Friday, October 03, 2014

Lying Medicare Advantage Plans (and CMS, Center for Medicare & Medicaid Services) Which Covers for Them

Twice yesterday I called CMS (Centers for Medicare & Medicaid Services) to ask about the July 2014 contract signed between Medicare Advantage Plans that my clients have with Humana and UnitedHealth Care. 

                                                    Twice I was hung up on. 

I was simply pressing to speak to someone ANYONE at CMS who could give me details about outpatient mental health care changes that have already gone into effect though they are not supposed to until 1.1.2015.  I was told to do this by the NC Insurance Commissioner's Office, the SHIIP Division which oversees Medicare and has no power in any way over Medicare Advantage Plans. 

Prior to calling CMS I called Palmetto GBA, a company which oversees Medicare in NC.  There was no one to speak to AT ALL regardless of what triage tree I tried e.g., "try 4.....go back to beginning", etc.

In 2008, the NC State Legislature passed a bill which demanded mental health parity.  That is to say, that mental health services were to be covered in a similar manner to physical health services.

Great! But as NC SHIIP personnel at the NC Insurance Commissioner's Office informed me this week, that did not pertain to policies associated with Medicare-eligible consumers.  That would be: disabled people or anyone 65 or older.  THE MEDICARE ADVANTAGE PLANS WERE EXEMPTED.

In July, 2014, Humana; UnitedHealth Care and assumeably, other Medicare Advantage Plans signed a NEW CONTRACT with CMS. This is not well known, to say the least.  I knew that something was up as my remissions came back (for Humana) with half the reimbursement I had received the first half of the year.  (AND AS PER BELOW, THIS IS NOT SUPPOSED TO START UNTIL 1.1.2015 according to the 2015 Medicare Manual, just released to Medicare insured).

And I knew something was terribly wrong with UnitedHealth Care as I have appealed numerous times (if you go over 60 days to appeal they use this as an excuse to gig you) and had been paid nothing to see a client of mine with SPMI (Severe Persistent Mental Illness) who switched from Medicare to UnitedHealth Care 1.1.2014.

 I learned about this'new contract' in a round-a-bout way as associated with talking with Humana/ UnitedHealth Care/ CMS/ NC Insurance Commissioner's Office (SHIIP, specifically, which 'oversees' these plans; according to head of SHIIP in NC, there is NO over-seeing of these plans at all in NC as they are federally mandated/ created plans; she took 2 days to return my calls and then I had to call her).

SHIIP representative John Ciccone in Waynesville, NC has indicated to me that he advises all who come to him the following re: the Medicare Advantage Plans: 1. they have nothing to do with Medicare 2. they are completely unregulated 3. they write their own rules.

I have always advised my clients to stick to Medicare and avoid the Siren-like lures of the Medicare-Advantage Plans----an oxymoron if there ever was one. They are enticed with the promise of cheaper medications, mostly. And these are impoverished people who cannot afford an additional payment related to an extension of Medicare Part D which administers medications.  Psychotropic meds can be very expensive.

In any case, this is my experience these past two weeks re: CMS/ Humana/ UnitedHealth Care as associated with diminished reimbusement (HALF OF MY PAYMENT PRIOR TO JULY, 2014); non-payment after numerous appeals and complaints----and being hung up on twice today by CMS as I asked to have information re: the new contract signed between CMS and these two companies

I will get to NCBCBS in a subsequent post.  They don't even pay though I am a designated provider on their panel since 2008. They tell their insured all kinds of inane stories about how this entity didn't talk to this one; errors codes on my remittance say I am out of network (when I am assigned a number) and any other bullshit you can think of to cause you to pull your run down the street with your hair on fire....

So, let's take a look at the Medicare & You: Official U.S. government Medicare handbook (2015).

Section 5 (page 75): Learn about medicare Advantage Plans (Part C) & Other Medicare Health Plans: 

"In all types of Medicare Advantage Plans, you're always covered for emergency and urgent care." 

