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Thread: Insurance Woes

  1. #1
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    Default 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?
    Last edited by beeinformed; 11-30-2012 at 07:33 PM.

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    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

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    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!!!!!
    Knowing how to think empowers you far beyond those who only know what to think. -NdT


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    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.
    Last edited by drz; 12-11-2012 at 02:29 PM.

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    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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    Quote Originally Posted by Sangye View Post
    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.
    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.
    Knowing how to think empowers you far beyond those who only know what to think. -NdT


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    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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    Quote Originally Posted by Sangye View Post
    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.
    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.

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    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...
    Knowing how to think empowers you far beyond those who only know what to think. -NdT


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    Quote Originally Posted by Dirty Don View Post
    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...

    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.

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