1. Plans ignore appeals submitted by members and their physicians. Part D plans routinely fail to respond to requests for drug coverage. Time and again patients or their physicians submit requests for coverage and weeks, if not months, pass before their plan reached a decision—if one was provided at all.

2. Consumer representatives cannot provide information to members about the status of their appeals. When Part D enrollees do not receive a response to their appeal, it is virtually impossible to get any information about the status of a pending appeal from Plan customer service representatives. When advocates call customer service lines to inquire on behalf of clients, they are told that consumer representatives have no access to the appeals database. Advocates are then referred to another hotline, and forced to leave messages. Guess what? Often, these messages are never returned.

3. Plans do not take into account submitted medical support, but rather “rubber stamp” denials, and customer service representatives cannot advise members what (additional) medical documentation is needed. Part D plans notoriously fail to read physicians’ supporting statements indicating that alternative medications have been harmful or ineffective. Plans deny medications for failure to meet step therapy or prior authorization requirements even when physicians explicitly indicate that such requirements have been met. Furthermore, when frustrated members call their plan for advice, customer service representatives routinely tell them they must meet plan requirements. They rarely, if ever, provide substantive advice about the appeals process or what additional medical information may be necessary to win an appeal.

4. Customer service representatives often misinform members about their appeals rights. Medicare private plans must abide by strict timelines in issuing decisions. Plans must return decisions on standard (not expedited) exception requests for coverage within 72 clock hours and appeals decisions within seven calendar days. Clients who call their Part D plans to find out the status of their appeals are repeatedly been told by representatives that these timelines count only business hours, not clock hours. Plan representatives claim that the plans have 30 days to make decisions. This is only true for grievances, not for requests for coverage.

By making the appeals process as frustrating and protracted as possible, Part D plans are driving many of their enrollees to simply give up and either stop taking needed medications or pay out of their own pockets. The Medicare rights Center (MRC) has created an advocate’s manual for navigating the Medicare private drug plan appeals process . This easy-to-understand Part D appeals manual has consumer-friendly language for advocates who help people with Medicare get the drugs they need. This 25-page manual offers a complete overview of the entire appeals process, real-life case examples from their Client Services department, a glossary of important Part D appeals terms, a sample appeals protocol for advocates, and links to important resources and documents. The manual can be accessed and downloaded at http://www.medicarerights.org/partd_appeals_manual.pdf. [Source: Asclepios/MRC Advocacy 14 Aug 08 ++]

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The mandatory Medicare Part B enrolment rule does not apply if the beneficiary has an active duty sponsor, is enrolled in the US Family Health Plan, or is covered under Tricare Reserve Select. Tricare beneficiaries who are changing Tricare coverage, such as those switching to Tricare for Life and those Tricare beneficiaries with potentially successful Social Security claims should particularly take heed of the Medicare Part B requirement if they want to continue Tricare coverage. The clear message from Tricare Management Activity to Tricare beneficiaries covered by Medicare Part A is that if they decline Medicare Part B coverage, they do so at their peril as this could terminate Tricare payments of claims. It is possible to later enroll in Medicare Part B for those who decline the initial coverage but substantial penalties could apply. Questions on this requirement should be directed to your Tricare contractor. You can also visit the Tricare website for your region or program as follows.

• North Region: www.healthnetfederalservices.com

• West Region: www.triwest.com

• South Region: www.humana-military.com

• Tricare for Life: www.tricare-4u.com

[Source: NGAUS Leg Up 5 Sep 08 ++]

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Only aggressive oversight and enforcement—levying hefty fines and freezing enrollment—by the Centers for Medicare and Medicaid Services (CMS) will discourage plans from employing agents who flout the rules. (A little due diligence and oversight by the plans will uncover who most of these agents are.) CMS can send a signal of a new, no-nonsense approach with the marketing rules it sets for the new season. Here are three examples:

• No cold-calling prospective clients. Period. No exceptions, including cold calls that follow up mailings.

• No outrageous commissions, bonuses or promises of trips to Vegas that encourage agents to sell unsuitable plans to boost their sales volume. Reports of agents engaging in fraudulent and abusive marketing invariably lead back to plans that pay the highest commissions, or give volume-based bonuses. CMS needs to ensure high commissions are not used to push low-value plans.

