Opuscula Patience main Requirement For Medicare

MEDICARE THE PROGRAM IS NOT the problem.

Dealing with Medicare Advantage plan providers IS the problem.

MY SPOUSE IS becoming eligible for Medicare and I’m looking for a new plan provider.

We each have specific criteria.

I go through this exercise almost every year, so I know where to look for answers to me requirements. For the record, I check each providers’
Most recent Evidence of Coverage (EOC)
Providers’ List
Formulary.

The EOC tells me what the plan promised Centers for Medicare and Medicaid Services, a/k/a CMS. (What happened to the second “M” is beyond my ken.) The EOC is the one document that is cast into concrete and cannot be changed from January 1 to December 31.

The Providers’ List tells me who I can have as my Primary Care Provider (PCP), what specialists I MAY be able to see, what hospitals are contracted with the plan vendor, what urgent care facilities, and similar information. This list is “subject to change”; the vendor may add/change/delete providers on a whim.

The Formulary is the list of prescription drugs the plan will cover and what the co-pay is for each. Different plans rate the same drugs at different “tiers” or co-pays. As with the Providers’ List, the formulary is “subject to change.” (The co-pays are fixed by the EOC, but the drugs, and their “tiers” can change.)

Since my Spouse’s coverage start date is at hand, I checked several plans.

Most plan vendors are willing to send a sales person to the prospective customer. In an area with a high “geezer” population, Medicare Advantage vendors are highly competitive.

Still, it pays to follow the Coast Guard (and Boy Scout) motto: Be Prepared.

With the Spouse’s requirements before me I went to the Florida Blue Cross/Blue Shield, a/k/a Florida Blue, site.

Blue forces prospective clients to travel to one of its often inconvenient offices to confirm what it promises on the web.

Armed with a list of things to be confirmed, things I culled from Blue’s web site, we made an appointment and fought traffic to one of Blue’s sales offices.

When we arrived at the agreed upon hour, we discovered that keeping appointments is NOT important to Blue sales folks. After about a 10 minute wait we were shown into a cube where we met a gentleman with English as his second language. (My Spouse speaks several languages [to my two], none of which was the sale clerk’s primary language.)

The clerk looked at our list of concerns – things we read were available from Blue’s web site – and one by one he ticked them off as “not available.”

Apparently everything on Blue’s web site is a lie . . . or perhaps the sales clerk lied to us. We’ll never know, and frankly, Scarlet . . .

In any event, we decided Blue as not suitable.

We had two other primary options.

AvMed and Humana.

Both plans offered the providers we want, and both plans sent sales people to the house.

Humana – a company with which I have a year’s experience – limits its Primary Care Provider (or Physicians or Practitioners – take your choice) to specific specialists.

My critical specialist is on Humana’s Providers’ List, but he is not on my PCP’s capitated list. (I like my PCP, but because of the Humana limitation, this will be the second time I leave his practice for the same reason.)

AvMed, my first Advantage plan, has a lot going for it, but it, too, is starting to limit the specialists to whom a particular PCP can refer.

My problem with AvMed is that it charges a co-pay for one of my medications that is greater than the retail cost at Publix, my favorite pharmacy.)

Humana’s co-pay for the same medication is US$0 if I use the plan’s captive mail order pharmacy.

Humana offers my Spouse her preferred PCP and has other PCPs who can refer to my critical specialist.

Never mind that I had to contact the PCP candidates on my own to ask about a referral to my critical specialist.

AvMed has some additional charges Humana does not.

For example, AvMed gives hospital in-patients the first 5 days with zero co-pay. As my first AvMed sales person told me, and as my experience proves, most acute hospital stays are five days or less.

With Humana, on the other hand, all in-patient days are free of co-pays.

As good as Humana looked on paper, we had some concerns.

Humana’s sales person sat at out dinner table and electronically completed my Spouse’s application for coverage.

He confirmed that her PCP choice was on the vendor’s Providers’ List. He confirmed that a critical specialist also was on the Providers’ List.

When he pressed SEND we thought everything was in order.

AND THEN

And then the Spouse received a letter from Humana telling her that her PCP “couldn’t be found” on the vendor’s Providers’ List.

I found the physician in the Providers’ List sans problem. Am I smarter than a Humana clerk? Rhetorical question.

