Insurance Woes

Hi,

I currently have a Medicare Advantage plan that allows me to see doctors out of network and the doctor that I am seeing out of network for almost two years, is my Rheumatologist. This plan will not be continued in 2013 and the only option I have is to join this insurance provider's HMO plan, which will not allow me to see out of network doctors.

The insurance provider has a program called "In For Out Option" which would allow me to see an out of network doctor The criteria for this program is that "the physician, has to be the only doctor in my area who can provide this service"

This is what the insurance provider wants the doctor to say or something similar to that and I quote "I am the only provider within the patient's area that can provide this service for her".

Do you have any suggestions/comments as to how to modify this statement, if the doctor doesn't feel comfortable making this definitive statement?

You can't see the Rheumatologist with a referral from PCP? I am just starting my Medicare journey and trying to learn what I can.
Dale

One option which we've used, is to select a supplemental plan, though a bit more expensive, which cooperates well with the needed doc. When we went on, we simply asked the preferred docs which plans best fit them...in our case Mayo...they told us, we chose that plan...period. If that is not an option, then getting the docs to REdefine what and how they are needed for the medical plans to kick in is delicate. My ENT simply wrote a letter after I badgered her office & staff, short & quick, to our then insurance company...SHE was the ONE who best did what she was doing and what she was doing was severely needed by me AND caused by the disease...worked, never heard from insurance again on the questioned procedure...and they paid up too!!! Don't know if this helps, but it seems there's always a workaround IF you look for it and apply it...kind of like 'asking' for help!!! Huh!!!!!

Do you have the option of just going with plain Medicare and not one of the Advantage plans? The Advantage plans sometimes are cheaper or have extra perks but as you say they have to make up for it with some limitations in coverage or access.

I have just plain Medicare and can see any provider that will accept Medicare. Their reimbursement rates are so low that more and more providers refuse to accept Medicare assignments anymore and it will get much worse after next round of cuts in rates for providers so you may want to check with your doctors and find out what Medicare plans they accept. In our area most clinics opted out from most of the Medicare Advantage plans due to trouble with collections and their low rates. Some centers of excellence like Mayo clinic won't accept Medicare assignment either so do your homework on where you want access and then get best plan you can afford to get.

You most likely will also want a Medicare supplement policy to help pay the co-pays and a good drug plan if you are a heavy consumer of health care services like many of us. My choice is to go with a premium plans that is more expensive but eliminates any co-pays for medical services. The down side is that with supplemental plans they don't pay any thing unless Medicare covers that services so many things for me aren't covered like hearing aids, glasses, and most of my diabetic supplies.

Beeinformed, you've probably resolved this by now, but just in case you haven't.... Tell your doctor what's going on with the insurance company. No doubt he's dealt with that scenario before and will know what to do.

drz, Mayo doesn't accept Medicare? I wonder if that's regional, because the Arizona Mayo Clinic was full of elderly folks. If you have Medicare a non-Medicare provider cannot treat you-- it's illegal.

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Originally Posted by Sangye

drz, Mayo doesn't accept Medicare? I wonder if that's regional, because the Arizona Mayo Clinic was full of elderly folks. If you have Medicare a non-Medicare provider cannot treat you-- it's illegal.

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It isn't that Mayo doesn't accept Medicare, it's that one should have a good supplemental to pay the 'excess' rates Mayo sometimes charges...Medicare won't pay that. At Mayo, my charges, on the bill, always indicate (and Mayo's payment tables show it) that Mayo adds some kind of charge above other hospitals' similar rates. It's not a regional thing, they declared this over a year ago to my best knowledge.

Oh, I see. When I went to Mayo AZ I didn't have Medicare and they didn't take the insurance I had. My policy covered what they considered a typical expense, but I had to pay that extra amount every time. Several hundred each visit!

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Originally Posted by Sangye

Beeinformed, you've probably resolved this by now, but just in case you haven't.... Tell your doctor what's going on with the insurance company. No doubt he's dealt with that scenario before and will know what to do.

drz, Mayo doesn't accept Medicare? I wonder if that's regional, because the Arizona Mayo Clinic was full of elderly folks. If you have Medicare a non-Medicare provider cannot treat you-- it's illegal.

