United Healthcare

[JimG454455]

Just curious when you guys are going to address and speak to this issue. My guess is many of your members are negatively affected by Advantage plans and more specifically the ones AARP endorses - United healthcare. I am currently living the nightmare of dealing with UHC. Their denial, delay and defend strategies have all been applied to my care which has had a significant negative impact to my care and recovery.  I joined AARP because of your advocacies for seniors. What is currently in the news about the horrors of our healthcare system that are affecting seniors most needs to be talked about.

The fact that AARP has been mostly silent on these matters AND endorses the worst offender is a disservice to your members. You lend your respected name, which I know your are paid handsomely for,  at the peril of your members.

The exposure and pressure to reform their cruel practices needs more coverage, not just a silent endorsement.

Please step up and help us on this issue.

Regards

Jim Groll

[b118512t]

I commented on several posts on this topic yesterday (12/12), and today they are all gone.

[GailL1]

@JimG454455 

What endorsement?  You need to read the fine print.

The thing is the AARP is NOT endorsing anything that bears their branded name.  It is purely a financial arrangement between the organization and the third party vender and they do seem to reintegrate this on their benefits page and the venders do the same on their AARP-branded products.

In fact, these deals are initiated by the profit making arm of the AARP -

AARP Services, Inc.  

Now perhaps the “endorsement” is implied or so it is interpreted by members by the use of the branded name but ALL of the disclosures I have read from the AARP does not support that implication.  

Like this:

AARP.org - Medicare Related Options 

quote:  Paid for by funding provided by companies that make available AARP-branded products and services for AARP members. Content is managed by AARP Services, Inc.

Then further disclosures on all the different Medicare related plans:

[quote] 

DISCLOSURES

AARP commercial member benefits are provided by third parties, not by AARP or its affiliates. Providers pay a royalty fee to AARP for the use of its intellectual property. These fees are used for the general purposes of AARP. Some provider offers are subject to change and may have restrictions.

Plus, these type of product - specifically insurance products - should not be purchased based on any recommendation - they should be purchased based on the needs and pocketbook of the beneficiary or member.  

[CBtoo]

Regardless of whether or not AARP is endorsing UHC (or Oak Street Health or anything else for that matter) is sort of a technicality (yes a legal technicality but I am using the more general use of the word). Most people assume AARP wouldn't associate themselves with the dregs of the earth companies so to speak and would want their name associated with something that is good.

Yes the fine print says legally what they are doing but many don't read the fine print - or can't read it as it may be in tiny type or hard to find. And a very well done International research study documented that if you are German or Japanese you are most likely to read instructions, fine print, or anything else before you even took the laptop computer out of the box (they were rigged to have a self fixable problem where how to fix it was in the user manual). And...if you were American you were the least likely of all first world countries in the study to read that stuff prior to trying to use it. This means companies need to design what they do around that since this is a society thing and they will get less blow back from consumers if they take that into account when they do something.

Certainly I'd suspect there'd be fewer complaints if AARP made that obvious with their relationship with UHC. And people would be less likely to jump to conclusions, Many would then realize that AARP likely (and I don't know this as a fact) allowed UHC to use their name as a marketing device (rather than another insurance company) as they were willing to pay them more in royalties than other insurance companies. I'd guess (and again I don't know this for a fact) that likely some of what they get is also dependent upon how many sign up, or share of the market for the person's age (or some other metric) and so it gives incentive for AARP to put what they do on their website even though we are then directed to the UHC site (this way UHC can see how we got there to pay AARP IF IN FACT this is part of their royalty agreement. As that one article I posted already indicates both AARP and UHC are pretty secretive about the details of their relationship. 

But before people trash AARP and UHC for this (despite it does, in my opinion, imply a conflict of interest with respect to what AARP's mission although the money goes to their for profit arm and not their non-profit arm), what they both are doing is VERY common in the business world and not an anomaly. Do I think AARP should be far more upfront and open about getting paid to advertise UHC's products - YES!. We need to trip over it because of AARP's mission and what can easily be implied, and not have to find it in the fine print - if we even were to go looking.