Of course when I tried to log on to Humana’s site using the Spouse’s ID – a temporary one issued a week before – the system returned “ID unknown.” I managed to get to the Providers’ List claiming to be a potential customer (which I was).

The Clerks-on-the-loose, since they were unable to find the PCP I so easily found, took it upon themselves to assign my Spouse to a PCP in another town, probably going by the ZIP code.

The Spouse called Humana’s main office and, after telling the clerk that yes, the PCP she wants IS on the list and “here is his Humana ID.” The Humana clerk, confronted with the evidence – the PCP’s Humana ID – agreed to change her PCP back to the one originally agreed upon and a new ID was sent out.

Humana sent my Spouse her ID card, but addressed to our street in a neighboring town. Again, a ZIP-code assumption. Somehow, the local post office distribution center went only by the 5+4-digit ZIP and delivered the card to the correct address. (Since some of our letter carriers cannot read NUMBERS, the fact that the USPS got the mail to the correct address is noteworthy.)

The Spouse called again to straighten out the address.

We know the sales person entered the information correctly because he was sitting with us when he keyed the data.

This does NOT bode well.

Granted, the clerks at Humana HQ are fixing the problems, but meanwhile the Spouse is wasting time having to call to correct clerical errors that should never have been made in the first place.

My concern is that as a Humana subscriber, if she uses the plan she’ll have to waste more time with the clerks to get the plan to do what it promises in the CMS-approved Evidence of Coverage.

On the other hand, she can sign up with a different provider until December 7, 2018 for the coming year.

My only complaint with Humana when I had it for a year was discovering that my PCP was unable to refer me to my specialist. That problem never occurred when I had AvMed “back in the day.” Then, as now, the AvMed’s medication co-pays caused me to look elsewhere.

AvMed had, perhaps still has, another problem that bothers this former Enterprise Risk Management practitioner. It gives – gave? – each customer a personal customer service person. Great idea.

The problem was that this person would get sick or go on vacation and no one was assigned to handle that person’s email and phone calls.

It you promise customer support, provide it; make certain someone fills in for the missing support person. AvMed failed to understand that.

AvMed apparently also fails to do any competitive analysis.

MEANWHILE there are fewer and fewer independent Advantage companies. Major players, such as Anthem and Aetna, are buying up smaller, usually local area companies. Most of the Anthem and Aetna properties are similar to Humana in that they limit their PCP’s referral options.

TO THEIR CREDIT, both Humana and AvMed – unlike Florida Blue – web sites are accurate; the information is confirmed by their sales staffs, albeit sometimes with a little “encouragement” from the consumer.

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 Medicare Advantage

Insurer proves Don’t trust Medicare info On the Internet

I’VE SPENT SEVERAL DAYS staring at Medicare Advantage providers.
I THOUGHT I found a provider that met the basic requirements:

PCP-check
Specialists-check
Hospital-check.

I checked and double checked the information.

But just to be sure . . .

THIS MORNING THE SPOUSE and I drove into another county to sit with a Florida Blue representative. We had an appointment, but the clerks were not ready for us.

Off to a bad start.

I explained that I had checked and rechecked my information early on the day of the appointment. All the doctors and the hospital checked out for both Florida Blue’s Premier and Classic Advantage plans.

We gave the clerk our list of things to confirm. The list started with the doctors and hospital and went on from there.

Absence of the doctors and hospital from the Florida Blue Provider’s List is a show stopper.

The clerk started down the provided list.

NONE of the doctors the Florida Blue web site repeatedly showed me as available on the Premier and Classic plans showed up for on the clerk’s computer.

Not one.

They DID appear for OTHER Florida Blue plans, the “extra cost” PPO plans.

“Well, the site is updated overnight,” the clerk told us.

OK, but I checked less than an hour ago, at 10 a.m. I replied. No overnight update here.

On line, all indications are that the practitioners found on the Provider’s List – accessed from the specific plan’s page – are for that plan. There is NO indication on the provider’s list that the provider is available only on a plan other than the plan which accessed the list.

BOTTOM LINE: NEVER trust a vendor’s web site.

I fail to see how lying to potential customers can benefit anyone; not Florida Blue nor the prospective client.

As soon as mid-October rolls around the “victim” of Florida Blue’s web site will have an opportunity to select another provider.

