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There's an issue that I am just sick over. I did sales seminars last fall for a regional large MA carrier. During the presentation regarding HMOs, I told beneficiaries that you can't go out of network with an HMO, "unless it's an emergency." I wrote up an elderly couple on the plan afterwards, as their $0 premium Humana plan was leaving the area. The issue is when they went out of state in late January on vacation, and the wife had an attack of diverticulitis. She was admitted to the ER and kept overnight. The next day the carrier provided a verbal authorization to the hospital (with an authorization number), but now she is receiving huge bills and the carrier is sending letters, "claim denied," while the hospital is demanding payment.
I've been back and forth with my contact at the carrier, who says he is "working on it." I don't know what to do at this point - sit tight and wait a little longer, or help the client file a grievance before she takes further action? Also, if someone feels they are having an emergency but are unsure if it's OK to go to the ER, are they just supposed to not go, and end up in a lot worse shape?
I will NEVER sell another HMO after this, unless it's a carrier with an extended network, like Aetna or UHC (but their networks are very skinny here). I'm going to focus on Med Supps and Life now, and the PDPs I'll refer to Ritter's call center. Also if I do another seminar it will be educational only for Med Supps. I feel like during the MA seminars, you can't disclose everything, such as most plans cover physical therapy as a specialist co-pay. There are a lot of carriers and plans in my area, and only one of them has a PPO with $15 copay for both physical and occupational therapy. But everyone wants the $0 HMO with all the bells and whistles as they are never going to get sick (or end up in the ER) and not pay $159 for the PPO.
I've been back and forth with my contact at the carrier, who says he is "working on it." I don't know what to do at this point - sit tight and wait a little longer, or help the client file a grievance before she takes further action? Also, if someone feels they are having an emergency but are unsure if it's OK to go to the ER, are they just supposed to not go, and end up in a lot worse shape?
I will NEVER sell another HMO after this, unless it's a carrier with an extended network, like Aetna or UHC (but their networks are very skinny here). I'm going to focus on Med Supps and Life now, and the PDPs I'll refer to Ritter's call center. Also if I do another seminar it will be educational only for Med Supps. I feel like during the MA seminars, you can't disclose everything, such as most plans cover physical therapy as a specialist co-pay. There are a lot of carriers and plans in my area, and only one of them has a PPO with $15 copay for both physical and occupational therapy. But everyone wants the $0 HMO with all the bells and whistles as they are never going to get sick (or end up in the ER) and not pay $159 for the PPO.
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