Medicare Advantage PPO plans

[braumeister]

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Originally Posted by Pluperfect Does traditional Medicare ever involve approvals? Like if I'm getting a test done or surgery, I just schedule it with a provider who accepts Medicare and the first Medicare hears about it when they get the bill?

I've not had anything overly complicated while using traditional Medicare, just normal care and a couple of surgeries. I've never had to get advance approval for anything.

There was one incident a few years ago where my doc wanted me to have a slightly unusual test and he asked his front office people if it was "covered" for me. They came back and said no. He didn't want me to have to pay for it so he told them to keep looking and find a way to code it. A few phone calls, some computer research, and ten minutes later they told him they found a good code. I got scheduled and had the test, and never a peep from Medicare. So I've been quite pleased.

[Dash man]

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Originally Posted by Pluperfect I'm new to Medicare and have almost no experience with how it actually works when getting treatment. VanWinkle asked something I'm curious about: Does traditional Medicare ever involve approvals? Like if I'm getting a test done or surgery, I just schedule it with a provider who accepts Medicare and the first Medicare hears about it when they get the bill? But with a Medicare Advantage PPO, I have to let them know I'm planning to have a test or surgery, and they get a say in whether it will be covered? Do I have to stay in contact with them about everything I'm doing? In the case of Medicare's restriction on Dash man's nerve ablation, how would a person know there is a restriction? Is this something doctors know and factor into their treatment plan?

The doctors take care of any needed approvals. In the case of my nerve ablation, he knows the Medicare rules. My doctor told me.

[MissMolly]

There is essentially no requirement for pre-approval for traditional Medicare except in very limited circumstance (like Hospice). For Medicare Advantage pre-approval is usually required but it is not something you do, it's something your doctor does. Even then, it's more a formality than anything in my experience. We've had several surgeries with our MA plan. The doctors would schedule the surgery and I would ask about pre-approval. They just waved their hands and said "won't be a problem". And it wasn't. I would watch on my health insurance portal and sure enough, a day or two later I could see the approval. We have never been denied or delayed care due to pre-approval. For us, it's a non-issue.

[youbet]

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Originally Posted by MissMolly There is essentially no requirement for pre-approval for traditional Medicare except in very limited circumstance (like Hospice).

Doc gave me an order for a "sleep test" because of symptoms I've been experiencing. When I called to schedule the test, they gave me a tentative date but said it would require approval by Medicare which could take up to two weeks. So, I'm waiting for the approval phone call so I know my appointment date is firm.

In ten years on Medicare, I've only had a handful of delays to get approval like this, but, as you say, they do occur.

[athena53]

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Originally Posted by MissMolly There is essentially no requirement for pre-approval for traditional Medicare except in very limited circumstance (like Hospice).

Pre-approval? No, but your doc better know what codes Medicare will approve. Braumeister's doc got it right. I've told this story before but my first gyno exam after Medicare kicked in she ordered the usual bloodwork. It included a lipids panel because my total cholesterol runs high, and an a1c because my fasting glucose is usually a bit over 100 and a1c is in the high end of normal. The lab sent me a bill for $800 because Medicare kicked it back as "not medically necessary." I tried to get the office to re-code it. No success. A technicality saved me- they hadn't had me sign the waiver form agreeing to be responsible for whatever Medicare didn't pay.

Goodbye, Doc (even though I really liked her). Hello, requestatest.com. Just had blood drawn this AM. Medicare doesn't cover but there will be no surprise bills.

[Chuckanut]

Before I had my knee replacement regular Medicare supposedly required that I try alternatives such as PT, lubricant shots in the knee, etc.

[CRLLS]

Yes. Medicare requires some input on procedures. It doesn't cover every course of treatment. Whether the Dr follows the traditionally course of treatment or jumps right to the most effective but best outcome is a problem. So is treatments that may not be considered "medically necessary". DW and I have had several surgeries since being on original Medicare. None of them required "us" getting approval. Extended PT was always handled between the therapist, the Dr's office and Medicare. The Drs have always gotten approval before scheduling the surgery. They have our Medicare account number before we even see the Dr. so they know what to expect from MC. There can always be a situation where our personal intervention may be required, just like company insurance or ACA coverage. Procedures such as an appendectomy may not be covered depending on the "reasonable and necessary" clause of Medicare. i.e., you can't just ask for an appendectomy because you simply want one. In some questionable cases, the DR may have to provide the argument for "reasonable and necessary".

[Katsmeow]

I do not have an MA plan (am on traditional Medicare for reasons that many here have expounded on). I do recall some people indicating that even though a MA may be a PPO plan that doesn't mean all doctors will accept. I seem to recall their being some instances when doctors would take an MA patient as out of network (even though allowed by the plan) but would take someone on traditional Medicare. I don't recall the details and have no personal knowledge. But I might research whether everyone that takes traditional Medicare will tae the MA plan.