Florida Blue is not the only web site of which to be wary.

Other sites tell me that many of the doctors we want are on their list.

HOWEVER, some of these sites are capitated. See Medicare plans: Beware the plan is not “capitated” (http://tinyurl.com/ycmmlw42)

True, Doctor A IS on the plan’s provider list, but PCP B cannot refer a patient to Doctor A since Doctor A is not on the PCP’s abbreviated (capitated) list.

It is a pain in the posterior – that is not covered by any plan – but prospective clients need to beard the lion and visit the insurer’s physical site as my Spouse and I did this morning. Alternatively, have a representative make a house call. (Florida Blue does NOT offer this convenience; AvMed does and an AvMed representative is scheduled to visit. Will AvMed have the providers we need; its Provider’s List claims it has almost all the doctors. (Sadly, the list lacks an excellent PCP. Maybe it and the PCP’s practice will get back together for 2019.)

I am certain our experience with Florida Blue, AvMed, and Aetna’s Coventry – the capitated plan -- are not unique to the companies or to the geographic area.

How can you know if your PCP can refer to Doctor A? Ask the PCP’s referral person. The referral clerk is the only person guaranteed to know; the PCP probably has no clue – that’s why there is a referral person.

We almost signed up with Florida Blue because the web site showed us it has the doctors and hospitals we need. Had we signed up, in November the plan could have been unceremoniously dumped in favor of a more honest plan.

No matter what a vendor's web site claims – and this applies to ANY vendor – confirm your understanding with a person who has the authority to “put it in writing.”

Thanks to Florida Blue, lesson learned.

It will be interesting to see if Florida Blue does anything with its web site to correct the mis-information – assuming the clerk with whom we spoke this morning escalates the problem.

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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 Medicare plans – Part 2

Opuscula Patient welfare Vs. AvMed profit

THIS IS ALL ABOUT what I perceive as a way for AvMed to increase its profits at the expense of its subscribers – its raison d’être.

For 2017, AvMed raised the “tier” – the level that determines the subscriber’s copay for a specific prescription – for one of my medications from Tier 2 – copay $7 – to Tier 4 – copay $75. The drug, Fenofibrate, has been on the market for several years and replaced, for me, Omega 3 which, like Finofibrate, AvMed jumped from Tier 2 to Tier 4 for 2016.

Sharon Robison, Manager, AvMed Medicare Member Engagement Center - no address included in her communication – informed me by mail that I could avoid a $75 copay for Fenofibrate by having my Primary Care Physician (PCP) prescribe Gemfibrozil instead. Gemfibrozal is Tier 2; the copay is $7.

I checked with my pharmacy and found out the full retail price for Fenofibrate is LESS THAN the AvMed copay – and that’s sans coupons, discounts, or drug discount cards. We are in the final throes of the 2016 presidential election disaster – no matter who wins, America loses – and my level of skepticism on all things is high; my suspicion is that AvMed is using Fenofibrate as a money maker – over and above what it gets from the government.

My pharmacist told me that Fenofibrate was developed several years ago to supplement Gemfibrozal because the later often was contra-indicated for people taking statins – which I do. Ms. Robison’s missive failed to apprise me of that little fact.

According to the National Institutes of Health (NIH),

Compared with gemfibrozil, fenofibrate produced significantly greater reductions in total cholesterol, LDL, and triglycerides and significantly greater increases in HDL. These changes were evident in patients receiving and not receiving concomitant statin therapy.

Between my pharmacist and the NIH, there appears no medical advantage for the patient to switch from fenofibrate to gemfibrozil; indeed this would be a step back.

It is interesting that of the several companies in the area that offer Medicare Advantage plans, one plan, HealthSun, rates Fenofibrate as a Tier 1; i.e., $0 copay. Others listed it as Tier 2 or Tier 3; only AvMed listed it in the $75 copay tier. AvMed’s copay was the same if the drug is purchased from a local pharmacy or via AvMed’s mail order partner.

The Center for Medicare and Medicaid Services generally sets guidelines for Medicare programs (which explains why most Advantage plans look pretty much alike). It apparently allows program owners, e.g., AvMed, Humana, and United Healthcare, flexibility with charges, most noticeably in re hospital stays and, to my chagrin, pharmacy copays.

