Key To Preventing Big Medicare Advantage Mistakes

Anyone who has had an MRI, a surgical procedure or even a vaccination comes face to face with informed consent. Patients have the right to receive information about care and treatments so they can make well-informed decisions. This process requires a healthcare professional to:

• Provide the name and a description of the proposed procedure and an explanation of its purpose (information should be provided in both medical and layman’s terms)
• Educate a patient about the risks, benefits, and alternatives of a given procedure or intervention, and
• Assess the patient’s understanding of those elements.

Informed consent ensures that patients understand what they are getting into, what can go wrong and the consequences. The world of Medicare Advantage could use something like this.

As a nurse educator, I hear from many beneficiaries about their experiences with Medicare Advantage and, many times, the stories are not good. Here’s a sample.

A son found out his father’s retiree coverage had changed to Medicare Advantage when bills for doctors’ visits started arriving. His dad’s physicians were all out-of-network in the new plan.

A woman had a knee replacement. Two months later, she received a bill for $60,000. She discovered her procedure had not been authorized.

A man, enrolled in a “free” plan, was a month into chemotherapy treatments when the bills started arriving. By the end of the year, he had paid $8,100.

After explaining what happened in each situation, I heard, “I didn’t know that” or “No one ever told me about this.” With informed consent, they would have known how Medicare Advantage plans work and would not have been caught off guard.

These three clients highlight the most common issues that beneficiaries encounter with an Advantage plan: networks, prior authorization and costs. Here’s a short list of the informed consent elements that address these, along with an explanation of why it is so important to know this.

Networks

A network is a group of doctors, other health care providers, hospitals, and facilities under contract with the plan. Many plans will cover routine or nonemergency care only from in-network providers. (Any plan must cover emergency care, no matter what.) Networks are different for every plan and can change at any time.

There are four important elements about Medicare Advantage networks and informed consent

• I understand that I may need to choose a primary physician.
• I acknowledge that I need to see physicians and healthcare providers in the plan’s network.
• I am aware that if I utilize out-of-network providers for routine (nonemergency) care, I can be responsible for the full cost.
• I accept that, if the network changes, I may have to find new healthcare providers at the start of a new year or at any time during the year.

Prior Authorization

Just about every Medicare Advantage plan requires prior authorization for healthcare services. The goals are to ensure patient safety and optimal care, promote appropriate and effective use of healthcare services, and control costs. However, in many cases, the process leads to a delay in care or a denial.

Prior authorization informed consent should include these points.

• I realize my plan can require prior authorization of any physician’s order.
• I am aware that this could mean a delay in receiving care, a modification of the physician’s plan, or possibly, a denial of the order.
• I acknowledge that, if the plan denies the request and I proceed with the service or procedure, I will likely be liable for the full cost, no matter the circumstances.

Costs

Many believe that a zero-premium plan means Medicare is free. The list of freebies in life is very short and Medicare is not on it. There is cost sharing, which means members share costs with the Advantage plan. Plans must have an out-of-pocket maximum. But until reaching that limit, members will write checks for most services.

To avoid sticker shock, those considering Medicare Advantage need to know about these cost issues.

• I realize that a Medicare Advantage plan, even one with no or a low monthly premium, can charge copayments or coinsurance for services.
• I acknowledge that I will be responsible for costs up to my plan’s out-of-pocket limit.
• I understand that the maximum limit in 2025 is $9,350 for in-network and $14,000 for in- and out-of-network combined. (A plan may set a lower limit.)

The annual J.D. Power study on Medicare Advantage noted that only 38% of new members and 45% of established ones believed their plan met expectations. These results are due to many factors like members’ unrealistic expectations (costs), unforeseen circumstances (networks), or unclear requirements (prior authorization). But the biggest reason is likely lack of knowledge about how plans work.

Unfortunately, filling that knowledge gap is not an easy task. Information is scattered across many resources, including these:

Knowledge is power and, when it comes to your health, you need all the power you can get. If you know about these important informed consent elements, you won’t get tripped up when needing medical care. Stay alert.