A challenging aspect of performing therapy in a Nursing home is knowing what insurance the resident has. Very unfortunately the plan of care is directly impacted by that insurance also.
Insurance policies are too complicated
Most of our senior citizens do not have the ability to truely understand what their rights and options are when it comes to choosing coverage. There are huge differences in different plans and significant differences between traditional Medicare and Medicare Advantage plans.
Even the Medicare Advantage plans are enormously complicated and drastically different. This is not only true from different companies, but even different plans can be significantly different.
Most Seniors and families don’t understand what they have
Most of the seniors we deal with believe they have Medicare. They do not even realize that they are in an Advantage plan. They also really don’t understand how they are now in a managed care plan and don’t have the choices they thought they had.
This is especially true for family members as we explain that their loved ones are in a managed care plan and need to have authorization through a “gatekeeper”.
Advantage plans
There are some good things about some of the Advantage plans. They do offer some benefits that traditionally is not covered under Medicare. The cavat is weighing the full pros and cons of what is covered based on your current age and current health status.
Unfortunately most seniors do not have the capacity to adequately evaluate their true needs and pick a plan that adequately covers the most situations they can find themselves in.
The other unfortunate fact is there are definitely some people out there who would freely take advantage of people to get them into a plan that happens to give the broker the biggest incentive.
As Healthcare providers we need to know the coverage
Unfortunately as confusing it is for coverage to the residents, it can also be confusing to the providers. Often the nontraditional Medicare plans have different rules and regulations that we as providers need to know in order to get payment for our services. It is also imperative for being up to date on the current rules. Frequently these plans and insurance companies change the rules and regulations. If you are not up to date with changes you might inadvertently get denied coverage because something is missing.
They are also often a manged care program with a third party admintering authorizations and benefits.
The use of a third party can complicate things as they strictly manage coverage. This can be very confusing to the families and residents as they wonder why a representative from their insurance company gives different information than the third party manager.
Scrutiny from Congress
Medicare Advantage plans have been more closely scrutinized by congress as well as CMS due to their practices. There have been many complaints of delayed authorization limiting care as well as denials of payment after authorization was abtained.
Hopefully with some oversight as well as assistance to the seniors using and signing up for these programs, a fair and reasonable middle ground can be found.