There was a time when access to “my” specialists was critical, but that time has passed. I now can, albeit reluctantly, deal with PCP capitation.

Medicare programs are highly competitive. I can’t understand why AvMed would shoot itself in the wallet by what appears to be price gouging. I don’t sit in the AvMed board room so I’m not privy to management’s decision making processes, but if appearances count for anything . . .

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 @UHCsouthflorida.com.

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

Any
Some
None

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.

Opuscula You’d better Shop around

WHEN IT COMES TO MEDICARE ADVANTAGE plans, Smokey Robinson and the Miracles got it right: “You got’ta shop around.”

This scrivener seconds that emotion.

A LITTLE HISTORY

I had an “regular” AvMed plan when I was working for a now-defunct company called DMR. When I signed up for Medicare years later I ended up with an AvMed Medicare Advantage plan. We had a decent relationship until AvMed cancelled my PCP, a doctor who was an excellent diagnostician.

Miffed, I signed up with Humana – for a year.

With Humana I discovered “capitated” PCPs.

Capitated & Decapitated

With AvMed, my PCP could refer me to ANY specialist on AvMed’s Providers’ List.

Not so with Humana.

While Humana had a lengthy Providers’ List, the doctor who became my PCP had a very much reduced list of specialists to whom he could refer.

Humana was unable to tell me which doctors could refer me to my vascular surgeon (Abdominal Aerobic Aneurysm, FemPop Aneurysm); it was left to me to contact PCP prospect after PCP prospect until I found a PCP whose personal specialists list included my vascular surgeon.

Fortunately, with Medicare, a patient can change PCPs every month. I did. During the year I was a Humana client I changed PCPs three times.

As soon as October rolled around, I signed up once more with AvMed.

Prescription “tiers”

Medicare Advantage programs have multiple “tiers” for prescriptions. “Tier 1” usually are free to the plan client. These typically are low cost generic medicines. Publix, a supermarket chain in Florida and Georgia, fills some prescriptions for “Tier 1” drugs at no cost to plan or plan client; consequently Publix gets ALL my prescriptions.

I started the year with a Tier 2 medication. The next year, AvMed jumped it from Tier 2 to Tier 4. Tiere 2 cost me $7 for a 30-day supply of pills; AvMed now demands a $75 copay for the same number of pills. Quite a jump.

I checked some discount pharmacy offers and discovered that a number of sources offer the medication at prices LESS THAN AvMed’s $75 copay.

Did all Advantage plans list my medication as a Tier 4? I already knew Tier 4 copays varied by plan provider.

Turns out different plans put the medication at different tiers. I found one – HealthSun – that showed the medication as a Tier 1 (no copay) on its Formulary list. Others listed the medication as Tier 2 or 3.

THINGS TO CHECK

When comparing Medicare Advantage plans, ask the competing providers for

EVIDENCE OF COVERAGE; this commits the plan to provide the things it promised Medicare to provide. Skip any overviews; they are just marketing.

FORMULARY; this lists all the medications the plan covers. If your medication is missing from the list, ask why; is there an alternative. The Formulary also tells you the medication’s tier level. (The Evidence of Coverage sets out the copay for each tier level.)

PROVIDERS’ LIST; this identifies all the physicians who work with the plan - BUT CHECK FOR “CAPITATION” - as well as hospitals, urgent care centers, pharmacies, and other suppliers.

In most cases, the information is online. You may have to contact the plan to find out the URLs, but usually they will be provided quickly. AGAIN, check about capitation.. If you have specialists who have been treating you and you want to keep them, this is a critical question. Some plans have a mix of capitated and non-capitated PCPs and many plan Customer Service reps will tell you which are capitated. If you select a capitated PCP, you need to call the doctor and find out if you can be referred to your preferred specialists. (HealthSun, ibid., has both and CSR Malissa Soriano has proven to really provide “customer service” in sorting out who is and who is not capitated.)

Medicare Advantage programs can be wonderful things, but as with any insurance – home, health, auto, etc. – keep in mind what Smokey Robinson and the Miracles advise: “You better shop around.”

Opuscula AvMed copay Greater than Pharmacy’s price

I AM A MEDICARE ADVANTAGE subscriber. Most of my Medicare years have been with AvMed – I had Humana for a year and quickly returned to AvMed – but my loyalty is starting to waiver.