[Gotadimple]

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Originally Posted by Katsmeow I do not have an MA plan (am on traditional Medicare for reasons that many here have expounded on). I do recall some people indicating that even though a MA may be a PPO plan that doesn't mean all doctors will accept. I seem to recall their being some instances when doctors would take an MA patient as out of network (even though allowed by the plan) but would take someone on traditional Medicare. I don't recall the details and have no personal knowledge. But I might research whether everyone that takes traditional Medicare will tae the MA plan.

MA is a separate contract from traditional Medicare, and a plan needs to be approved to have a MA contract by CMS. A doctor signs a contract with CMS and they are then able and willing to accept Medicare patients. They can stop at that point and not have a contract for Medicare Advantage because that is a private plan (funded in part by Medicare) with a specific network for the PPO plan vs. the HMO plan. In the case of MA, networks can be broad or narrow depending on the carrier's effort to establish a network - but their network must be approved by CMS if they want a Medicare Advantage contract.

- Rita

[VanWinkle]

I am confused about the fear of doctors not being in the PPO Medicare Advantage Plan you choose. What did everyone do during their working years when most corporations and small business were enrolled in HMO or PPO plans with networks of Drs. We all checked to make sure our Drs were in the plan first. Thinking the best doctors accept Medicare but not Medicare Advantage is not realistic. Medicare payments are very low compared to the billed amount.

[Dash man]

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Originally Posted by VanWinkle I am confused about the fear of doctors not being in the PPO Medicare Advantage Plan you choose. What did everyone do during their working years when most corporations and small business were enrolled in HMO or PPO plans with networks of Drs. We all checked to make sure our Drs were in the plan first. Thinking the best doctors accept Medicare but not Medicare Advantage is not realistic. Medicare payments are very low compared to the billed amount.

Nobody pays the billed amount. Medicare does pay quickly and reliably.
Providers have to be under contract with the MA insurers, or they’re considered out of network. Many insurers are difficult to work with. Contracts can end mid year leaving the patient having to find someone new, which can be difficult in some situations.
With Medicare, if Medicare pays, the insurers pays.

[VanWinkle]

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Originally Posted by Dash man Nobody pays the billed amount. Medicare does pay quickly and reliably. Providers have to be under contract with the MA insurers, or they’re considered out of network. Many insurers are difficult to work with. Contracts can end mid year leaving the patient having to find someone new, which can be difficult in some situations. With Medicare, if Medicare pays, the insurers pays.

What did you do during your working years for insurance? Just curious.

[Dash man]

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Originally Posted by VanWinkle What did you do during your working years for insurance? Just curious.

Not sure of the relevance, but I had a very good plan through Aetna.

[Irishgirlyc58]

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Originally Posted by VanWinkle I am confused about the fear of doctors not being in the PPO Medicare Advantage Plan you choose. What did everyone do during their working years when most corporations and small business were enrolled in HMO or PPO plans with networks of Drs. We all checked to make sure our Drs were in the plan first. Thinking the best doctors accept Medicare but not Medicare Advantage is not realistic. Medicare payments are very low compared to the billed amount.

I wondered the same.
I think part of the issue is that when you get your insurance through your employer you can change insurance companies during open enrollment without going through any type of health screening. This is assuming you live in an area with different insurance options. That isn’t the case for everyone.
Of course the insurance company going out of network can happen mid year even then leaving people in areas without a lot of options high and dry.

But I agree that the problem is there regardless of how you get your insurance. I think there are just more options to change when you are in that larger employer covered pool.

For billing insurance companies are difficult to deal with but then so is Medicare.

[Katsmeow]

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Originally Posted by VanWinkle Thinking the best doctors accept Medicare but not Medicare Advantage is not realistic. Medicare payments are very low compared to the billed amount.

I never said that the best doctors accept Medicare but not Medicare Advantage.

However, my understanding from some people is that some doctors who accept Medicare do not accept Medicare Advantage as out of network.

The reality is that for many specialties where most patients are Medicare age it is impractical not to accept traditional Medicare. (FWIW, in my experience, this isn't always the case for doctors who have tend to treat younger patients. They can turn down Medicare patients without losing much money.)

These doctors also may be in network providers to one or more MA plans. However, they may not want to be an out of network provider for someone on an MA plan because it is a hassle to them.

Also, I would caution people about being too sure on a MA plan that their doctors are all in network. That works until it doesn't. That is, a doctor leaves the network or, well, retires. Or you need a doctor for something new. Or you need to go to a hospital or other facility that isn't in your plan. A few years ago a relative wished her mother could go to the same rehab facility my mother was in. But she couldn't go because she had an MA plan and it wasn't in network. My mother was in traditional Medicare and could choose to go the facility she wanted to go to.

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Originally Posted by Irishgirlyc58 I wondered the same. I think part of the issue is that when you get your insurance through your employer you can change insurance companies during open enrollment without going through any type of health screening. This is assuming you live in an area with different insurance options. That isn’t the case for everyone. Of course the insurance company going out of network can happen mid year even then leaving people in areas without a lot of options high and dry. But I agree that the problem is there regardless of how you get your insurance. I think there are just more options to change when you are in that larger employer covered pool. For billing insurance companies are difficult to deal with but then so is Medicare.