.This next bit only read if you care about details of risk pools and other more technical things (inclosed in === lines, final more general comment on the other side of the second === at the end).

======

If there had been more than one community rated supplement company in my state I would have compared them critically and not been influenced by AARP's advertising of UHC's products (but I know many are). BUT there is only this one it is what it is. And in some degree it is a mixed product for it's "price" pool. The underlying risk pool is community (eg all of us in one risk group so generally healthier younger people keep the overall price down) however the rates are more like age attained -  eg what they call their "discount" structure which makes the full price premium more expensive due to giving discounts to younger people (up through 75 or 80 depending on when you first turned 65 - I also wonder if they have separated us into two different risk blocks as well but I have no way to find out).

But they have to give the discounts so younger people will even sign up. Many don't think to ask what their premium would be if they were 80 or older and see that community rated risk pools are generally cheaper at that stage of their life. However the pot of money needs to be the same to meet expenses regardless of how the company structures their premiums. As a result if some pay less others have to pay more to meet the needed amount.

Based on how the discount has now been changed for newer signees to get a discount through basically the average of men and women's average life span (eg 80 vs the earlier 75 - so averaging the male and female life span and rounding) it really is driving up older people's premiums the same way age attained risk pools do even though the underlying risk pool is community. The advantages of this being a community risk pool is diluted that way for older people. When I checked when I first signed up I did see that other companies tended to charge more if I had been 80 or 90 (ages I asked about) and found those companies/agents were really reluctant to give me those figures. 

Of course if you don't pass medical underwriting (and don't live in some of the states that allow you to switch every year without medical underwriting) and can bail to a different plan if you are ticked enough then it is what it is. You can switch to an advantage plan (and suffer the consequences of networks (which exclude places like the Mayo, MD Anderson Cancer Center, and many others for out of state advantage plans even those that are PPO, HMO, or SELECT) out of pocket maximums that tend to be more than premiums plus supplement deductible than an advantage plan premiums (if any) plus out of pocket minus money saved by dental, etc (well unless you have a supplement with those "extras" then that part is closer to break even).

If you get an advantage plan and the move such that it isn't accepted in that state then you have guaranteed rights to switch supplement insurance companies with no medical underwriting (and I do NOT know the situation with UHC's advantage plans across state lines other than your premium may change) and you can get a supplement back without medical underwriting (some states say it has to be with the same company others don't have rules about that). 

=======
But I'd guess for most of us if we don't pass medical underwriting (and eventually most won't if they live long enough) we are "stuck" with our UHC supplement and the AARP royalty (which no doubt is added to our premium costs) and it is what it is. And it is a shame AARP doesn't take a more active roll in addressing complaints about what UHC does regardless of the technicality of a royalty and no responsibilities with respect to that. One would have hoped that AARP's larger mission of elder concerns and protecting senior citizens would mean they would become involved to address repeated complaints either with their for profit arm (where the royalties go) or their non-profit arm (the organization we pay membership to). By the way after you sign up for a supplement and are accepted you can drop your AARP membership and keep your supplement (medicare rules; by the way you don't need a membership to sign up for an advantage plan). In the end some of the people reading this can bail from UHC and some of us can't and for those of us who can't it is what it is.

[GailL1]

@CBtoo 

If you and others in your state have a problem

• with the way Gap plans are rated
• or when a disabled beneficiary may obtain a Gap plan or not
• or when added GI rights are added

Then solicit your state’s legislature to change it - there are plenty of states at present that have done such things, albeit premiums are higher in those states since they added to the risk involved by offering such lenient plan designs.

What about if we got rid of both Medicare Advantage plans and Medigap plans - beneficiaries would then have to become much more frugal where they spend their part of their healthcare dollars.  

I guess since I was self-employed my entire working career, I am use to reading contracts down to the last minute detail and discount things I don’t need for my dollars.

