Sunday, September 23, 2018


One faux pas
After another

MY SPOUSE JUST SIGNED UP with a Medicare Advantage plan.
She sat with the salesman in our dining room and together they filled out the forms, making certain all the i’s were dotted and t’s crossed.

AND THEN the clerks got involved.

The Spouse received a letter from the plan the other day.

The letter informed her that the Primary Care Provider (PCP) was not listed as a PCP but as a specialist.

Being a reasonable person, I went to the plan’s web site.

The first requirement was to enter the Member ID.

I entered the Spouse’s Member ID and the system returned that the ID was “not found.”

She received a temporary ID “card” more than a week before the plan told me she didn’t exist.

I took a “just looking” approach and got to the provider gateway.

I entered the practitioner’s name and מצאתי (also Eureka, ¡Lo encontré!, and Je l'ai trouvé!) – I found it. (We live in an area where many different languages are spoken, sometimes even English.)

The doctor is listed in the plan’s Provider List – all on line – as a PCP. He ALSO is listed as a specialist.

If I can find the physician’s information on the plan’s on-line list of providers – the plan no longer publishes a paper list – WHY DID THE CLERK FAIL TO FIND THE INFORMATION?

As my geek son would mutter: “Does not compute.” What my cop son would say isn’t suitable even for an R-rated blog. How my daughter would react -- I won't go there.

So, the plan, thanks to lazy clerks is two for two – two errors for two tries. Not an auspicious beginning. The Spouse called the sales agent who also promised to be her personal representative to give him a chance to straighten things out. She is waiting for a call back. Will the agent redeem the plan? Will the agent actually call back?

The clerk arbitrarily assigned her to a PCP who is totally unknown to her.

She can, and will, change her PCP choice back to the original – the one the clerk was unable to find on the plan’s web site. Medicare allows a change at the first of each month, so the clerks have a few days to correct their blindness.

The Spouse also can start with a different plan in January (making her decision on or before Pearl Harbor Day). Unless you flunked history, you know that Pearl Harbor Day – a “day that will live in infamy” – is December 7.

WHEN I WAS A newspaper printer about to become a cub reporter, I asked a rewrite man what I needed to succeed.

Mr. Lidel, the rewrite guy and very experienced reporter, told me

    Keep the leed to 10 words or less and Spell the person’s name correctly.

The 10-word limitation on “leeds” (the lead paragraph) applied only to news, not features. Mr. Lidel knew that headline writers often grabbed the headline from the first (leed) paragraph. He was – as usual – correct.

I saw a tv advertisement for a new-to-me Medicare Advantage plan provider. I asked for some additional information – the plan’s 2018 Evidence of Coverage, the cast-into-concrete agreement with CM(M)S1 on what the plan will provide subscribers, the plan’s Provider List, specifically one specialist, and if the plan’s PCPs were “capitated.”

“Capitated” PCPs are allowed – perhaps they agree – to refer patients to specific plan specialists, even if there are many more specialists available in the plan.

I received an email addressed to Mr. Glen.

Error Number One, and to a former reporter (and later editor) a Major Faux Pas.

My name was clearly given on my initial contact with the company. Even the email address included my surname.

Yet the “blind in one eye and can’t see out of the other” clerk managed to misspell my name.

She blamed CMS for her inability to provide the requested information, but if I contacted her after 1 October she could provide the information.

A little research on my part – research I should have done before my email – showed me that the company was a start-up, albeit one “not ready for prime time.”

Apparently it pitched its product to CMS, as all Medicare Advantage plans must do, and CMS had not yet approved the product.

The clerk should have, had she been honest, responded that the company was awaiting CMS approval and that was expected on or before 1 October.

    Plans may add or delete practitioners and may add, delete, or change pharmaceuticals during a calendar year, but the plan’s Evidence of Coverage, is cast into concrete. The EoC spells out exactly what the plan will provide and any co-pays or deductibles. All Medicare Advantage plans must offer at least what Medicare offers (see Medicare & You2). Many plans’ EoCs include a table listing what the plan promises and what Medicare provides.

I am bothered that the clerk was unable to answer the basic question: Are (will) plan PCPs be allowed to refer to ANY specialist on the plan’s Provider List. Even if she was unable to answer my question about a specific specialist, she should have been able to answer the capitation question.

I understand Medicare Advantage plan providers are in a highly competitive business, especially in areas with high concentrations of geezers – I’m happy to claim that appellation – but to advertise sans product seems akin to going to a formal party without trousers.

By this stage, the plan should have a stable of physicians signed up, hospitals agreeing to accept the plan, medical labs, and so on (and on and on). If nothing else, it should know how it intends to operate … and it should share it’s plan with the clerks who answer emails.

I have not written off this plan, but it has enough strikes against it to generate suspicion.

Two plan providers – one well established – have entrusted their subscribers information to, apparently, incompetent clerks. Thanks to these clerks, both plan providers have more “pas” than a red “faux.”


1. CMS: Centers for Medicare and Medicaid Services


PLAGIARISM is the act of appropriating the literary composition of another, or parts or passages of his writings, or the ideas or language of the same, and passing them off as the product of one’s own mind.

Truth is an absolute defense to defamation. Defamation is a false statement of fact. If the statement was accurate, then by definition it wasn’t defamatory.

Comments on Fox Paws