• Clear explanation of plan benefits and coverage restrictions on all marketing material. In particular, the Summary of Benefits and the CMS plan finder must clearly list what, if any, services, are excluded from the financial protection provided by an annual limit on enrollee out-of-pocket spending.

[Source: Medicare Consumer Advocacy Update 4 Sep 08 ++]

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Lott at the hospital association, which represents UCLA and about 170 other medical facilities, said patients are wrong to think that the charge on their bill reflects the actual cost of treatment. Rather, he said, hospitals use a “cost-plus” system by which charges include both the cost of a service and a portion of general overhead, including treatment of uninsured people who can’t afford the provider’s cost-plus prices. At the same time, insurance companies, along with state and federal authorities representing Medi-Cal and Medicare members, negotiate lower rates in return for delivering thousands of patients to a particular clinic or hospital. The upshot is that providers are overcharging insured patients because they have no other way of meeting total expenses, while insurers are paying significantly less than the billed amount because they know they’re being hit up for unrelated costs. Insurers’ underpayments, in turn, only force providers to increase bills even more. It’s a system that both condones and perpetuates inflation while all but eliminating transparency in the marketplace. It also spells doom for the 45 million Americans lacking health coverage, who have no choice but to pay the full amount of a hospital’s cost-plus charges and thus can be wiped out financially by a major medical problem.

“Healthcare is the one sector where market mechanisms work least,” said Peter Lindert, an economics professor at UC Davis who specializes in public-health issues. “Prices are whatever you can get away with.” As my colleague Jordan Rau reported last week, California state lawmakers managed to pass some bills in the latest session that address healthcare problems but came up well short of their goal of reforming the system to make it friendlier — and more accessible — to patients. Among legislation torpedoed by lobbyists for doctors and hospitals was a bill that would have given the state new powers to collect information on prices charged by healthcare providers. Support for the bill dwindled after lobbyists managed to exempt doctors from the reporting requirement and inserted language recognizing the “tremendous burden” that revealing actual costs would be for providers. Score that a win for the status quo and a setback for anyone who thinks healthcare costs are out of control. “We are rapidly approaching a time where important policy discussions are going to have to be had on this issue,” said Santiago Munoz, associate vice president of clinical services development in the UC president’s office. What’s needed is a massive infusion of political courage to tackle genuine healthcare reform. [Source: Los Angeles Times Consumer Confidential David Lazarus article 7 Sep 08 ++]

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• First, there is a trend in prescription drug cost growth generally — prices tend to increase because of price increases for existing drugs, the growth in the average number of prescriptions per person, and the introduction of new drugs.

• Second, the 2008 premiums were calculated as part of a demonstration project that has now expired. This project resulted in premiums being 50 cents less in 2008 than had been projected. That change is now reflected in the 2009 premium.

• Third, drug distributors participating in Part D have found coverage for catastrophic care to be higher than expected. So they have adjusted their 2009 bids to reflect those higher-than-anticipated costs.

There are steps Medicare beneficiaries can take to reduce the impact of premium increases, Weems added. In 2009, Medicare beneficiaries will continue to have access to what’s known as enhanced drug coverage, which allows people to pay additional premiums to cover gaps in their drug coverage. Some low-income beneficiaries will be able to have their gap coverage at minimal or no cost. In addition, 97% of people in stand-alone prescription drug plans will have access to a 2009 plan with equal or lower-cost premiums than their 2008 plan. Moreover, many Medicare beneficiaries will have access to a Medicare Advantage plan that offers lower prescription drug premiums than a stand-alone plan.” Currently, 24.4 million Medicare beneficiaries are enrolled in the Part D drug plan.