Yes, it is a selling point to offer these auxiliary benefits - anything to set themselves apart from the rest of the pack in completion for your dollars - like loss leaders, so to speak.

Of course, they know the buying habits of many Americans to want something for nothing - but that nothing really never exist.

I do get upset at beneficiaries when they use these extra things as a decision making tool rather than their own medical or financial needs. 

In most metro areas, one can find a great MAPD plan - harder to do when there are fewer providers.  Many will not chose a Medigap plan where they don’t have as close to 1st dollar coverage as possible.  But just like CMS cancelling the sale of Medigap plans H, I, E, J (in 2010) and plans C & F (2020), the next one to go will be G - then they become closed book plans (by the government) and premiums will rise and rise since there will be no younger and healthier added into the plans - and the plans will continue to pay out more and more because those left in it will keep getting older and older, and most likely sicker and sicker.  

[AndrewC394210]

People can also solicit their federal representatives to support Jayapal and Sander's  Medicare for All Act, which expands Medicare to completely cover all non-elective procedures and adds dental and vision.

[shamit]

@GailL1 .  I also don't know where the following from you came from:

"What about if we got rid of both Medicare Advantage plans and Medigap plans - beneficiaries would then have to become much more frugal where they spend their part of their healthcare dollars.  

My mother spent a lot of time in the hospital and had 3 surgeries to save her life back in 1994.  The hospital cost was over a million dollars.  I hate to think what it would cost now.  Most seniors wouldn't have that kind of money to pay the 20% that Medicare does not cover.  I guess to be frugal the only solution was for her to refuse surgery and die. 

I usually agree with you on a lot of things but I simply can't agree with this.

[GailL1]

@shamit 

Think about it - you are right, most seniors wouldn’t be able to handle their part of the cost.  Thus a few things might happen:

1.  Providers would have to modify their pricing so that these multitudes of seniors would still be their clients - or maybe they would just have to accept what Medicare pays now for that negotiated rate.

2.  Seniors would think twice about getting some care - The reason that CMS has discontinued some of the more lucrative Medigap plans - the ones that allowed for 1st dollar coverage like Plan F, Plan C or even a longer time ago, Plan J, is because they know that when there is some out of pocket cost, it saves health care dollars for Medicare because beneficiaries think twice about getting some care.  Yes, I am talking more about Part B coverage.  Utilization of Part B coverage makes our Part B premiums go up.  Part A which covers inpatient hospital care and skilled nursing facilities is already paid for during a senior’s working years - that’s where the payroll contributions go along with the employers match - to the Medicare HI Trust Fund.

3.  Medigap isn’t health insurance - it is financial protection insurance that works with Traditional Medicare to pay or help pay the beneficiary’s out of pocket cost.  If it were not available, beneficiaries, who don’t have some other type of help with out of pocket cost, would have to make some other arrangements to cover their part of the cost.  In 2022, over 3 MILLION seniors did not have any outside help with paying their part of these cost.  They didn’t have a Medigap, they didn’t have Medicaid, they didn’t have some other type coverage that filled the bill in paying these cost - they either paid them themselves, using their credit or made a payment plan with the provider or they cashed in or borrowed against some of their investments to pay these cost or they got hit with a delinquent notice and damage to their credit standing.

4.  OR perhaps with only having Medicare, the Traditional program, and nothing else to lessen the financial blow of an illness or disease, it might force the powers that be to change the program of Medicare to allow for AT LEAST an annual or even a lifetimes limit on Traditional Medicare’s out of pocket cost.

Many beneficiaries have gone thru a life time of not planning for what happens when they can no longer work.  Then they are hit with the  realization that they have had a misconception of Medicare - 

What happens if the powers that be decide to end Medicare Part C -  it sounds to me that is what many on this board and others which I frequent want - to get rid of Medicare Advantage.  

