Medicare malfeasance
Jan 05, 2022 | 1669 views | 0 0 comments | 30 30 recommendations | email to a friend | print
Dear Editor,

After reading the new prior authorization pamphlet for the NYC Medicare Advantage Plus Program, I fully understand how truly terrible it is. To call it misleading is an understatement.

It would have been easier for them to list the procedures and treatments that don't need a preauthorization, rather than the two pages of everything that does (along with a disclaimer saying that the list is not even complete).

The brochure says attempts to minimize their prior authorization policy by saying “Just like the plans for active City employees, certain medical procedures will require preauthorization under the NYC Medicare Advantage Plus Plan.”

While this may be true, it glosses over the fact that one of the main reasons people prefer original Medicare is because they do not need to get preauthorization for most things.

This is more important for seniors than younger people, because as we get older we need more types of procedures and treatments. Having to get prior authorizations for everything creates added obstacles and adds more time, delaying the services we need.

The second paragraph of the brochure states that “Prior authorization helps ensure you get the proper care. It helps us work with your doctor to evaluate services for medical necessity before you receive treatment or services.”

What does that even mean? Who knows your medical history better than your own doctor?

He or she is the person that actually saw you and physically examined you and is referring you for things that they believe are medically necessary. How would the clerks working at Emblem Health be able to determine what your condition calls for without ever seeing your?

After all, they only have your doctor's paperwork to refer to. If they decide against it, then they are disqualifying what your doctor recommends, insinuating they know better.

The bottom line here is simple. Medicare Advantage Programs get a certain amount of money from the government for each person in a process called risk adjustment. The only way they make a profit is by spending less than they were allocated.

So the less they approve for you, the more money they make for themselves.


Lee Rottenberg

Middle Village

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