CCH talks insurance [Columbus Telegram, Neb.]

Oct. 27—For many, the details of health insurance can be confusing but it's important that people understand what plan they have so they aren't left with unexpected coverage, according to Columbus Community Hospital officials.

Community members have expressed concern over CCH not accepting Medicare Advantage (Part C).

"We've been talking about this at the American Hospital Association level. The Office of the Inspector General — the OIG — put out a report in April of '22 where we have some Medicare Advantage Organizations, where denials and prior authorization requests have raised some concerns about beneficiary access to medically necessary care," said CCH President/CEO Mike Hansen.

"What's really important is for people to really understand what they're getting, what the level of coverage is and where they can access providers in the community and hospitals in the community and understand exactly what they've got."

Previously Medicare Advantage was not offered in rural areas until about 2018 or 2019, noted CCH Vice President of Financial Services Chad Van Cleave.

The issue is that people see Medicare Advantage as a cost effective way to reduce their out of pocket expenses from a premium standpoint but don't understand the difference between HMO and PPO plans, he said.

"HMO is a plan that's sold as a narrow network so Medicare Advantage will contract and they'll create their own networks with certain providers, whereas a PPO access allows somebody to go to a broader network of providers," he said, adding that those who have a PPO plan would have access to providers, like the hospital, who do not have a direct agreement.

Van Cleave said that CCH is a member of the Platte Valley PHO (physician hospital organization). It's a nonprofit organization that is made up of providers in the community, both hospital and independently owned clinics.

Platte Valley PHO looks at contracts and decides what to sign as community providers. Platte Valley PHO has declined to sign a narrow network agreement with any Medicare Advantage plans, Van Cleave said.

A big reason behind this decision is that while Medicare Advantage rolls Part A (inpatient and hospitalization), Part B (outpatient care) and Part D (prescription drug coverage) into a package, it essentially gets rid of supplemental insurance, he noted.

Although there are incremental increases with age, supplemental insurance helps cover the gap between what Medicare covers and what an individual would pay out of pocket.

Additionally, these plans require preauthorization/precertification, which is when a treatment or service must be approved by the health insurance or plan before needed care can be provided. Traditional Medicare does not require preauthorization. Some commercial insurance companies have this require, but it becomes an issue when this is used to deny or delay care, Van Cleave said.

An OIG report released earlier this year found that among prior authorization (preauthorization) requests that Medicare Advantage Organizations denied, 13% met Medicare coverage rules.

"Having to receive preauth/precert, the number one concern of our physicians is delay or denial of treatment of Medicare patients," Van Cleave said. "Some people say it was because 'you don't get paid,' we get paid the same (whether) Medicare traditional versus Medicare Advantage. ...It's because we don't get to treat our patients the way that we feel medically they should be treated, even for medical necessary treatments."

In turn, increased preauthorization/precertification requests create additional costs.

"It increases the cost of health care for our practices, for providers, by having to hire more nurses, physicians are spending more of their time on preauth/precert, back end billing and collecting from Medicare Advantage plans," Van Cleave said. "...Physicians in our community, they would estimate 20% to 25% increase in their cost of care by having to hire additional staff to manage everything with Medicare Advantage."

Van Cleave said that residents considering their options in terms in Medicare plans should find a local agent that they can trust. An agent based out of the Columbus area, even from Omaha, would not understand what's available in this community, he added.

"I think the challenge that we see in our market is typically that people that are buying the Medicare Advantage plans are the ones that are trying to save money because of premiums or their supplemental, and they're choosing Medicare Advantage not realizing what they're buying," he said.

Notably, Van Cleave said that Platte Valley PHO has signed agreement with Medica Prime Solution for what's known as Medicare cost plans. The Medicare cost plans are similar to Medicare Advantage but do not require preauthorization/precertification and are meant for rural communities, he said.

With Medicare cost plans, there are different cost options to choose from and it does not require preauthorization.

"We still recommend that every beneficiary has an individual meeting with a licensed professional who sells insurance to have that conversation that meets their needs," Van Cleave said.

Hannah Schrodt can be reached via email at [email protected].

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