form. I tried using the form and it didn’t go through. I guess the website is loaded with people complaining. The medication denials for pain medicine by mail order after the patient has been told it is covered and to go ahead and mail the Rx in. After they (part D Plan) receives it? They mail it back to you saying they can’t fill it. The patient is disabled so I clearly see this as a violation of the ADA, especially after the company takes your money each month and you can’t even change plans for another year !. I will have to call using the number instead. Bottom line? COMPLAIN !!
It sure sounds like a mess! I have been noticing more PBM rejections with goofy reasons for rejecting to pay. Below is quite an astounding statement:
“In 61 percent of audits, insurers “inappropriately rejected claims” for prescription drugs. Insurers enforced “unapproved quantity limits” and required patients to get permission before filling prescriptions when such “prior authorization” was not allowed.” This is something that we pharmacists have been seeing for a long time. One of the worst is wanting a switch to a different generic proton-pump inhibitor(can we say kickback). Just have a patient, recently released from the hospital with 8 new rx’s. You can bet that at least 2 of them will be rejected by the PBM, and in some cases the number can go much higher. It is no wonder that patients complain when they come to pick up their meds at the pharmacy. But, us poor pharmacists, have no control over the payment of the medication and a lot of patients don’t know this. This just goes to highlight the pitiful state of healthcare with regard to insurance paying for prescription medication. It seems that the government is just now addressing this problem. We have people just out of the hospital after having open heart surgery and the PBM is requiring a prior authorization for one of their main medications! For any patient reading this blog, if you have a problem with getting your medication paid by your Medicare insurance plan, be sure and fill out complaint on the link provided above. If you don’t complain, you don’t get anything.