COLORADO SPRINGS, Colo. (KRDO) - Low monthly premiums and specialized healthcare for seniors are just some of the promises of Medicare Advantage.

However, some patients and healthcare advocates are now warning about frequent denials of care and fewer provider options that can also come with a Medicare Advantage plan.

Dianne Dunn is one of those patients. 

While going through her daily physical therapy routine inside her Denver home, she talked to KRDO13 about her 16-month journey that began with a nearly fatal car crash. 

Back in July of 2022 at Wadsworth and 32nd Street in Denver, a driver illegally turned in front of her, and the impact nearly killed her. 

“The hood comes up into the windshield,” she recalled, “and the dash or the under-dash, it collapsed and pushed into my legs and scraped them, so it cut me really badly.” 

She went home after 12 days in a Denver hospital, then went back for skin grafts to repair the damage. 

However, after just a few days after surgery, she was told it was time to check out of the rehab center. 

She immediately questioned how she could be told to leave when she wasn’t allowed to stand up for more than a few minutes per day. 

“I said, 'I'm still bound to this bed, Iim not allowed out of bed.  How can I go home?'  And they said, 'Well Medicare is not actually saying you have to discharge.  It's just that they will not pay for you after three days from now.'" 

She later found out that the discharge notice was sent without her Medicare Advantage provider, United Healthcare, ever seeing any documents or paperwork shared by her doctors. 

“And the first thing I thought of was ‘Wait, you wanted to discharge me and you didn’t know how I’m doing medically?’” she said. 

After a series of appeals, Diane got the care she fought for but always felt like her provider really wasn't working for her. 

“Was my health and well-being the priority of United Healthcare?  No.  Absolutely not,” she says. 

United Healthcare couldn't comment on her case, but in a statement to KRDO13 said, "Medicare Advantage enrollment has doubled in the last decade because of the incredible value it delivers for members. Compared to original Medicare, Medicare Advantage plans offer broader coverage and benefits, drive better health outcomes, and higher consumer satisfaction." 

The number of people 65 and older choosing Medicare Advantage has indeed risen tremendously in the last 10 years. 

The most recent data from October 2023 shows that 32.6 million seniors have a Medicare Advantage plan, making up 49% of all seniors enrolled in Medicare. 

In 2013, it was just 14.8 million, or 28% of seniors enrolled in Medicare.

16 months after the accident that left her scarred both physically and mentally, Diane hopes seniors and their families will do their homework themselves, or find an advocate to help them and fight on their behalf when they need help the most. 

A physician's perspective 

Traditional Medicare is managed by the federal government. 

Medicare Advantage plans are offered through private companies, similar to health insurance coverage offered by most employers. 

When a participant enrolls in a Medicare Advantage plan, the federal government (Medicare) then pays a fixed monthly amount to the private provider that is supposed to cover each beneficiary’s medical expenses. 

That monthly fee ranges tremendously depending on the patient’s needs. 

Retired physician Dr. Madeleine Jacobs operated a family practice in the city of Florence for 30 years. 

She closed her practice in 2017, but claims it was not because she was tired of practicing. 

Instead, she believes the system became more about profiteering than patient care and was tired was seeing people dying unnecessarily from treatable diseases. 

“The purpose of health care in this country is to maximize profit, and a major way they do that is by denying care,” she says. 

She believes the deterioration began around 2010, and believes Medicare Advantage, in particular, created an increasing amount of obstacles for both her office and her patients. 

“Very often, they (patients) could not see people that I recommended they see.  And the billing was much more difficult.  For Medicare, you send it to Medicare, you send it to the gap plan, and we had way less problems than we did with Medicare Advantage programs,” she says. 

Jacobs believes a transformational shift is needed in the health care industry, and has become an advocate for universal health care. 

She pointed out that the United States is now the only industrialized nation in the world without universal health care.

Supporters of the Medicare Advantage option point out that surveys have consistently shown that the overall satisfaction level is about the same as with traditional Medicare. 

For most people, Medicare Advantage offers lower monthly premiums (often nothing at all), a less complicated system, and there are frequently extra benefits beyond what traditional Medicare does. 

Those extra benefits might include vision and dental coverage, or perks like fitness memberships. 

However, opponents claim those with Medicare Advantage plans report far more denials of care, they have to stay within their plan’s network to avoid extra fees, and they frequently need prior authorization from the plan provider for a particular test or procedure. 

Choosing between Medicare and Medicare Advantage 

Marcia Marill is a Medicare Broker for Colorado Medicare Choices in Colorado Springs. 

Rather than work for the federal government or a particular private plan provider, she compares all Medicare and Medicare Advantage options to help find seniors the best plan that fits their health needs and their budgets. 

There is no fee to use a broker because brokers get a small commission when enrolling a client.  

"There are pros and cons to both sides of them,” she said when asked whether one option is typically better than the other. 

Marill admits that all the different costs and coverage plans can be overwhelming, and explained that her initial meetings with clients are simply to explain how the system is set up, rather than focus on a particular option. 