Last year AvMed raised the “tier level” – this determines the copay - for one of my medications from Tier 2 to Tier 4. On request, it provided my Primary Care Physician (PCP) with a lesser-cost Tier 2 alternative: fenofribrate. (My PCP claims he never got the message; I complained and AvMed sent the information directly to me. For this and several other reasons I have a new PCP.)

Generic fenofribrate was a Tier 2 drug; the copay was $7 for a 30-day supply (30 tablets). For the 2017 calendar year, AvMed moved the drug to Tier 4 with a $75 copay. That’s a painful increase: from $84/year to $900/year copay.

WHY the two-tier jump is beyond my ken and, thanks to a crashed hard drive, my email contacts with AvMed “disappeared.” (To its credit, AvMed customer service is pretty good.)

Perhaps the jump is the work of the current incumbent at 1600 Pennsylvania Avenue and his “law-by-sneakiness” Patient Protection and Affordable Care Act (PPACA); he has mucked about with the healthcare system to the detriment of many.

I don’t know if fenofribrate is a Tier 4 drug for all 2017 Medicare advantage plans – I suspect it may be; if it is, AvMed’s $75 copay is competitive with other plans’ Tier 4 copays:

BlueMedicare HMO MyTime Plus (HMO) - H1026-061-0 - $65
Optimum Platinum Plan (HMO) - H5594-002-0 - $69
Simply More (HMO) - H5471-051-0 - $75
CareOne (HMO) - H1019-001-0 - $85
Harmony Maximum (HMO) - H4627-006-0 - $85
Humana Gold Plus H1036-065C (HMO) - H1036-065-0 - $85
Optimum Gold Rewards Plan (HMO) - H5594-001-0 - $85
Preferred Choice Broward (HMO) - H1045-005-0 - $85
Medica HealthCare Plans MedicareMax (HMO) - H5420-003-1 - $89
Humana Gold Plus H1036-237 (HMO) - H1036-237-0 - $97
Coventry Summit Ideal (HMO) - H1609-018-0 - $100

The exception was HealthSun HealthAdvantage Plan (HMO) - H5431-012-0 - $30.

The information above is from https://q1medicare.com/PartD-SearchMA-Medicare-2017PlanFinder.php#results

For kicks, I checked GoodRx.com for Fenofribrate in my area. The site returned RETAIL (full) prices of

Walgreens - $76
CVS and Target/CVS - $77
Kmart - $82

Of those, with free discounts or coupons, the price for a 30-day supply of fenofribrate dropped to

Walmart - <$22 (d)
CVS@Target - $32 (c)
Walgreens - <$33 (c)
CVS - $43 (c)
Kmart - <$50 (c)
Publix <$60 (d)

In the above, c = with coupon; d = discount.

There also is a discount card available at My DiscountRx Card.pdf, but I have no idea the amount of discount using that card at my regular (Publix) pharmacy.

The question remains: If Medicare is supposed to help limited income seniors, WHY IS THE COPAY HIGHER THAN THE LOCAL DISCOUNT OPTIONS?

It will be a little inconvenient to fill the fenofribrate script since my new PCP will have to give me three scripts for the medicine – coupons and discounts are “subject to change” and what is “best price” at one pharmacy one month may not be the following month. As it is today, I insist that all scripts (prescriptions) be given to me to take to the pharmacy of my choice; I lack confidence in medical practice front offices. Currently, all scripts are for 90-day supplies; it is more convenient.

I wonder, given the RETAIL cost of finofribrate (ibid.) how much AvMed is about to make when my copay is about the same as the full price of the drug at local pharmacies. Unless, of course, AvMed knows that the wholesale cost of finofribrate is about to drastically jump – rather like stock market insider trading. (But that fails to explain why the HealthSun HealthAdvantage Plan only has a $30 copay for Tier 4 drugs.)

There is more to Advantage plans that “just” medications. There are related plans (e.g., dental, vision, hearing) and hospital/ER/urgent care copays to consider as well as being able to see ANY provider on the plan’s provider list (e.g., Humana’s capitated lists that limit PCP referrals). As with auto and home/renter insurance, it pays to compare plans. What may be good for me may not be good for others. There are options not only within Advantage plans, but there is “straight” Medicare and extra cost Medicare Supplement plans

Fortunately I have a little time to select a plan for 2017. Interestingly, the deadline is December 7, a date most plan participants will remember as Pearl Harbor Day, that “infamous” day in 1941. (Sixty years later, on 9-11-2001 we were attacked again.)

