Medicare Advantage is getting 'much, much worse' for spine

Spine

Medicare Advantage has been controversial this year with several major health systems dropping plan coverage due to denials, and some physicians following suit.

More than half of the nation's seniors are covered under Medicare Advantage plans, and health plan leaders see the number growing. But providers are less enthralled with MA plans, and the federal government has been looking into billing fraud allegations and high denial rates.

Harel Deutsch, MD, co-director of the Rush Spine Center in Chicago, has been frustrated with how prohibitive Medicare Advantage has become for years and sees the situation continuing to decline.

"It's gotten much, much worse [than it was a year ago]. It was bad back then, but now it's five times worse," he said during a panel at the Becker's 29th Annual Meeting in October. "Every time I turn on the TV, I see ads for Medicare Advantage and basically Medicare Advantage, they'll disapprove any surgery you apply for. A lot of times I have to tell patients, look, you have to wait until you can unenroll and then do that. Then you can have your surgery."

Dr. Deutsch recounted a recent instance where his team wanted to perform a cervical fusion with an interbody implant. Medicare Advantage denied the interbody device, which he hadn't heard from other payers.

"They'll deny surgeries for the craziest reasons," he said, later adding, "The only thing we can do is to try to educate patients not to enroll in it."

He sees regular Medicare plans approving surgeries more quickly and easily than the Medicare Advantage plans, which require surgeons to take extra steps for approval. Physicians and surgeons are also seeing Medicare Advantage deny spine and pain procedures that traditional Medicare approves.

"Medicare doesn't require a lot of jumping through hoops, but the Medicare Advantage programs will, basically they're not even real insurance plans, just deny the medical treatment and hope that you will tire out and eventually not have it," said Dr. Deutsch.

John Prunskis, MD, co-medical director of the Illinois Pain & Spine Institute based in Barrington, has a similar view of Medicare Advantage plans.

"Maybe you should call them 'Medicare Disadvantage' plans," he said during a session at the meeting. He implored physicians to educate their congressional representatives on Medicare Advantage plans and the high volume of denials they're seeing.

"If you want to take control of yourself, invite your Congressman to your surgery center and show them the cost savings, they'll probably know about that, but then explain to them the Medicare Disadvantage plan is actually profiting off our taxpayer dollars to not provide care to seniors that they're supposed to," said Dr. Prunskis.

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