Laura Waters: My experience with Medicare Advantage

This commentary was written by Laura Waters, am a retired environmental consultant living in South Burlington.

I saw the recent article in VTDigger about the state employees union fighting the state's plan to go to Medicare Advantage and felt compelled to respond with our recent experience. There are way too many glib sales pitches for Medicare Advantage that hide the “inconvenient truth” about these plans. A recent Health and Human Services report stated that Medicare Advantage plans deny millions of requests for medical care each year and tens of thousands of those denials are for tests and treatments that should have been approved and paid for and would have been paid for if the insured had been covered by traditional Medicare.

In the VTDigger article, Beth Fastiggi, commissioner of the Vermont Department of Human Resources, stated that “A lot of the negative information regarding Medicare Advantage is not necessarily regarding group MA plans” However, my 93-year-old parents are on United Healthcare Medicare Advantage that was negotiated for Bank of America employees, which was supposed to be better than the UHC Medicare Advantage regular plan.

Well, we just had a horrible experience with UHC Medicare Advantage denying coverage for my dad after he broke his hip and needed to be in rehab for 4-6 weeks. UHC determined that after 2 weeks he was ready to be discharged to his independent living apartment. This was someone who couldn’t even get out of bed without two aides and a Sara Stedy lift for his sit/stand transfers. I immediately appealed the decision which goes into a black hole with an “independent” organization, Kepro, that has an “independent” doctor review their decision. When you go through the appeal process, they make it as difficult as possible to engage since the appeal goes to Kepro which, of course, has every incentive to find ways to deny coverage. The patient and family have absolutely no way to engage with anyone with Kepro to have a meaningful conversation about the needs of the insured. The mysterious Kepro doctor denied my dad’s coverage and when I asked why, the person who called me told me that they didn’t know. The only recourse I had was to re-appeal the decision.

The denial went into effect on Saturday night, so it was impossible to get any information about why he was denied because Kepro wouldn't (couldn't) email me the doctor's letter. I had to wait until the following Monday to go to the rehab facility to collect the information. To make matters even more anxiety-ridden, I only had until 11:00 on Monday to respond with the “family letter.” If I missed the deadline, they would not accept my attached response detailing our concerns.

As I was trying to navigate this impossible process, I got in touch with Vermont Legal Aid and was told that since it is a Medicare Advantage plan they couldn't help us since it was completely outside of state regulations. 

Most of the folks in the state government who are advocating for this change are not old enough to have Medicare and are only parroting the talking points of the for-profit insurance companies. From our experience, Medicare Advantage works until you really need it — and that is what they are telling us at the rehab facility. They told us that we would never have been denied coverage for my dad if he had been in traditional Medicare. Once you are elderly or very ill, needing complicated or expensive tests and treatment, they do everything they can to deny coverage so they don't have to pay. 

After many, many hours of battling UHC and Kepro, we did prevail and he was allowed to stay until the end of September. However, I had the time and ability to take on this fight. What the insurers are counting on is that folks will give up and they won’t have to pay.

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