In a related development, Medicare officials announced 14 AUG that 10 doctors-group practices participating in Medicare’s Physician Group Practice Demonstration project showed improved quality of care for patients with congestive heart failure, coronary artery disease and diabetes. Based on these improvements, the 10 groups involved in the project are being paid $16.7 million in incentives designed to reward health-care providers for improving results and coordinating the health care needs of Medicare patients. Weems said in a prepared statement, “We are paying for better outcomes and we are getting higher quality and more value for the Medicare dollar. And these results show that by working in collaboration with the physician groups on new and innovative ways to reimburse for high quality care, we are on the right track to find a better way to pay physicians.” [Source: Health Day Steven Reinberg article 18 Aug 08 ++]

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Though the task force still has not taken a stand on the value of screening in younger men, the shift is certain to re-ignite the debate about the appropriateness of prostate cancer screening at any age. Screening for prostate cancer is typically performed with a blood test measuring prostate-specific antigen, or PSA, levels. Because it is not clear precisely what PSA level signals the presence of cancer, many men experience stressful false alarms that lead to unnecessary surgical biopsies to make a definitive diagnosis, which can be painful and in rare cases can cause serious complications. Widespread PSA testing has led to high rates of prostate cancer detection. Last year, more than 218,000 men in the United States were found to have the disease. About 28,000 die of it, making it the most common cancer and second-leading cancer killer among men.

Various studies suggest the disease is “over-diagnosed” – that is, detected at a point when the disease probably would not affect life expectancy – in 29 to 44% of cases. Prostate cancer often progresses very slowly, and a large number of these cancers discovered through screening probably will never cause symptoms during the patient’s lifetime, particularly if that patient is older. At the same time, aggressive treatment of prostate cancer can greatly reduce a patient’s quality of life, resulting in complications like impotence and incontinence. Past task force guidelines noted that there was no benefit to prostate cancer screening in men with less than 10 years left to live. Since it can be difficult to assess life expectancy, it was an informal recommendation that had limited impact on screening practices. The new guidelines take a more definitive stand; however, stating that the age of 75 is clearly the point at which screening is no longer appropriate. The task force was created by Congress to analyze current medical research and to make recommendations about preventive care for healthy people. Its guidelines are viewed as highly credible and often are relied on by practicing physicians in making decisions about patient care. It is estimated that one out of every three American men 75 and older is now screened for prostate cancer. [Source: International Herald tribune Tara Parker-Pope article 5 Aug 08 ++]

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You are confined to your bed (unable to get up from bed without help, unable to walk, and unable to sit in a chair or wheelchair); or

You need vital medical services during your trip that are only available in an ambulance, such as administration of medications or monitoring of vital functions; or

The hospital where you are receiving treatment is local, or is the closest facility that can provide the treatment you need; or

The cost of bringing treatment to your home is less than the cost of transporting you to the hospital and back by ambulance (for frequent trips, Medicare may require proof that the regular ambulance trips are more appropriate than hospitalization); or

The ambulance meets Medicare requirements.

For Medicare to cover transportation by ambulance the service must be provided within your service area and be medically necessary. If your service area does not have a facility that is adequately equipped or capable of treating you, transport to the closest appropriate facility will be covered. The service area is the geographical region around a facility that contains most of the patients whom the facility serves. For example, if you live in a town with a small community hospital and there is a larger urban hospital 20 miles away, the larger hospital would be part of your service area if it regularly serves people who live in your town. To find out what facilities are in your service area, contact your Medicare Part B carrier by calling 800-MEDICARE. Medicare will cover ambulance services to and from the following locations within your service area:

From your home, or any other place where the need arose to the closest appropriate hospital or skilled nursing facility (SNF).

From a hospital or SNF to your home if the facility is the closest appropriate one in relation to your home.

From a SNF to the nearest medical provider, if the SNF cannot provide you necessary treatment and the cost of transport is less then bringing the treatment to you, and back.

From your home to the nearest appropriate renal dialysis facility, and back.

[Source: Medicare Rights Center 12 Aug 08 ++]

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Twenty-one Senate Republicans voted for the bill this time, including four senators who had voted “nay” in the two previous Medicare votes. The Medicare bill is the third, along with the recent farm bill and a water resources bill, to become law despite Bush’s veto. Overall, Bush has vetoed 12 pieces of legislation during his presidency, including a “pocket veto” of last year’s defense authorization bill.

