2 New Devastating Medicare Advantage Stories

[Special Agent]

Anecdotal.

52-53 million people on MAPD. Are the vast majority facings issues like this? Or are the vast majority happy with their insurance?

Nothing on this planet is 100% certain except for taxes and death.

and medicare supplement premiums and part B deductible

 

[MedicareWAA]

Where are all the MA experts on the forum who have decided not to address this question?

I think this is a damn good question.

This varies by plan. Many have no such requirement, or the requirement is that the PCP be included in the care planning.

 

[Surancedawg]

This varies by plan. Many have no such requirement, or the requirement is that the PCP be included in the care planning.

This was a standard PPO MAPD in Florida. I have never run into this sort of thing with any other PPO plan. At this point, I’m leaning toward the CS reps that day were just boneheads.

 

[gregj]

Where are all the MA experts on the forum who have decided not to address this question?

I think this is a damn good question.

The answer to your preceding question would help resolve this. Mostly I'd chalk it up to an insurer really straining to clog up beneficiaries' treatment.

These things go in cycles. The CEO guy at UHC who years ago decreed they'd forego requiring specialist referrals from primary care docs, when their competitors were all in on referrals, retired a very rich man (sure, they abandoned that level of flexibility years ago, but it was cool for awhile).

 

[MedicareWAA]

The CEO guy at UHC who years ago decreed they'd forego requiring specialist referrals from primary care docs, when their competitors were all in on referrals, retired a very rich man (sure, they abandoned that level of flexibility years ago, but it was cool for awhile).

Still no HMO referral requirement on most of their plans. Then others followed. I guess the evil empire isn’t completely evil.

 

[sunny1ib]

I had a prospect recently who had a very frustrating experience involving getting a Prior Authorization from her PPO MAPD. It seems her doctor wanted to send her to have a lung function test. He called in to the carrier's PA line and submitted the PA request. A week went by with no response from the carrier. So he called in again and submitted another PA request. Another week passed by with no word from the carrier. Finally, the member called in to see what the hold up was.

The carrier's CS rep explained that they could not process the PA request because it was not submitted by the PCP named on her application! She went ahead and formally named the Family physician who was treating her as her PCP. Of course, they made the doctor submit a new PA request for the lung test.

I checked the plan provider directory for the lady and saw that the doctor in question was an In-Network PCP/Family Medicine doctor for her plan.

What confuses me about all of this is, since when does a PPO plan require that only the member's NAMED PCP can submit a PA request? Especially if the doctor who submitted it is also an In-Network provider? Maybe someone who understands the ins & outs of Prior Authorizations better than I do can explain this. (Then again, maybe the CS rep she was stuck dealing with didn't know what he was talking about).

For what it’s worth:

From my experience on these MAPD plans, you will want to check out the EOC. Usually the way the plan will pay or authorize is written in there. I my experience, there have been a few PAs that were denied because: the member did not meet all of the criteria before seeking the highest level treatment, it goes against medical guidelines (this typically applies to injectibles), or there is not enough information provided for the medical director to make final decision. Also, PCPs are being used more and more to schedule procedures for the specialists. The idea (from my understanding) is to make the PCP the gatekeeper for any managed care plan, and it allows specialists to contain patient load thru referrals only.

 

[somarco]

member did not meet all of the criteria before seeking the highest level treatment,

Managed care plans are bad about that . . . no hopping over to the next step. They also do that for Rx that is not generic . . . requiring step therapy BEFORE going to the more expensive (newer) brand name.

The agents that say you don't need a referral in a PPO plan often are not correct.