Then we will be hit with many beneficiaries coming over to Traditional Medicare.  It will probably be a tremendous medical cost because in many states those that are disabled who are less than 65 years old, and high users of medical care only have a choice of a Medicare Advantage plan.  

We are all gonna have to understand how Medicare works and what we can do to help the system last for those who come next.  I have lots of ideas to which some may agree and others who will think I am a bit crazy - which could be because I am pretty old. 

I am glad that your mom got the care she needed - but for me, I would rather have some other choices than to have a long, excruciating illness or disease if surgery and a long hospital stay are my only options especially if there was a question about how my life would be after treatment.  

We probably aren’t gonna end Medigap or Medicare Advantage plans but there are changes made to Medicare that could be very beneficial finance-wise which we are gonna have to face sooner rather than later.

[SusanM664094]

If the Congress performed proper oversite of the Medicare Plans, we might see some different outcomes. UHC has been in the courts for a decade now, fighting with the Feds for overbilling. And losing. And bringing more suits. [They have a lot of money] https://www.cbsnews.com/news/medicare-advantage-overbilling-feds-kill-bill-after-industry-opposition...

[GailL1]

@SusanM664094 

Recently UHC won the court case that you posted the article about.  They won this battle, IMO, as they should have because they are only doing what CMS has approved for them and the other insurers to do.

KHN.org 03/05/2025 - UnitedHealth Wins Ruling Over $2B in Alleged Medicare Advantage Overpayments 

from the link~

The Justice Department’s years-long court battle to force UnitedHealth Group to return billions of dollars in alleged Medicare Advantage overpayments hit a major setback Monday when a special master ruled the government had failed to prove its case.

In finding for UnitedHealth, Special Master Suzanne Segal found that the DOJ had not presented evidence to support its claim that the giant health insurer exaggerated how sick patients were to illegally pocket more than $2 billion in overpayments.

more at the link ~

[SusanM664094]

Certainly a step forward for them. "A special master assigned to the case by the judge issued a recommendation late Monday in favor of UnitedHealth. The judge will use the recommendation to determine whether the case will proceed"

And maybe another arrow for Dr. Oz, the new Administrator of the Centers for Medicare and Medicaid Services , who vows to go after Medicare Advantage plans. Story to continue....Lol. Stay tuned.

[LisaS961881]

Susan,

   I just found some very recent discussion about this in a very public forum:

https://www.warren.senate.gov/newsroom/press-releases/dr-oz-agrees-with-sen-warren-cracking-down-on-... 

that $83 billion a year figure shocked me.  Hopefully there will be some action as this becomes public knowledge.  

[SusanM664094]

Lol. The info about the money connection is being aired now. More news to come. https://www.foxbusiness.com/fox-news-politics/shameful-aarps-partnership-healthcare-giant-faces-back...

[LisaS961881]

….and just today:

https://www.newsweek.com/unitedhealth-group-medicare-fraud-investigation-doj-wsj-2072533 

[GailL1]

@LisaS961881 

That Newsweek articles sound like a WHOLE lot of speculation - Is there a DOJ criminal case - they don’t know.

Is there a judge appointed - they don’t know.

Is the judge gonna make a decision on moving forward with the case from last year - again they don’t know.

[SusanM664094]

It's an ongoing situation. Apparently there's multiple investigations.

https://www.reuters.com/business/healthcare-pharmaceuticals/unitedhealth-shares-drop-after-report-cr...

[LisaS961881]

Thank you for sharing this link.

~ Lisa

[TRL1111]

It's based on an anonymous source, which is different from speculation.  

The original reporting comes from the Wall Street Journal (Newsweek and other news outlets are just repeating it), and the Wall Street Journal is who did the excellent reporting recently about Advantage plans upcoding to obtain bigger payments from the government for their Advantage enrollees.  

But all of them upcode, and in the article a Congressman is quoted as saying this about upcoding:  "It's not necessarily fraud because some of this is legal but they're pushing the boundaries, and it's really immoral in fact."