                This is a lie as evidenced by the following recent article in the New York Times

Costs Can Go Up Fast When E.R. Is in Network but the Doctors Are Not

"....When legislators in Texas demanded some data from insurers last year, they learned that up to half of the hospitals that participated with UnitedHealthcare, Humana and Blue Cross-Blue Shield — Texas’s three biggest insurers — had no in-network emergency room doctors. Out-of-network payments to emergency room physicians accounted for 40 to 70 percent of the money spent on emergency care at in-network hospitals, researchers with the Center for Public Policy Priorities in Austin found.
“It’s very common and there’s little consumers can do to prevent it and protect themselves — it’s a roll of the dice,” said Stacey Pogue, a senior policy analyst with the nonpartisan center and an author of the study...."
SO, relatedly, I have been a Medicare provider for over 10 years.  This allowed me and my clients seamless delivery of services----for after all----they were Medicare Advantage companies----being supported by American tax payer $$---to the tune of 18% overhead administrative costs versus Medicare's 5% or less overhead administrative costs----RIGHT? And prior to July, 2014, the reimbursement was the same---more or less---for outpatient mental health services.

       Correct: until the new contract was signed in July, 2014 which is not to go into effect until 1.1.2015.  

After July, 2014, my remittances revealed as associated with Humana that they were paying me half of what Medicare would pay me for outpatient mental health services....half of what they had paid me prior to July, 2014.

When I called Humana, the woman on the phone did a very fast verbal tap dance around what I was paid until I basically said she was lying. These calls are recorded "for the purposes of training" and so she couldn't hang up.  This apparently was not so regarding the CMS phone calls outlined above.

When I challenged UnitedHealth Care as to why THEY WERE NOT PAYING ME AT ALL after 1.1.2014 for a previously Medicare insured client, they simply ignored me.  Then, mysteriously, after appeals to Maximus Federal which is sometimes mentioned in the small print on the remittances I receive outlining what I am paid and what the client is responsible for---but which was described by SHIIP personnel as a 'ghost entity' which simply feeds back to the companies themselves but which is supposed to be part of CMS----I started being paid by UnitedHealth Care albeit at a lesser rate with a descriptor associated with the money that it was 'tied' to Medicare.

Both of these companies have their mental health care/ behavioral health care outsourced to other companies.  So, you can call them or their ancillary companies and never get an answer----which assumeably is what they count on...that you give up. I call them while I am driving for otherwise I would not be able to work.

To suit, and as related to BUYER BEWARE, the following is in the 2015 Medicare Manual:

"If you're in a Medicare Advantage Plan, review the "evidence of Coverage (EOC) and "Annual Notice of Change" (ANOC) your plan sends you each year...The ANOC includes any changes in coverage, costs, provider networks, service area, and ore that will be effective in January." (NOT JULY). 

Broadly, as associated with 'changes' in Medicare Advantage Plans in NC for 2015, I found this website:

2015 Annual Notice of Changes

The documents below are the Annual Notices of Changes for each plan. The information in these documents tells you about the differences between the 2014 and 2015 plan. Please note this is only a summary of changes. It is important to read the Evidence of Coverage to understand how the plan works. For any questions or concerns, please call Customer Service.


                                                          Gee, that's helpful.

So, in googling "Humana 2014 Annual Notice of Change" here is what I found:

Humana website:
- See more at:

"...Medicare plans may change their coverage rules and costs each year. Every fall, you should receive information from Medicare or the private insurance company administering your Medicare benefits explaining how your Medicare health and/or drug coverage WILL CHANGE FOR THE UPCOMING YEAR. -

And, in googling "UnitedHealth Care 2014 Annual Notice of Change" here is what I found: quite simply put a  compendium of dog-chasing-his-tail information.

Post Script to this fine woman mentioned in the NYT article: Public Policy Priorities in Austin, Stacey Pogue: SISTER, TAKE A LOOK AT THIS. (


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