Insurance Oversight On Roids

Fourteen years ago I made the executive decision to specialize in geriatrics. This decision wasn’t made lightly. I considered not only the patient population, but also the business side of things. For example, that population would have huge growth requiring access to care. These individuals also deserved to have access to care to professionals who specialized and understood their age group and their needs. I even thought about Medicare. I figured Medicare would tap out at some point in time. I also poorly guessed that there would just be a holding pattern in payments with very small incremental increases in pay. Obviously I could never have been more wrong in my crystal ball prediction.

The buzz between Michigan colleagues and myself for 2017 has revolved around EvilCore. Blue Cross Blue Shield of Michigan has had a Medicare Advantage product for quite a few years. Well, this fabulous year, their product has implemented drastic changes that affect care. Medicare Advantage products are supposed to be similar to traditional Medicare. Subscribers are led to believe they are just swapping their traditional option for a Blue Cross product. Some subscribers even think they have Medicare AND Blue Cross Blue Shield because the product’s name is Medicare Plus Blue.

What is currently happening in Michigan with a very large Medicare Advantage product is far from what is stated as “following Medicare guidelines.” Let me bring you all up to speed. I blogged about Blue Cross Blue Shield of Michigan here many years ago. The focus of that blog post was on poor utilization management metrics: how physical therapists were being categorized as A, B, or C providers by Landmark. This categorization was based on number of visits. Physical therapists in Michigan have been analyzed for years – since about 2008. Physical therapists who bill on a HCFA-1500 are tracked in their care via their NPI number. Physical therapists who practice in a hospital have no individual data on the care they provide. So, the new twist, subscribers who have Medicare Advantage are allowed care based on the physical therapist category level.

EvilCore is micromanaging at an intensity greater than a worker compensation case manager and about like what Blue Cross Blue Shield does for its managed care network. In other words, seeing Preferred Provider Organization on the insurance card is misleading.

Some of the Medicare Advantage products follow Medicare’s $1,980 therapy cap. From a cost perspective this product has mitigated its financial risk. This product has not been honestly marketed. When a subscriber looks at physical therapy benefits, the subscriber is led to believe they are allowed $1,980 per year (or in some cases unlimited visits). The benefits are dependent upon whether the product is an individual plan or a retirement group plan. There is no documentation in product manuals about category level providers and what is allowed with regard to access to care.

I am having a major problem with this new twist for this population.

  • The product follows Medicare’s cap of $1,980 (and I believe in this product’s case, the cap is a hard cap). I don’t believe there is an actual hard cap of $3,700 because I can’t find any mention of it in provider manuals or when learning specific subscriber benefits.
  • It feels like this product is double dipping. It already has the cost protective cap and now it is additionally micromanaging care. When I say micromanaging, let me ask you something to contemplate. How many older adults do you know that meet their goals in 6 visits?
  • When you treat an older adult who is dehabilitated and has low tolerance to exercise and requires vitals to be monitored…. What is the frequency of visits that meets evidence based care?
  • What’s the point in providing documentation substantiating the need for services when reviewers immediately decline further care? EvilCore mentions patient specific functional goals… mentions the activity-specific balance confidence score…. Gives all these guidelines about “evidence,” yet seems to ignore evidence in documentation that substantiates the need for care beyond 6 visits.
  • Authorization is granted based on category level. For me, a category A is allowed 20 visits, 80 units over a specific amount of time. Category B is allowed 6 visits, 24 units over a month of time. Reality… cost is driven by units, not number of visits. Time is wasted because language indicates the sooner of the 3 being met requires authorization. This means that in 6 visits, only 10 or 12 units may have been billed and authorization is again required. Sadly, the typical decision is no visits or 1-4 visits…. If only granted 1 visit, the reauthorization process occurs yet again.
  • This population has a greater chance of being in a pre-frail or frail state. The kicker: it can take up to a year for an older adult to move from a pre-frail to a normal state. Medicare allows for treatment that reduces the decline (up to $3,700 of services). Medicare Plus Blue subscribers will have no chance in improving their health state.
  • Is Blue Cross Blue Shield robbing Peter to pay Paul? I am holding my fingers back and not sharing the hours upon hours I have spent on the phone and in emails advocating for my patients. At the same time, my feathers are ruffled. Payment for services is already crappy. I see the EvilCore site and I wonder: how much money is Blue Cross paying for oversight on roids?


When I look beyond today and think of tomorrow, I am scared for adults who have chosen Medicare Plus Blue. Based on the experience I had, I predict:

  • There will be far less Category A providers. Blue Cross Blue Shield has not shared the current mix of category providers.
  • Older adults will not receive necessary care. What has been implemented will frustrate and anger physical therapists to such a degree that they will provide the initial number of visits provided in the authorization process.
  • Due to slow response time for re-authorization, cost of care will increase. EvilCore is not able to respond in a timely manner when attempting to gain additional visits, resulting in a gap in care. This gap in care is significant enough that patients will lose some of their gains. (I have seen this in my FOTO reports. Function declines about 7-10 points due to the gap in care.)
  • I’ll be dropped into a lower category. When that happens, I will need to make a very difficult decision: to no longer accept patients who have Medicare Plus Blue.
  • Access to care will be challenging for these older adults. More providers will not accept Medicare Plus Blue.
  • Maybe Blue Cross Blue Shield will be required to eliminate these changes. I have emailed and phoned Centers for Medicare and Medicaid Services, the Medicare Advantage oversight group.
  • Although the MPTA has created a way for subscribers to advocate for themselves, it may not be successful because it isn’t easy to find and Blue Cross doesn’t seem to care.

Until next time,


3 responses to “Insurance Oversight On Roids

  1. alan vogel says:

    Take a look at what’s happening in Ca. work comp. Visit IPTA.

  2. Candace says:

    I’m recommending to all those using this BCBS plan to change because I’m no longer going to use it by the end of this year. They owe me tens of thousands of dollars..

    1. Selena Horner says:

      So sorry to hear that you have experienced a financial loss, Candace.

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