As with everything once you scratch the surface...it's complicated.

My question is why isn't the government investigating ALL of the Advantage plans?

[LisaS961881]

I appreciate your reply and agree with everything that you wrote.   Thank you for highlighting that specific quote.

[GailL1]

@TRL1111 

Doctors upcode - 

We can probably have a conversation on how a beneficairy should be rated as to their health risk under a Medicare Advantage plan.  

CMS has always been the government entity of setting the parameters - so maybe they just need to get on it.  

[TRL1111]

---

@GailL1 wrote:

Doctors upcode - 

---

I'm not sure what your point is, but yes, doctors upcode.  But the subject of the Wall Street Journal investigation was Advantage plans themselves upcoding their members to have diagnoses that their doctors haven't made.  They do this because the Advantage plan gets extra money from the government for each diagnosis its members have--the more diagnoses a member has, the more money the Advantage plan gets paid by the government for that member.  And apparently often the member's doctor doesn't find out it's happened, nor does the member.

Which is bad, but could be worse if the member tries to switch to traditional Medicare with a supplement and has to undergo medical underwriting, during which their medical condition is evaluated.

This upcoding is often done during the home visits that plans encourage members to agree to.  

Here's the WSJ article about the upcoding, and note that several companies are identified as doing it.

https://www.wsj.com/health/healthcare/medicare-health-insurance-diagnosis-payments-b4d99a5d?mod=RSSM... 

[GailL1]

@TRL1111 

Is that the one where they are questioning the use of AI in determining prior approvals?  I think it is Aetna, UHC and Cigna; maybe more - 

I posted an article that was dated back in March 2025 where the government case against UHC MA was dismissed concerning their risk adjustments.  

KFFHealth News 03/04/2025 - UnitedHealth Wins Ruling Over $2B in Alleged Medicare Advantage Overpaym... 

I have not heard that any new charges have been filed for risk adjustment against them.  

What is the case about that you and others are talking about here - I do not have access to the WSJ for free.  From the other links that have been reported here - they don’t say much.  

[TRL1111]

---

@GailL1 wrote:

Is that the one where they are questioning the use of AI in determining prior approvals?  I think it is Aetna, UHC and Cigna; maybe more - 

---

No.  As I said, it's an investigation into Advantage plans themselves upcoding their members to have diagnoses that their doctors haven't made, and for which the member receives no treatment, usually after a home visit where the Advantage representative asks a bunch of health questions.  They're called "insurer-driven diagnoses" in the article.

The Wall Street Journal really put the legwork into their investigation.  It was certainly eye-opening to me.

Did you actually try the WSJ link?  They're usually paywalled for me, but for some reason that one works.  Maybe it's a fluke.

Or you might this one; MSN.com sometimes posts WSJ articles without a paywall:

https://www.msn.com/en-us/health/other/insurers-pocketed-50-billion-from-medicare-for-diseases-no-do... 

I realize Advantage plans provide valuable coverage for people who can't afford a supplement, but they really are a snake pit, and every time I pay my supplement bill, I consider it a vote in favor of traditional Medicare and against Advantage plans.

[GailL1]

But that case has been dismissed - back in March 2025 and I have not hear of any new claim or any judge opening it it back up again.  It was dismissed on the grounds that it was not proven to be a bad concept or method since CMS has never laid down the rule as to how it should be done.

Then there is the case against (3) MA insurers with UHC being one that attempts to stop them from using AI to review medical records for prior approvals - What is wrong with that?  I would imagine that this is gonna be pretty commonplace in all types of health insurance - maybe other types of insurance as well.

Then there is the case of MA insurers sending medical aids out to a person’s home to evaluate them for all kinds of things from safety to nutrition of which adding a diagnosis+ code to their file may also be questioned.  But how can this be wrong when CMS has given some authority to do this sort of thing in their CMMI programs.  

