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Medicare’s annual open enrollment period (October 15 – December 7), is time for beneficiaries to take stock of their Medicare options for the upcoming calendar year – whether to choose traditional (real) Medicare or a private insurance Medicare Advantage (MA) plan.

The Center for Medicare Advocacy (the Center) has developed information, materials, and educational webinars to promote informed choice by beneficiaries. As the Center has discussed over the last few years, information about Medicare coverage options produced by the Medicare program is no longer neutral; instead, such information now actively promotes MA enrollment, and paints the MA program in the most favorable light, while downplaying its drawbacks. We have heard from a number of beneficiaries, advocates, and providers about their MA experiences. Last week we launched a series to highlight one of those first-hand reports, and to counter-balance MA industry advertising and Medicare program’s steering efforts. In today’s Alert, and upcoming CMA Alerts, we will write about other beneficiary, advocate, and provider experiences. These are all cautionary tales about Medicare Advantage that are not receiving adequate attention elsewhere.

We invite you to join this discussion by sending us your MA plan experiences to MedicareAdvantage@MedicareAdvocacy.org.

Case Study 2: Family History of Colon Cancer Should Increase the Frequency of Colonoscopies, but Ultimately the MA Plan, Not the Treating Doctor, May Determine When Procedures Will Occur[1]

Ms. McNeil has a family history of colon cancer that is well known to her doctors. Her mother’s father died of colon cancer at age 52, her father died of colon cancer at 76. Ms. McNeil and all of her siblings have had pre-cancerous polyps removed during each of multiple colonoscopies over the years. Because of a strong family history, and Ms. McNeil’s own personal medical history, her doctor has consistently recommended that Ms. McNeil should have a colonoscopy every 3 to 5 years.

Last year, Ms. McNeil joined an MA plan. When she had her scheduled colonoscopy this fall, her doctor told Ms. McNeil that the MA plan had notified him that it would only authorize a colonoscopy every 10 years, although the doctor recommended that she still have another colonoscopy in 3 to 5 years. Ms. McNeil also received a letter from the MA plan that coverage was for one colonoscopy every 10 years. Given this information, Ms. McNeil assumed that the benefit coverage in her MA plan limited her to a single colonoscopy every 10 years and she would have to pay out of pocket for her next colonoscopy (approximately $5,000).

If Ms. McNeil had been in traditional Medicare, she would have colonoscopies with the frequency that her doctor deems reasonable and necessary.  Colonoscopies are covered by Medicare as frequently as once every 24 months.[2] The doctor would document her family and personal history to justify the need for the testing and Medicare would cover the cost.

Ms. McNeil believed both her doctor and her private insurance MA plan when it told her that she could only be covered for one colonoscopy every 10 years, and she planned to accept it as “the way of things.” The Center, however, encouraged Ms. McNeil to challenge that decision as medically unacceptable. She knows it is her doctor’s professional opinion that she needs colonoscopies on a more frequent basis, and her doctor will support her request to the MA plan as medically reasonable and necessary. Her next colonoscopy should be covered; but will it?

The unfortunate truth is that MA plans have their own in-house doctors and medical case “utilization” reviewers who are allowed to override the decision of a patient’s treating doctors. Although MA plan doctors have never treated or examined Ms. McNeil, they may ultimately make a decision contrary to the recommendation of Ms. McNeil’s own doctors for the colonoscopy, or any other services, and deny coverage.

MA plans should not be allowed to override the expertise and opinion of treating providers at the expense of the patient’s health. MA plans should not be allowed to second guess providers through layers of in-house medical review as a vehicle to deny necessary care.

November 21, 2019 – K. Holt


Next Case

Case #3: Wasting time waiting for prior authorization – at what physical and emotional cost?

Again, we invite you to join this discussion by sending us your MA plan experiences to MedicareAdvantage@MedicareAdvocacy.org.


[1] Factual recount as reported to CMA on November 2, 2019. The names of the beneficiaries, provider, and MA plans have been withheld for privacy purposes.
[2] See https://www.medicare.gov/coverage/screening-colonoscopies

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