Claims Problems with Today's Options

GreenSky

Guru
5000 Post Club
15,319
Henderson, NV
Over the past few months, many of my clients have called me for help with claims. In every case, the provider has billed Pyramid a number of times without success.

Have others had this issue? I'm considering using other carriers because of this but am looking for feedback.

By the way, Aetna looks like they have a great plan in certain counties in California. $55 per month, zero copays for almost everything. But I don't know how they will handle PFFS claims.

Rick
 
By the way, Aetna looks like they have a great plan in certain counties in California. $55 per month, zero copays for almost everything. But I don't know how they will handle PFFS claims.

If there is a good PPO MA plan in the county and if all the prospect's docs and clinics and hospitals are part of it, I see no reason to 'risk' a PFFS plan.... especially one that is brand new to the area. I think it may border on being irresponsible to sell one. There are just too many moving parts and targets in PFFS plans for me to sleep well after selling them when there are options. Just my opinion.

As always, YMMV

Al
 
If there is a good PPO MA plan in the county and if all the prospect's docs and clinics and hospitals are part of it, I see no reason to 'risk' a PFFS plan.... especially one that is brand new to the area. I think it may border on being irresponsible to sell one. There are just too many moving parts and targets in PFFS plans for me to sleep well after selling them when there are options. Just my opinion.

As always, YMMV

Al
And amazingly, I actually agree with your post. However, in California there isn't a decent PPO available. The one from Blue Cross sucks! HMOs are even worse.

Rick
 
And amazingly, I actually agree with your post. However, in California there isn't a decent PPO available. The one from Blue Cross sucks! HMOs are even worse.

Rick

And I agree with YOU!!! I don't believe it! But it's true. We agree on something (of substance.) If you and I can agree... are the Israelis and Arabs next? :)

Al
 
I really think it's going to depend on the billing specialist and just how much of a 'specialist' he/she may be. I had a client call me (wrote him on Wellcare Freedom) and the specialist billed it right. But Wellcare accepted payment at a specialist rate versus pcp rate, and the client payed the copay at specialist rate - $40.00 versus $15.00. His PCP is an internal specialist but also practices and takes patients as a pcp and is listed as both general and specialist physician.

I called and spoke to her;she then called Wellcare; and the issue was resolved thankfully.

Now, will this happen on all occasions where you truly get a billing specialist who will take the time to ascertain some if not all claims for the various clients seniors and non - on medicare on and not; probably not. And how much time do you have to call; probably not a whole bunch of time. And these carriers don't want us calling on claims, according to most recert. tests.

I have not heard too many positive things on Aetna where I live for branding and educating to docs so I definitely will not be writing Aetna unless I hear a 180 happen fast on the PFFS and hmo/ppo not available in my state for Aetna.
 
Last edited:
Over the past few months, many of my clients have called me for help with claims. In every case, the providers has billed Pyramid a number of times without success.

Have others had this issue? Rick

Yes, I've had way more then my fair share of Pyramid mix ups. Lost, underpaid, and some double paid claims. My app submissions were a nightmare. What a time waister.

They are on my sub-par list for '08.

Oh, by the way, if you want to kill a provider relation (PFFS, PPO, or HMO), then just slooooooooow pay and make them resubmit and resubmit again. Providers love it!
 
Back
Top