How Medicare works with private “managed care” companies

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How does Medicare work with these managed care companies (e.g., United Healthcare)? What is Kepro? Is Kepro just another name for Medicare? If United Healthcare is just managing Medicare disbursements for its subscribers, how would it be permitted to have more stringent criteria than Medicare? Is it possible for Medicare to determine that a patient meets the criteria for care and for United to make the opposite determination? What happens then?

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2 Answers

Anonymous 0 Comments

In essence, Medicare Advantage plans act largely similar to normal health insurance plans, paid for by Medicare and the individual monthly premiums Medicare beneficiaries still have to pay, that manage benefits for a Medicare patient, although benefits in some situations will fall back to normal Medicare rules (long term skilled nursing facility coverage, etc).

As far as I am aware, Kepro isn’t an insurer, but a QIO: an intermediary who arbitrates disputes between a patient and provider when appeals are made. (For example, a nursing home who believes skilled nursing facility care is no longer necessary after a hospital stay, but the patient disagrees.)

[Edit, that last paragraph should have a “among other roles” as they generally play a larger part in ensuring cost efficiency]

Anonymous 0 Comments

In essence, Medicare Advantage plans act largely similar to normal health insurance plans, paid for by Medicare and the individual monthly premiums Medicare beneficiaries still have to pay, that manage benefits for a Medicare patient, although benefits in some situations will fall back to normal Medicare rules (long term skilled nursing facility coverage, etc).

As far as I am aware, Kepro isn’t an insurer, but a QIO: an intermediary who arbitrates disputes between a patient and provider when appeals are made. (For example, a nursing home who believes skilled nursing facility care is no longer necessary after a hospital stay, but the patient disagrees.)

[Edit, that last paragraph should have a “among other roles” as they generally play a larger part in ensuring cost efficiency]