Opuscula It pays To check The “facts”

’TIS THE SEASON FOR MEDICARE sign-up.

Geezers, and I’m happy to report I am one (it ”beats the alternative”) have from mid-October to Pearl Harbor Day to change plans. (If no change is recorded by the Centers for Medicare and Medicaid Services (CMS) the person automatically is re-enrolled in whatever plan is in effect at the end of the year.)

THIS YEAR, AS I DO EVERY year, I started comparing plans.

First question: Does the plan have the specialists I need?

Then I create a spreadsheet (I use LibreOffice’s Calc) listing in Col. 1 the benefits as they are listed by CMS’s Medicare & You booklet; it comes to my mail box shortly before the sign-up period commences.

This year I found two Medicare Advantage companies who claimed to have my specialist on their Providers’ List. Each got a column on my spreadsheet.

There are three documents every Advantage plan (potential) subscriber needs.
* Evidence of Coverage (EOC)
* Formulary (drug list), and
* Providers’ List (doctors, hospitals, urgent care, etc.)

One of the plans is new to my area (but well established elsewhere). It allows its PCPs to refer to any doctor on its Providers’ List.

One of the plans limits its Primary Care Physicians (PCPs) to an abbreviated list of specialists.

Both plans’ “beyond Medicare requirements” benefits were comparable.

Checking with the one plan’s prospective PCPs to see which could refer me to my specialist I discovered one who told me her practice referred to my specialist, but a patient reported that the specialist did not accept the insurer’s subscribers.

What to do?

Go visit the specialist’s office and ask “What’s going on between the office and the Advantage insurance company?”

The answer: “We HAD a problem, but that has been resolved.”

OK, I continued, what about the other Advantage company, the one that allows a PCP to refer me to any specialist?

“Sorry, we don’t accept that plan.”

But the company rep insisted the specialist was on the list.

The company’s Providers’ List listed my specialist.

I’m not blaming the company rep. She only repeated what she was told, AND she had the Providers’ List to support her position.

THE BOTTOM LINE

The bottom line, at least for this scrivener, is “Check with the specialist.”

It the specialist is critical to your well-being, a phone call, or better, a visit to the specialist’s office, is worth your time.

In the end I signed up with the company that limits its PCPs since I had found several local PCPs who assured me they refer to my specialist. (The one who told me about the insurer-specialist mix-up is about to become my new PCP. My current PCP, who also accepts this Advantage company will not/cannot refer me to my specialist. Pity.)

THE OTHER SIDE OF THE COIN

My spouse and I used to share an excellent ophthalmologist who somehow became a resident of a Federal gaol. The reason he was incarcerated was non-medical; no one ever has questioned his professional skills.

Because of his residency at a Federal facility, Medicare banished him from its list of acceptable practitioners.

Apparently the doctor is back in Medicare’s good graces.

The doctor’s staff said he was again accepting Medicare patients.

Hard to believe.

BUT, I found this gentleman’s name on the Providers’ List of the plan to which I just appended my (digital) signature.

I wonder if the PCP I selected can refer me to my preferred ophthalmologist as well as my preferred vascular surgeon.

If truth be told, it’s the surgeon’s team anesthesiologist I want at the head of the table. The surgeon’s good, but the anesthesiologist has the patient’s life in her (or his) hands.

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