CMS can set any sort of rules they want over MA plan insurers - they started some just this year on prior approvals - CMS can make the rules very strict on how to determine when a MA member can be risk rated up for additional payments.

The big reason why they don’t is they know that if they do, more MA insurers will leave the Medicare Part C program and even thought they are now saving them any money now - sending all these beneficiaries back to Traditional Medicare would be a disaster for Medicare, the program.  They may have to become managed care if that happened.  

[CBtoo]

Using AI: Research has documented that right now anyway, AI is ONLY good for simple, uncomplicated, one problem only, type of cases OR in the use with diagnosis when it has been trained on by zillions, for example, of mammograms with known results. It is pretty good at picking up  breast cancer in mammograms although it may miss other issues seen on them that radiologists know to flag. And yes there are some cases out there like that (eg simple ones). Many are not. Will AI improve over the years? Likely? Is it good enough to use today - likely not in many ways it is currently being used. And that, in my opinion, is the problem with using AI except for what it is already known to be good at.

Unfortunately insurance companies (not just medicare) has been using computers with automated systems to approve/reject referrals, approval for tests, claims, etc. for years. Been past lawsuits over that. Or using (which is just as bad in my opinion) RN's to make decisions on things they were never trained about in RN school with respect to rejecting or accepting referrals, approvals for tests, etc. Especially when the decision is made in 15 seconds or less (typically as some companies have quotas).

[GailL1]

@CBtoo  There are books and manuals from our government which can be used for coverage - like the CMS Medicare Coverage Determination - it is constantly under review for medical protocols, best practices, FDA approval of medical devices - this is where many insurance companies get their review techniques and information.

CMS.gov - Medicare Coverage - General Information 

There is one also for Medicare - Part D

This is the type of information that is fed into the AI memory - but in a way, you might be right because of the continuing question of whether medical care is a science or an art?

AI is gonna be around, getting better and better and being used more and more - we just have to make sure that we pay attention to the rule - “garbage in means garbage out” so that means to me that what is founded to be right at the current time is pretty conclusive and that changes continue to be made when science moves forward.  

[TRL1111]

---

@GailL1 wrote:

Then there is the case of MA insurers sending medical aids out to a person’s home to evaluate them for all kinds of things from safety to nutrition of which adding a diagnosis+ code to their file may also be questioned.  But how can this be wrong when CMS has given some authority to do this sort of thing in their CMMI programs.  

---

Did you read the article?  Here's how it can be "wrong":

==========================

Some diagnoses claimed by insurers were demonstrably false, the Journal found, because the conditions already had been cured. More than 66,000 Medicare Advantage patients were diagnosed with diabetic cataracts even though they already had gotten cataract surgery, which replaces the damaged lens of an eye with a plastic insert.

“It’s anatomically impossible,” said Dr. Hogan Knox, an eye specialist at University of Alabama at Birmingham. “Once a lens is removed, the cataract never comes back.”

Another 36,000 diabetic cataract patients didn’t receive any medical services or prescription drugs related to diabetes.

===========================

[GailL1]

It is very rare, maybe never, that a person with diabetic eye disease ever gets cured.  

National Institute of Diabetes and Digestive and Kidney Diseases - Diabetic Eye Disease 

These insurers don’t or should not go into this half-baked.  They have or should have research behind them in their decision.  Diabetes can be far reaching in it’s affect on the body and with the eyes and the blood vessel changes in a diabetic person, the test and evaluations are ongoing.  

Having a diagnosis of diabetes with diabetic eye disease involvement in and of itself is a higher rating for a Medicare beneficiary whether under Traditional Medicare or a MA plan.  It also calls for the testing and the treatment to be done by a specialist - an Opthalmologist - which would added cost to this condition.  

A Medicare patient that is NOT diabetic can get these same preventive test annually from a lower cost professional - like an Optician licensed to do them.  If there is any problem noted the lower cost professional can refer them to the higher treating professional. 