Opuscula Ripping off Medicare

 

MY MEDICARE INSURANCE company, AvMed just sent me a notice that it paid a doctor $343.00 on a bill of $350.00.

My co-pay was zero.

So why am I complaining?

I WAS IN THE hospital overnight for a "fem-pop bypass" to bypass an aneurysm.

I was admitted Wednesday morning and discharged Thursday evening.

The surgeon chatted with me before the operation (he's cut on me before) and he had me as a "show-n-tell" for some floor nurses and one of his partners the next day.

Today, AvMed informs me it paid another physician $343.00.

I never saw the physician.

Neither my wife nor son, who were with me, saw any physicians other than the surgeon. The Spouse supposes that this doctor's nurse came by to say "Hello," but I don't recall any nurses or nurses' aids that were not identified on the huge white board on the wall.

Again, my co-pay for this invisible doctor's visit was $0 - nada, effis, nothing.

BUT I THINK MEDICARE - FUNDED BY MY TAX DOLLARS - IS GETTING RIPPED OFF; the doctors who bill for visits not made are thieves.

Maybe this phantom physician has to make his payments on a prestigious car; my surgeon drives a leased Jaguar - we chat about cars and other topics between surgeries.

I may not have a co-pay, but in the end, I am - and all tax-payers are - paying for services not rendered. That, plain and simple, is theft.

Maybe $343.00 is a pittance to AvMed, too little in the grand scheme of things to investigate. But consider: if you add up phantom physician visits at one a day times 256 days (52 5-day work weeks) time $350 (the fee billed) the Grand Total is a healthy $91,000 (91 thousand). Granted that's probably peanuts for a lot of doctors and they do have debt - college and medical school aren't inexpensive, even the off-shore schools can be pricy.

Mind, that $91,000 total is for ONE visit to ONE patient for ONE day. Any invisible doctor should be able bill for 8 to 16 "visits" per day. Think about it: $350 times 12 "visits" per day and our phantom physician has billed Medicare or some other insurance company $4,200 - and the doctor may not have set foot in the hospital.

Even if the doctor sends a nurse in his or her stead, the doctor still is raking it in; nurses, as important as they are, don't get the dollars doctors do.

It's fraud, Medicare fraud, and while Medicare,gov preaches "report fraud," I suspect when fraud is reported, the individual fraud - e.g., $350 - is just to picayunish for the government to consider. The Medicare budget for 2014 was $511 billion.

Opuscula Is reading A lost art?

 

WHEN I WAS CREATING technical manuals for the Navy, I was told that I should write to a fifth grade level.

Keep It Simple (Stupid) - writing to the KISS principle.

Now, trying to communicate with AvMed customer service representatives I am discovering that even fifth grade may be too advanced.

AvMed, as probably most insurance providers, has different co-pays for different providers and different venues.

My plan, with which I am generally satisfied (providing POTUS doesn't chop any more out of the allegedly protected Medicare budget) has two levels of co-pay for specialists: $10 and $30. Before POTUS messed with Medicare it was $5 and $25.

POTUS, for the acronym-innocent, stands for President Of The United States.

I needed an appointment with a specialist, but I had forgotten the co-pay rates. I'm sure the provider would have told me, but like the Coast Guard and Boy Scouts, I wanted to "be prepared."

I sentr my question -"What are specialist copays?" - to customer service, a/k/a Member Services. I also sent an email to the person who is supposed to be my personal contact with AvMed.

My personal contact was Out Of Office (OOO). Apparently no one covers for her when she's away on vacation, sick leave, or for whatever reason. I'm sure her absence was justified. As a risk management practitioner and former customer service manager, I know that is NOT how to run a customer service organization; someone must cover for absent personnel..

Member Services responded telling me I needed to inform it of the provider's name in order for Member Services to give me an answer to my query which, I remind you, was simply "What are the two co-payment levels?"

I know that English comprehension is not (effectively) taught in our schools.

Grammar? Forget it.