At issue in this bill was how the government should respond to a planned reduction in Medicare doctors’ fees, mandated by a formula that requires the cuts if certain spending targets are not reached. Under the formula, a 10.6% cut in fees for doctors was supposed to go into effect 1 JUL, but Congress overwhelmingly voted instead to reduce the reimbursement to insurance companies that serve Medicare beneficiaries under its managed-care program. Those reductions would allow the postponement of the pay cut to doctors for 18 months, but would cost the insurers $14 billion over five years. Bush said the cuts to insurers would harm the managed-care program, which his administration sees as giving seniors more choices and eventually leading to lower health costs for the federal government. “I support the primary objective of this legislation, to forestall reductions in physician payments,” Bush said in his veto message. “Yet taking choices away from seniors to pay physicians is wrong.” He called the bill “fiscally irresponsible” and charged that it “would undermine the Medicare prescription drug program.” But Democrats said their legislation would prevent doctors from fleeing the traditional treatment practices that are used by more than 8% of the mostly elderly Medicare patients. They said private insurers were receiving too much funding in the Medicare Advantage program. “I guess the president is voting with them and not with America’s seniors and those with disabilities when he vetoed this bill,” said House Speaker Nancy Pelosi (D-CA).

The House and Senate votes followed a large political push by the American Medical Association — which ran ads in home states and districts of key Republicans — and AARP, which held a lobbying campaign in which 1.2 million of its activists contacted members of Congress urging the veto override.

Health-care experts said Congress is simply moving the problem down the road, since lawmakers will be confronted within the year with the need to take additional steps or allow a major cut in physician fees. “This is stopgap Medicare legislation,” said Charles N. “Chip” Kahn III, president of the Federation of American Hospitals. “It is not confronting any of the major spending or organizational issues concerning Medicare.” Yesterday’s congressional votes were not as dramatic as the maneuvering that occurred last month over the original legislation. On 26 JUN, Senate Democrats fell one vote short of the 60 needed to pass the measure. But on the day of the veto vote, Sen. Edward M. Kennedy (D-MA) — recuperating from brain surgery to remove a cancerous tumor — left Boston after a morning treatment of chemotherapy and radiation at Massachusetts General Hospital to return to the Senate for another Medicare vote. Once his vote assured Democrats of the 60 needed for passage, another nine Republicans switched sides, pushing the margin to a veto-proof 69 votes. The bill affects the 9.2 million active and retired military personnel and their family members who use the military’s Tricare system, because it uses payment rates set by Medicare. [Source: Washington Post Michael Abramowitz & Paul Kane article 16Jul 08 ++]

Much of the controversy over the Medicare bill enacted 15 JUL concerned how much to pay the insurance companies that offer private Medicare Advantage health plans. The bill made modest adjustments to the formula that determines the subsidies these companies receive, which will save taxpayers $45 billion over the next 10 years. The insurance lobby tried unsuccessfully to convince Congress that these subsidy reductions would result in benefit cuts and higher costs for enrollees in their plans. The lobbyists did not mention that, for every dollar they receive, insurance companies on average pay 87 cents for medical care, with some plans paying even less. The rest goes to administrative and marketing expenses and, of course, to profit. Original Medicare spends about 3 cents on the dollar on administrative costs. No money is diverted towards marketing or profit. The lobbyists also did not mention that most of the excess subsidies that insurance companies receive remain untouched by this bill. These subsidies will cost taxpayers $150 billion over the next ten years, compared to the cost of providing coverage through Original Medicare.

Insurance companies are not the only middlemen who are taking an excessive cut of the dollars they receive from taxpayers and people with Medicare. Since the Part D drug benefit began in 2006, some pharmacy benefit managers have been overcharging consumers for drugs, particularly for some widely used generics: often the price for the consumer is double or triple the price that pharmacy benefit managers pay to pharmacies. This overcharging, sometimes called lock-in pricing, pushes consumers into the doughnut hole, where they are forced to pay inflated prices. It also raises costs to Medicare for covering low-income people with Medicare under the Extra Help program. The political influence of the pharmacy benefit managers has allowed this scam to continue, although the Centers for Medicare & Medicaid Services has recently proposed regulations to put an end to the practice. The Medicare Rights Center and other consumer groups support these new regulations. The cut taken by the middlemen in our health care system has impacts far beyond Medicare. According to a recent report comparing health care in the U.S. with care in other industrialized countries, the U.S. tops the chart on the percentage of health care spending that goes to administrative costs, marketing and profits. We also have the highest rates of death from preventable or treatable diseases. And we have the highest percentage (over one third) of adults who go without care or medicine because of the cost. [Source: Weekly Medicare Consumer Advocacy Update 17 Jul 08 ++]

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