Unveiling the Medicare Advantage Game: Navigating the Controversial Landscape of Health Insurance

It’s that time of the year again when the insurance maze becomes a challenge to conquer for the upcoming year. If you’re navigating the world of Medicare, this year’s twists and turns might have left you incredibly perplexed. Let’s dive into the intriguing world of Medicare Advantage plans, adding a dash of complexity and a pinch of controversy to the mix.

How Medicare Advantage Differs from Medicare

Medicare Advantage plans were designed to spice things up by inviting private insurers to the health insurance fiesta. In recent years, private insurers have been shaking things up by offering alternative healthcare options, making the pot even more tempting. The beauty lies in these plans not having to strictly adhere to Medicare guidelines; they can sprinkle in extra benefits beyond the standard offerings.

Remember our chat about acupuncture benefits in “Medicare Says I Have Acupuncture Benefits. Is That True?” It turns out that many Medicare holders find themselves unable to use their acupuncture benefits because acupuncturists aren’t Medicare-approved providers. 

However, Advantage plans play the game differently. They offer additional acupuncture benefits that surpass Medicare’s limits. When they offer benefits beyond the Medicare standard, they can allow a broader range of providers to join the party. 

Marketing Hype Snares the Unsuspecting

Let me share a recent story about a client who signed up with Humana this year, enticed by the promise of using benefits for out-of-network providers. Humana, known for its strategic moves, has set its sights on the lucrative Medicare Advantage market, as highlighted in a February 2023 article: Humana Exit from Employer Coverage Illuminates Medicare’s Lure.

Verifying Benefits the Difference Between What the Member and Provider are Told

Now, the plot thickens. I went through hoops trying to figure out if Humana would cover my client’s acupuncture treatments. The information provided electronically should have covered acupuncture benefits but didn’t. I tried to get through to a customer service representative. I couldn’t. What I saw suggested Humana wasn’t going to cover out-of-network benefits for acupuncture. But my client was positive Humana did cover out-of-network acupuncture. She thought this because she specifically addressed that when buying the plan. 

The law states insurance companies are not liable for inaccurate information. That leaves insurance companies with little incentive to inform the member or provider (remember the Wells Fargo scandal?). The only way to prove Humana wouldn’t pay for the acupuncture benefits was by submitting a claim and waiting for Humana to process it. 

Sometimes the Only Way to Get Accurate Benefits is By Submitting a Claim

Fast forward to January 16, 2024, and the claim processing saga begins. The claim was submitted on January 2, 2024. Humana processed and denied the claim on January 12, 2024. Humana didn’t send out the electronic notification of denial. I had to call on January 16, 2024, to find the claim had been denied. The reason Humana denied it? They denied because I was an out-of-network provider. 

Here’s the kicker – this isn’t an isolated incident. Over the past eight years, I’ve witnessed this insurance marketing tangled benefits explanation countless times. Their marketing feels more like a bait-and-switch, with insurers dancing behind the scenes, sharing some information but not all the information. 

The insurance companies put providers in very uncomfortable situations with the members. That is probably intentional. Of course, being that insurance companies have been doing this for the past eight years, providers and members are becoming more aware of these legal tangles insurance companies play. 

Why Does My Insurance Cost So Much?

Insurance comes at a hefty cost nowadays, and it stings even more when your plan decides to switch things up annually. Many Medicare Advantage members are waking up to the harsh reality too late – the coverage they thought they had is slipping through their fingers.

Behind the scenes, insurance is a goldmine. In 2023, Humana struck gold with a cool $3 billion profit, and United Healthcare soared to an impressive $22 billion. Yes, you read that right – amazing profit numbers! But wait, there’s more to the story. Picture this: oversized salary packages for senior executives. In 2023, the Humana CEO pocketed a sweet $17 million, while the United Healthcare CEO cleaned up with a whopping $21 million.

Hold on to your seats because the giant paydays get even ‘gianter’ – United’s CEOs have documented multiple $100 million pay years, not to mention those eye-watering retirement packages and severance payouts for poor performance. 

These numbers are so large, it’s hard to understand them. Another way to look at it is the pay differential between lowest and highest paid (CEO) employee. Insurance has some of the highest differences. Humana’s CEO receives a salary 238 times higher than the lowest-paid employee, while United Healthcare’s CEO surpasses this ratio with a figure of 331 times. These statistics shed light on the substantial pay differentials within Corporate America and why you are paying so much and getting so little. 

Now, where does all this money come from? Well, it comes from the insurance policies purchased adjusted for the payout to providers. That means to continue to capture huge profits and huge salaries, only three people can be impacted: the member who pays their premium, the provider who receives payment (or not) from the insurance company, and the employee. Three huge stakeholders who have never had a seat on the Board of Directors.

The stage is set, the players are in position, and the insurance drama unfolds. But here’s the twist – your voice matters! It’s time to make a difference. Consider contacting your US Senator, US House of Representatives, the US President, and AARP. Let your voice be heard in this insurance saga!

I Wrote My Representatives and What Happened?

Just an FYI if you live in Washington State, yes I know our US Senator Offices don’t write back. If they do, it is some canned letter of “look at what a good job I’m doing” leaving me thinking – thanks for not reading my email. The U.S. President Biden’s office has always written back with something incredibly pertinent to what I wrote about it. When I wrote about non-payment from the VA, I never heard from my Senators or House of Representatives. I was ghosted by my State Senators. I heard from my letter to the President Biden. The President’s office actually got me in touch with a Director at TriWest who was responsible for getting me paid! On this issue, the lack of transparency by insurance companies, crickets from the U.S. Senators. I reached out to Marie Gluesenkamp Perez and her office actually called me back on this issue.