Who Pays for Prior Authorizations?

Under Medicare Advantage Plus (MAP) there will be prior authorizations for lots of procedures that did not have prior authorizations under Medicare. The list I found is long, and likely incomplete. So there will be staff, probably dedicated staff, reviewing requests from doctors to do stuff that the doctors think needs to be done.

Background

Medicare Advantage Plus is Medicare Part C. It is privatized Medicare. It is the plan the Municipal Labor Coalition (MLC), including the United Federation of Teachers (UFT), pushed for, and negotiated with the City to contract for. The provider will be called “Anthem” – I think. Some members are calling the plan “Mulgrewcare” with pejorative intent – attaching Mulgrew’s name to something has become a cheap way to indicate disapproval.

It is the MLC (and UFT’s) intent to force as many Medicare-eligible retirees as possible off of Medicare and onto MAP (Mulgrewcare). They have a two-pronged approach:

• Charge retirees $191 each month to remain on Medicare
• Limit the times that retirees can switch off of MAP back to Medicare.

As there has been significant pushback from retirees, the UFT leadership’s stance has shifted – Mulgrew was trying to get everyone off Medicare as quickly as possible (last July? was his initial target) but now says the later date (it still hasn’t happened) was his idea. The promotional pitch has also shifted as pushback has changed – at first it was about the secret negotiations, then about the overall sneakiness, then about the lack of documentation, then about providers who might not accept the plan, etc.

What I see? A significant number of Medicare-eligible retirees are talking about opting out (a third? a quarter? of those eligible. I’d like to know the real number – but maybe we don’t know yet. Maybe we can’t know until there is an implementation date that arrives without a judge stopping it.) And it is those with higher pensions, with greater financial security, who are announcing that choice. It says a lot – for the most part those who are opting out are those who can afford to.

Prior Authorizations Question

I’m not wild about clerks making decisions about my doctor’s judgment. Maybe they will agree with my doctor. But if they disagree, will I miss a necessary procedure? Many of us have gotten preauthorizations – no problem – right? Except until there is a problem.

I have a genetic condition that lifts my lifetime risk of colon cancer from 4% (general population) to 50%. I need to get screenings more often than most of you do. And last summer I got a call – some clerk in Arizona let me know that I’d been preapproved. Made me wonder – who the clerk was (not a doctor, clearly), and how they decided, and what would happen if next time the clerk got it wrong. I think my doctor has a pretty good idea of what I need, and no one I know volunteers for extra colonoscopies – why was this clerk even involved?

Here’s why:

Cost savings

Not my cost. The insurance company’s cost. And the Stabilization Fund’s costs. That’s another post for another time. The MLC and the City and the UFT Leadership are more concerned with the health of this fund than they are with the health of our retirees.

• Cost savings for NYC ✔️
• Cost savings for Emblem / Anthem ✔️
• Cost savings for the Stabilization Fund ✔️
• Cost savings for you or me? ❌

It costs money to staff offices with people to process prior authorizations. Emblem or Anthem or Aetna do not spend money they don’t have to. In fact, the prior authorizations are designed to SAVE money. Just not our money.

How will prior authorizations save money? They have to save enough to cover the clerks’ pay – and then some. The only way prior authorizations save that money is by denying coverage.

Prior Authorizations? Prior Denials?

There are prior authorizations. It costs money to pay the clerks to authorize procedures. Anthem only gets that money back by denying procedures. Which procedures will be denied?

Ask Mulgrew – which procedures will be denied?

Remember, there is no savings to Anthem or the City or the Fund unless they are denying procedures that used to not require approval.

Ask Sorkin and Usatch from the Welfare Fund – which procedures that members currently get will be denied?

No insurance company will spend money that it is not getting back. Anthem is paying clerks to work on prior authorizations (and denials). Anthem already knows – probably – why the costs make sense to them. They already know what they are planning to deny.

And so does Mulgrew. Ask him. Ask Mulgrew which members are currently getting procedures that he wants to cut off.

Prior authorizations only work for a profit-making company if there are prior denials. And the UFT leadership would not enter into these agreements without knowing exactly what these prior were going to be.

They know. They should tell us. They will not tell us unless they feel like they have to.

No retiree wants to save Anthem money by having a necessary procedure denied. But that’s in the works. Only, we don’t know today which retirees, and which procedures.

But Mulgrew and the Welfare Fund know. Ask. Ask. Ask. Remind them, if they have information that we need, they need to share it.

Retirees need full information, not infomercials.