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I should have clarified that many providers won't accept Medicare ASSIGNMENT so you are responsible for all the charges. They might help you file the claims but you are responsible for the whole bill. This is true for many health care facilities. See quote off their site below.

They do accept Medicare assignment for my outpatient services since I am a Minnesota resident, but they refused several times to take me for inpatient care when I was initially diagnosed because of "my insurance" which was Medicare as primary and BCBS as supplemental. I suspect most of the people wealthy enough to "snowbird" in AZ can afford to pay the full bill so Medicare assignment is probably not an issue. This policy change is also rather recent and made big news when it was announced as it may be a harbinger of things to come for all of us.

Quote from their web site:
Mayo Clinic files claims to Medicare Part A and Part B on your behalf.
When claims are sent to Medicare on a nonassigned basis, the benefits for the services are sent directly to you. The law doesn't require health care providers to accept Medicare's approved amount as payment in full, and providers are entitled to bill you for the difference between their billed amount and Medicare's approved amount. Mayo Clinic limits its charges according to the limits set forth by the Centers for Medicare & Medicaid Services (CMS) for the Medicare program. You're responsible for payment of all billed charges, including those that exceed Medicare's approved amount.

What about Medicare and Mayo Clinic services and visit charges?
Mayo Clinic is a nonparticipating provider in the Medicare program. If you live outside Minnesota, Medicare will send payment and a Medicare Summary Notice (MSN) to you directly. Mayo Clinic also receives a copy of the MSN and will file claims to your supplemental insurance on your behalf. Claims processing often takes four to eight weeks.
Checks received from Medicare should be deposited into your personal bank account, and a personal check for the full amount due should be returned to Mayo Clinic in the envelope provided in your Monthly Statement of Account. These checks also may be endorsed — write "Pay to Mayo Clinic Only" on the back and sign your name — and sent to Mayo Clinic.

For all that explanation drz, sounds like Mayo accepts Medicare, just uses it differently. And, naturally, costs more...Mayo has more. As I'm NOT a snowbird, I have no f...... idea what you mean by your comment...actually I do, watch it buddy...some peoples' fairness is rooted in an entirely different idea of who deserves what...so, Mayo is doing just that...yes, I'm a lucky guy...some others aren't...world spins, and I need more coffee...

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Originally Posted by Dirty Don

For all that explanation drz, sounds like Mayo accepts Medicare, just uses it differently. And, naturally, costs more...Mayo has more. As I'm NOT a snowbird, I have no f...... idea what you mean by your comment...actually I do, watch it buddy...some peoples' fairness is rooted in an entirely different idea of who deserves what...so, Mayo is doing just that...yes, I'm a lucky guy...some others aren't...world spins, and I need more coffee...

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Since I consider both of you dear friends and my time may be short i am going to butt in here. I don't believe that drz meant to stereo type snowbirds, many of the winter visitors we have in Yuma do NOT have the financial resources they barely make it here. I think he just meant to talk about those that are lucky enough to be able to pay for their care. If you want to talk about lucky the fact that most of us here have access to a computer, we have food to eat and a relatively safe place to lay our head each night. That puts us in the top 5% of the world population.

Now...when an insult is given or taken I believe it is all about intention. What was the intention behind the insult. Therefore, I don't believe that the intention was to insult. So let this be a gentle reminder to make sure we are not using stereo-types in our language and that we have a good cup of coffee before we respond to a perceived insult.

I love you guys and I'm sending light and energy to both of you.

Oh man MOM!!! We just were having a friendly chat!! LOL! If the pot's not boiling, then nothing's on the stove for dinner...HUH!? Anyway, we are friends...stereotypes aside...hehe, ya gotta love a good reactionary commentary...some people let it slide, some go after it, some don't get it, and, sadly, most just stay within their own little worlds where it's safe...

So back to the Medicare and Mayo question, how is it that everyone praises Mayo's cost-controls and holds them up as an example?

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Originally Posted by Sangye

So back to the Medicare and Mayo question, how is it that everyone praises Mayo's cost-controls and holds them up as an example?