Sure, there may be some who evaluate these beneficiaries towards the higher risk when they are not - but that happens because in some cases human’s are making the call on the extent of the condition.  Diabetes and its affect on the body can be very costly in the vast treatment areas.

All CMS has to do is set down some rules - but they seem not to  be able to do that - they do not want even the appearance that they are trying to control care - so they specifically have MA plans to do it.

State MEDICAID programs use risk based MCO’s to manage their MEDICAID programs in much the same way -

KFF.org - 10 Things To Know About MEDICAID Managed Care 

See #2

Nothing in government or their constant striving to save money is ever simple. I could write a whole lot more but will end with the fact that CMS could control this - they are already lowering the amount of paid to MA plans for service to their beneficiaries.  But they won’t because MA plans are important to the overall program.  

[TRL1111]

---

@GailL1 wrote:

It is very rare, maybe never, that a person with diabetic eye disease ever gets cured.  

---

Did you read the article the WSJ published about its investigation into insurer-driven diagnoses?

It's not just diabetic cataracts (which can't exist if a person has had cataract surgery), but other conditions that insurers diagnose but for which the person doesn't receive treatment.

[SusanM664094]

"how a beneficairy should be rated as to their health risk under a Medicare Advantage plan"

And why should this be done? What would be the reasoning? Could they opt out of signing up the sicker patient to be more profitable?

[GailL1]

---

@SusanM664094 wrote:

"how a beneficairy should be rated as to their health risk under a Medicare Advantage plan"

And why should this be done? What would be the reasoning? Could they opt out of signing up the sicker patient to be more profitable?

---

Really ?  I guess you don’t understand how Medicare and Medicare Advantage work together to cover the beneficiary.  

This is gonna be a VERY simplistic explanation: 

Medicare (or CMS) pays the Medicare Advantage plan basically a per beneficiary average health cost which they determine in the regular Medicare program.  This comes from both the Part A and Part B Trust Funds.

So just like in the regular program, there are some people who are sicker than others.  It is up to the Medicare Advantage plan to prove to CMS that some of the beneficiaries in their MA plan are sicker - they do this by a risk adjustment.  

When they do this - CMS pays them MORE than the average for these beneficiaries because they are costing them more or will cost them more than the average.

Now sometimes the MA insurer will search for different coding from the doctors indicating diagnosis codes or other treatment /test hints that the doc is looking for things more serious in order to get a jump on these patients before they start costing them too much before the CMS adjustment.  So the Medicare Advantage insurer will scrutinize their claims and diagnosis data for those that will or may cost them more.

Medicare Advantage plans are managed care meaning they have to make sure all protochols and best practices ae being used in the treatment of their member beneficiaries.  This is how MA plans hold down cost because they can ask for details and have things like prior approvals. Managed care is their methods of holding down cost (managed care is also used in MEDICAID too).  Traditional Medicare uses only paying a % of the cost that has been negotiated to hold down their cost with some prior approvals and stated coverage restrictions.

So NO, MA plans do not refuse any beneficiary - Medicare Advantage is a Part of Medicare - Medicare Part C.  They just want to be paid fairly - CMS does not go back and pay for any beneficiary that has chosen a MA plan - it is up to the MA plan to up their risk assessment of a beneficiary before they are paid more for that beneficiary.

This has been the routine since MA plans were invented in the early 2000 - but CMS really did not give any details as to what these plans could look for to add to this risk assessment money.

So thru the years, MA plans or at least some of them have been stretching the limits in proving these risk assessments.  Course, then there are the docs who also upcode their patients making them seems sicker than they maybe to be paid more money.

None of this would even be questioned if CMS had some hard and fast rules on when a patient could be rated higher risk - 

Medicare Advantage plans came about to save the Medicare system money - they did at 1st but now since they are being paid for many who are rated as higher risk, they aren’t saving money.  But they do still provide for a segment of the Medicare beneficiaries who cannot afford to pay for a lucrative Medigap plan - the ones that can handle the copays but not a monthly premium of several hundreds of dollars.