“You need to sit down with somebody that will take the time to explain it to you,” is her best advice for seniors, whether they are working with a broker, a family member, or a friend. 

Diane believes many seniors go with a Medicare Advantage plan based on aggressive marketing and false promises, which include mailboxes full of flyers and television commercials featuring familiar celebrities. 

“They (providers) were saying, 'Ooo here's all these great things.  We'll take care of your drugs, we'll take care of all these things if you're ever in the hospital or in rehab.’  And then they didn't really come through for me on that,” she says. 

Colorado hospitals confirm challenges 

Some of Colorado’s largest and smallest hospitals are also feeling the squeeze from Medicare Advantage providers and confirmed that some of the obstacles witnessed by Dr. Jacobs in Fremont County continue today. 

In a statement to KRDO13, UCHealth says, “We have seen coverage problems and claim denials with some of these (Medicare Advantage) plans, and this is causing our teams to spend a lot more time appealing denials and helping patients access the care they need.” 

“We recommend that patients contact their insurance provider when they have questions about network coverage, and patients may also contact UCHealth’s billing estimates team which can confirm coverage and provide a patient with an estimate if needed.” 

The Colorado Hospital Association paints an even bleaker picture about the state of the industry, claiming that 70 percent of Colorado hospitals now have “unsustainable finances”, partly due to the lack of reimbursement from insurance companies including Medicare Advantage plan providers. 

“Especially in Colorado’s rural hospitals, we are hearing increasing reports of surprise denials, refusals to pay for inpatient care, and other payment issues with Medicare Advantage plans. It is important to note that these issues happen AFTER patient care has been provided, so hospitals have no way to recoup the cost of the care that was provided,” says Julie Lonborg, CHA senior vice president. 

The Arkansas Valley Regional Medical Center in La Junta is among those rural hospitals feeling the pinch and is now going as far as recommending its patients not choose a Medicare Advantage plan. 

"Medicare Advantage plans are not conducting themselves in an ethical business way,” writes CEO Andy Flemer, “They consistently deny claims for Inpatient, Emergency Department, and Outpatient services even when AVRMC has an authorization for the services rendered.” 

Flemer says Medicare Advantage plans initially did not get much attention for many years and enrollments remained very low, but in the last 3-5 years, the enrollments have skyrocketed and their reimbursements have declined as a result. 

“Back in 2018, AVRMC received additional funding from CMS related to the Cost Report. With the rapid growth of Medicare Advantage enrollments since 2017, that additional funding has declined from about $1 million annually to about $200K in 2022 and even less for 2023,” he writes. 

Flemer is encouraging Medicare Advantage plan members to switch back to original Medicare and reminds them that they have until March 31 to do so.

Lawmakers take notice 

The issue of aggressive enrollment practices often involving so-called “marketing middlemen” paid by the Medicare Advantage providers was discussed by members of the U.S. Senate Committee on Finance in October. 

“Six billion taxpayer dollars went toward marketing middlemen who may have sold your elderly parents, your grandparents, or your neighbors the wrong plan,” said Democratic Sen. Ron Wyden of Oregon, “It's outrageous.  It's a ripoff.  It's gotta stop.” 

“The complexity of the health care system poses significant challenges for Americans,” added Republican Sen. Mike Crapo of Idaho, “Seniors need clear credible, and accurate information to navigate the coverage and service landscape.” 

It’s one of several Congressional hearings that have been held in recent years in response to complaints about care denials, prior authorizations, and other issues. 

Neither of Colorado’s senators responded to KRDO13’s request for comment on the issue. 

In November, the White House also proposed new rules to address predatory marketing and increase access to services. 

When asked by KRDO13 what the Center for Medicare Services is doing in response to the concerns raised by beneficiaries, a CMS spokesperson responded, “CMS is working to protect Medicare beneficiaries by ensuring they receive accurate and accessible information about Medicare coverage. These efforts include strengthening oversight of Third-Party Marketing Organizations (TPMOs) to detect and prevent the use of confusing or potentially misleading activities to enroll beneficiaries in Medicare Advantage (MA) and Part D plans.” 

“Most recently, to further protect people with Medicare through stronger marketing policies and to promote a competitive marketplace in MA, CMS proposed added guardrails to plan compensation for agents and brokers.” 

Regarding the actions of marketing agents of Medicare Advantage providers, the CMS spokesperson said plan providers are required to investigate all allegations and take appropriate action against their contracted agents, and the complaints from beneficiaries or caregivers about agents of the various plans can lead to compliance action against the plans. 

There are also calls for change at the state level. 

Wednesday, a large group of healthcare providers and state lawmakers from both parties held a news conference outside the capitol in Denver to promote House Bill 1149, which would address prior authorization requirements that often leave patients waiting weeks or months before a recommended procedure or treatment is approved. 

“Nothing is more frustrating than when these painstakingly thought out decisions regarding a procedure or medication are taken out of the hands of my patient and I, because of outdated overly bureaucratic prior authorization processes. Doctors should be the ones practicing medicine, not insurance carriers,” said vascular surgeon Dr. Omar Mubarak.