What is Prior Authorization in Medicare Advantage Plans?
Prior authorization is a process required by Medicare Advantage (MA) plans where your doctor must get approval from your insurance company before providing certain treatments or procedures. While this process is meant to control healthcare costs, it can lead to delays, denials, and life-threatening consequences for seniors who need urgent care.
A Real-Life Story: How Prior Authorization Created a Healthcare Nightmare
At The Benefit Link, we have seen firsthand how prior authorization can negatively impact seniors. One recent case highlights the serious risks associated with Medicare Advantage plans:
- An 84-year-old woman, who had been on a Medicare Supplement Plan for years, switched to a Medicare Advantage Plan after seeing a commercial that promoted “$0 premiums.”
- She was in good health and didn’t take prescription medications, but she required regular injections for macular degeneration.
- During her annual physical in December, her doctor ordered bloodwork, which showed concerning results. Further tests revealed lymphoma.
- Her daughter immediately scheduled an appointment with a specialist for early January, expecting quick access to care.
The Roadblocks She Faced
- The Specialist Didn’t Accept Her Medicare Advantage Plan
- When they arrived at the appointment, they were told that the doctor did not take her insurance.
- This was the first major shock, as her previous Medicare Supplement would have allowed her to see any doctor that accepted Medicare.
- Waiting Six Weeks for a Referral
- Her new plan required a referral from a primary care physician before seeing a specialist.
- It took six weeks just to get the necessary referral.
- When they finally received the referral, they were only given one doctor—60 miles away.
- More Delays Due to Prior Authorization
- After traveling an hour to the appointment, they were told they still could not be seen because the Medicare Advantage plan had not yet approved the visit.
- The insurance company controlled whether the treatment could even begin.
The Growing Problem: Medicare Advantage Denials Are on the Rise
Many seniors believe that because their Medicare Advantage Plan has worked well so far, they won’t face issues in the future. However, denials have increased ninefold in the last five years due to federal investigations into Medicare Advantage plans for high rates of claim denials and prior authorization delays.
The Key Takeaway: Medicare Advantage Plans Put You at Risk
- You might not experience issues until you need urgent medical care.
- Prior authorization can delay life-saving treatments.
- Doctors may not accept your plan, forcing you to travel long distances.
- Insurance companies—not your doctor—decide if your treatment is necessary.
What Can You Do to Protect Yourself?
- Understand the risks of Medicare Advantage Plans before enrolling.
- Consider a Medicare Supplement (Medigap) Plan, which allows you to see any doctor who accepts Medicare—without prior authorization requirements.
- Seek expert guidance to ensure you’re making the best decision for your healthcare needs.
Need help navigating your Medicare options? Call us today at *
817-539-0626 to speak with a Medicare expert who can ensure you have the coverage you need—before it’s too late.