None of this reflects my experience. Before Medicare I received my insurance through DH's employer. There really weren't significantly different insurance options.

However, it is was a good PPO plan where we could see out of network people. And, you now, the main reason I was ecstatic when I turned 65 was because I could get off that plan and go to traditional Medicare.

Even though I had good insurance with good providers it was a complete PITA to deal with. One of my children had to go the hospital (in network) by ambulance. We had no choice on the ambulance. The ambulance was out of network so we had to deal with balance billing. We also had other medical needs that required out of network doctors. The insurer paid a pittance of the charged amount. That is, let's say the charge was $400. The insurer would theoretically pay 60%. But, they would first cut that $400 down to $150 and then pay 60% of that. Just a real pain to deal with.

Even when there weren't balance billings costs it was still a pain. The out of network people didn't work my insurer. Often it was up to me to file the claim. The insurer might send an inquiry to them and then deny the claim when they didn't get a response. For example, once they sent an inquiry to a provider and denied it when they didn't get a response. She never got the inquiry as they simply addressed it to the very tall building she was in with no suite number. This sounds like it should be simple to resolve but took months. I would call the insurance company on an out of network claim, be told to do X. I would do X. They wouldn't pay. Then I would call back and be told to do Y.

Or I remember the time that there was a series of claims for the same service (different dates of course). They paid a bunch of claims. Then, they abruptly denied a claim. So, I called and pointed out that this was a claim that they were paying. They then said they would pull back all the prior payments.

Also, I hated dealing with co-payments and tracking were I was on the out of pocket maximum. It was just a pain.

Traditional Medicare is worth it to me because I don't have to deal with any of that. Before I was on Medicare I hours every year dealing with bills and deductibles and co-pays and providers, etc.

Now? I have to pay attention to meeting the part B deductible. And, then, I am done. I usually don't sign that I will pay for something if Medicare doesn't pay for it. (I did one time for something under $100). I look at my EOBs occasionally. In the last 3 years I've only had to call a provider about a billing issue once! (And that was easily solved).

You couldn't pay me to have to deal with networks and out of network providers. I do understand some people feel that they must use MA because of the low premiums. But, so far, that hasn't been required for me.

[Doribe]

I have a Medicare Advantage PPO with United Healthcare. This is a benefit from my previous employer. The co-pay is the same for in-network and out-of-network. The annual out of pocket is low and there is no maximum. I've been on it for one year and have no complaints.

[Pluperfect]

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Originally Posted by Katsmeow However, my understanding from some people is that some doctors who accept Medicare do not accept Medicare Advantage as out of network.

Can you explain this a little more?

I know some doctors accept traditional Medicare and aren't in any Medicare Advantage networks.

But it sounds like you're saying the doctors have a say as to whether they're "out of network," while it seems to me it's binary--if they're not in network, then they obviously are out of network. If they're out of network, then the MA plan would pay any claims under their out-of-network policy provisions, like the plan pays 60% to the provider and the insured pays 40% to the provider.

But when I think about it, the provider didn't sign up for this, so why should the provider have to split the check? And how would the provider even know what the patient's coinsurance was, if the provider doesn't work with that plan?

Or...is it a case where a provider would find out you have a particular MA plan and would say, "We refuse to treat you because we don't work with your (or any) MA plan. If you want to pay us yourself, up front, fine. Otherwise, we're not treating you." They're out of network because they're not in network (binary), but they refuse to see patients that will require them to participate in any out-of-network process.

Could they do this? Would they?

[RetMD21]

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Originally Posted by athena53 Pre-approval? No, but your doc better know what codes Medicare will approve. Braumeister's doc got it right. I've told this story before but my first gyno exam after Medicare kicked in she ordered the usual bloodwork. It included a lipids panel because my total cholesterol runs high, and an a1c because my fasting glucose is usually a bit over 100 and a1c is in the high end of normal. The lab sent me a bill for $800 because Medicare kicked it back as "not medically necessary." I tried to get the office to re-code it. No success. A technicality saved me- they hadn't had me sign the waiver form agreeing to be responsible for whatever Medicare didn't pay. Goodbye, Doc (even though I really liked her). Hello, requestatest.com. Just had blood drawn this AM. Medicare doesn't cover but there will be no surprise bills.

Yeah, it's complicated. Medicare will pay for lipid screening every 5 years but you can get the tests more often if the office codes you as having an abnormality. I don't think most doctors and offices understand. Especially since Medicare and other insurances all have their own rules. If Medicare determines it isn't covered you get charged the list price unfortunately.

[Dash man]

Here’s an article explaining that the Mayo Clinic will not schedule regular appointments with Medicare Advantage in Arizona and Florida. They sent letters to their patients advising them to sign up for regular Medicare and a supplement.

https://www.medpagetoday.com/special...lusives/101320

[seattledan]

This Youtube video convinced me for my personal situation why I would never go with it.

https://www.youtube.com/watch?v=hrkbOjBtBsw