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Part of their cost controls are related to the 'high cost' of the kind of work they do...expensive stuff. I could see that I guess. They are incredibly well organized throughout most aspects of their medical efforts including insurance and financial help. Mmmm, other than that...not sure...I do know they are incredibly thorough with all that we've had to deal with them. Medicare, then, would come under those efforts. I don't see where their handling of Medicare the way they do is 'across the board' thus making them exclusive to some. Since they have higher costs than say Banner, a popular and larger system here in AZ, and Medicare picks up percentages of what it sees as definitive, there's always a bit left under the financial carpet to clean up. And, as said earlier by drz, they do run 'assistance' programs which seem pretty non-discriminatory in that they have paid for all kinds of medical needs, large and small.

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Originally Posted by Sangye

So back to the Medicare and Mayo question, how is it that everyone praises Mayo's cost-controls and holds them up as an example?

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The main thing is all doctors are salaried, not having any incentive to inflate their earning by unnecessary tests or procedures to run up your costs to increase their income. Sort of like the difference between dealing with a salesman on pure commission or one on a pure salary if you could find one. The other is their supposed coordination of services between departments to reduce any duplication or unneeded overlap of services which keeps costs down.

Their history and initial philosophy by the founding Mayo's was also to give every patient the best possible care regardless of costs. And they did so in their early days. I think they have had to compromise on that some but they still do many great innovative and life saving things for many people on a charity basis since many rich donors have and do donate many millions each year to Mayo. Its history, art collections, and museums also make it well worth a visit even without needing their health care services.

But they still do have their mishandled cases that you hear about at times and I have sometimes got much better service or care at some of our other fine medical facilities, (like my BAHA surgery) but then no facility is perfect all the time. Your experience depends upon the staff you get and how well they treat you.

And, just FYI, Mayo, at their Scottsdale hospital, is now building an advanced nuclear cancer treatment center. It is being built around a machine designed to pinpoint the very cancers and destroy them...I know part of it is laser too. The really neat thing is it's for children with cancer. It will be a 'full service' treatment center. So, yes, they do charge a lot, but they are innovative, specialized (which most of us should appreciate), and give back to the community with their programs, research, and advanced treatments in given areas. I sometimes feel I have to defend them as my original hospital had only an inkling of what WG is, but Mayo pinpointed it within 24 hours, and their staff is now keeping me upright and healthy. Just a perspective...drz and Sangye have not had good experiences with them...I believe they are in the minority.

[QUOTE=Dirty Don;..drz and Sangye have not had good experiences with them...I believe they are in the minority.[/QUOTE]

I have had some very good experiences at Mayo Clinic in Minnesota. I had a surgery for my Dupytrens Contractures at Mayo once I got in to see the right person. The initial appointment was botched as they gave me a surgeon who didn't believe in the "needle" surgery for Dupytrens. It was a new innovative procedure which few surgeons endorsed or knew how to perform.

I also had my first ear surgery at Mayo four decades ago and got excellent service when I had problems with it. Back then no other facility around was experienced in doing that kind of ear surgery but Mayo was innovative and pioneering just like they were in my hand surgery.

I have had excellent service from Dr. Specks for my GPA. Only one time the lab lost my record and kept me waiting an extra half hour but that is no biggey in grand scheme of things. I also believe my survival during my initial treatment for Wegener's and my still being alive today was also closely related to the consultation Dr. Specks from Mayo provided my treating physician

The negative experience I had at Mayo was the surgeon I saw last fall to inquire about getting a BAHA. He didn't seem to want to do it for me at Medicare rates so he was very discouraging me and they put me off for months even to try complete the evaluation for the surgery so I went elsewhere and got it done in less than three weeks by a surgeon who has also done hundreds of them so on that case I got much better service elsewhere. Some other people I know here have also had an occasional negative experiences at Mayo but then no facility is perfect all the time. There are more cases of where they saved some one's life or treated some one with a very difficult or poor prognosis and the results seemed to be a medical miracle. I personally know two people who are still alive today after their incurable terminal cancers were treat at Mayo.

They are the largest non-profit medical facility in the world for a reason and that is because of their reputation for excellence which they have earned and maintained through their excellent work.