I don’t like the idea of private Medicare but this article is populist handwaving. Here is an article from real healthcare researchers with aggregates statistics: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9465897/
Notable:
> Private health insurers in Medicare Advantage must abide by all explicit Medicare coverage determinations including national coverage determinations (NCD) and local coverage determinations (LCDs). In the absence of an NCD, LCD, or other explicit Medicare coverage determination, however, Medicare Advantage insurers can apply additional coverage restrictions if they determine that a service fails to meet the “reasonable and necessary” standard.
It sounds like virtually no claims are denied even under Medicare Advantage:
> Denied services accounted for 1.40% (95% CI 1.39–1.41) of total services (paid and denied services), and denied spending accounted for 0.68% (95% CI 0.67–0.70) of total spending (paid and denied spending).
However, it sounds like MA plans will deny things that the ordinary Medicare rules by themselves wouldn’t deny.
> On average, Medicare coverage rules accounted for 85% of denied services and 64% of denied spending, with Aetna Medicare Advantage coverage rules accounting for the remainder.
It seems like an unaccounted for confouder that LCD/NCD/MUE denials are the bread and butter of a claims clearinghouse and the claims would not be sent to the payer if they failed those tests. My bias may be showing, but it doesn't seem like they accounted for that at all..
Notable:
> Private health insurers in Medicare Advantage must abide by all explicit Medicare coverage determinations including national coverage determinations (NCD) and local coverage determinations (LCDs). In the absence of an NCD, LCD, or other explicit Medicare coverage determination, however, Medicare Advantage insurers can apply additional coverage restrictions if they determine that a service fails to meet the “reasonable and necessary” standard.
It sounds like virtually no claims are denied even under Medicare Advantage:
> Denied services accounted for 1.40% (95% CI 1.39–1.41) of total services (paid and denied services), and denied spending accounted for 0.68% (95% CI 0.67–0.70) of total spending (paid and denied spending).
However, it sounds like MA plans will deny things that the ordinary Medicare rules by themselves wouldn’t deny.
> On average, Medicare coverage rules accounted for 85% of denied services and 64% of denied spending, with Aetna Medicare Advantage coverage rules accounting for the remainder.