Thursday, October 20, 2016

Dangers of compartmentalization

UHC finds another way
To discourage business

UNITED HEALTH CARE, or United Healthcare – either way, UHC – provides several Medicare Advantage plans in South Florida and perhaps elsewhere.

On its web site it lists two email addresses for its Preferred Choice and Medica plans: MemberServices and Enroll, both

Member Services is for existing members. The Customer Service Representative with whom I dealt either (a) didn’t know what customer service means, (b) considered the answers to questions I asked a state secret, and (c) lacked initiative.

Still, that was better than the Enroll address. Several emails sent to Enroll bounced.

I mentioned that to the Member Services CSR and her reply: We have nothing to do with Enroll or IT services (ergo my comment re lack of initiative). Were you or I alerted to a problem with customer or prospective customer support we would have quickly escalated the issueto a supervisor. An Enroll CSR I contacted by phone put me on “hold and forget.”

The dangers of compartmentalization.

Granted, with enough digging a determined person probably can find most sought-after information.

But some information won’t be found.

Some plans from Humana, and Aetna's Coventry Summit Ideal plan “capitate” their Primary Care Physicians (PCPs).

What is “capitate” you ask?

Basically it means that while the plan may list 1,000 specialists, a specific PCP may refer to only 100 specialists on the plan list. It’s a “sub-network.”

Some plans, such as HealthSun – that, incidentally has good customer service – has some “capitated” and some non-“capitated” PCPs. An email to HealthSun CSRs with a short list of prospective PCPs will generate an answer: who is “capitated” and who is not “capitated.” (There is a temptation to wonder: If a “capitated” PCP becomes a non-“capitated” PCP, does that mean the PCP was “decapitated?”)

Both Preferred Choice and Medica plans have extensive provider lists, but finding out if

of the PCPs is “capitated” is an impossibility except by phone. (A call to Aetna's customer service for Coventry's Summit Ideal was answered promptly; there was no email option. All Summit Ideal PCPs are "capitated.")

The reason it is an impossibility for a "some" answer is volume.

As an example, a prospective member checks the PCP options. The prospective member (hereafter “PC”) fails to find his/her current PCP – everyone should have a personal physician – so the PC looks at the plan’s provider list and selects 8 or 10 plan PCPs within the PC’s area. Few people want to travel 20 miles, or even 10 miles, to visit a PCP.

Admittedly the PC could call the number associated with Enroll, but then, if the plan has both “capitated” and non-“capitated” PCPs, the Enroll CSR would have to write down the names of “n” PCP candidates, check while the PC is on hold (more often “hold and forget” as happened when I called the UHC Enroll number), and then have the Enroll CSR read back the list noting who is, and who is not, “capitated.”

Medicare Advantage plans are “big bucks” business. The plans’ owner gets far more federal dollars than a we pay Medicare – currently slightly more than $100/month. Apparently for some, such as AvMed, the formulary is a major money maker.

The sad thing about the UHC plans is that while their Evidence of Coverage and Formulary contain information that I can appreciate, I can’t contact anyone who can – or perhaps will – answer my questions without a run-around or “hold and forget.” AvMed had email accessible CSRs and even assigned a “personal” CSR (who, when she vacationed, failed to have a backup to check her emails). HealthSun’s CSR response is a great marketing tool for the plan.

The bottom line for me regarding UHC’s Medica and Preferred Choice plans is that while they both are pretty good, the lack of customer support is a show stopper, at least for this scrivener.

No comments: