Medicare Advantage Plans: Making Up Their Own Rules

Reports of payer abuse continue unabated, and among the worst offenders cited by physician advisors are Aetna, Humana, and UnitedHealthcare.

Case in point: When a physician advisor recently challenged an Aetna medical director about an observation payment, the medical director didn’t have an answer, but retorted by simply saying “whatever is in our contract.”

This is but one example of Medicare Advantage (MA) plans misusing commercial guidelines and making up their own rules, as they see fit, in order to avoid paying hospitals equitably for the care they provide to their members. Reporting on this development during this edition of Monitor Mondays is Steve Phillipson, Director of Hospital Medicine at Aspirus Wausau Hospital, in Wausau, Wis.

Other segments to appear during the live broadcast include:

• RAC Report: Healthcare attorney Knicole Emanuel returns to the broadcast to report on the latest audits by Recovery Audit Contractors (RACs) and other third-party auditors. Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.
  
  
• Monday Focus: Marvin D. Mitchell, Director of Case Management and Social Services at San Gorgonio Memorial Hospital in Banning, Calif., east of Los Angeles, reports on the potentially adverse issues associated with “copy-and-paste” functionality in electronic medical records (EMRs).
  
  
• SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SdoH), has the latest news on this trending topic that is attracting significant media attention. 
  
  
• Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.
  
  
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.