I'll admit I'm a slave to spell check; knowing my limitations I run spell check frequently as I compile my thoughts and always after I make a change - those gremlins always manage to sneak in when a minor change is made.

But - I thought - I asked a very simple, straight question: What are the AvMed specialist co-pays?

With the exception of one year, I have been with AvMed since 2010. The benefits provided by AvMed have been OK - it did cancel the PCP that saved my life, something I still resent, but it came through for me when I needed AAA surgery. (As with most Medicare dental plans, AvMed's plans - two different sub-insurers - leaves a lot to be desired.)

I spent a year with Humana which, thanks to PCP capitation and some fresh off the boat PCPs, caused me to come running back to AvMed. Humana's customer service is no better than AvMed's; perhaps that's because once a person signs up for a plan, the person is "stuck" with that provider for a calendar year. Given a captive client, why bother?

I don't mind having to get referrals from my PCP - he knows who is good and who is not quite so good. I also like knowing my complete medical history is in one place. My current PCP may not be the diagnostician my previous AvMed PCP was, but, like my other AvMed PCP, he listens and he gets me referred to specialists when we - he and I - think it necessary.

AvMed is a pretty good insurance provider - just don't expect any service form Member Services.

Forget Waldo, where's HIPAA? Insurance companies place Customer information at risk

 

IN A NEW YORK TIMES ARTICLE heded "Anthem Hacking Points to Security Vulnerability of Health Care Industry" we learn that The cyber attack on Anthem, one of the nation’s largest health insurers, points to the vulnerability of health care companies, which security specialists say are behind other industries in protecting sensitive personal information.

Where are the largest databases of Americans' personal information outside of government computers? Health care providers.

Now, with all tax-paying Americans obliged to have health insurance else face a tax penalty, information on all tax-paying Americans can be found in one or another insurer's database.

Get HIP(PA)

HIPAA, a/k/a Health Insurance Portability and Accountability Act of 1996 is supposed to have rules in place to protect patients' personal information, and although the protection is focused on medical records, all patient-related information - and that includes Social Security numbers, addresses, dates of birth, is included in the mandate.

Good grief; many medical practitioners and business won't even send or accept emails due to HIPAA penalty paranoia. (Faxes are OK, despite the fact that anyone passing by the fax machine can read incoming and outgoing information left lying in the area. Seems Dilbertian to this scrivener.)

Yet, hackers - Chinese if the Times article is to be believed - gained access to up to 80 million records that included Social Security numbers, birthdays, addresses, email, employment information, and income data for customers and employees, including its own chief executive.

I confess to being amused by the fact that Anthem's "own chief executive" was among the victims. Perhaps this executive will lead the way to find means to secure health care information - for Anthem and for other companies.

Apparently, Anthem and other health care companies had become increasingly aware of the criminal value of the information they have, in light of the large cyber attacks against financial service companies like JPMorgan Chase or retailers like Target according to Thomas Miller, Anthem’s chief information officer.

That, of course, begs the question: If "Anthem and other health care companies had become increasingly aware of the criminal value of the information they have" why didn't they aggressively work to protect that information?

According to Miller, Anthem was actively considering encrypting its internal database as well as taking other steps to improve its security.

Katherine Keefe, a global focus group leader for breach response services at Beazley, which underwrites cyber liability policies, said health care companies were attractive targets to hackers because the information health providers maintain about consumers tended to be more valuable on the black market than credit card information stolen from on a retailer.

The problem at Anthem, and based on the Times' piece, is that while executives apparently KNOW corporate databases are vulnerable, they are dragging their heels in actually remediating the vulnerabilities. Perhaps if more executives had their information compromised they would go from "considering" action to "doing" something to protect their, and their clients', information.

Advantage ours Things to consider In a Medicare plan

 

Over the years I have had two Medicare Advantage plans.

For several years I had a plan from AvMed. When AvMed failed to renew its contract with my long-time, and excellent, Primary Care Physician (PCP), I signed up with Humana.

Humana had some economic benefits and its Providers' Directory listed both my vascular surgeon and my long-time ophthalmologist.

CAPITATION

Humana has a program called "capitation" that basically restricts its PCPs - and there were 108 in the plan I had - to referrals to specific specialists; even if a specialist is on Humana's Providers' List, the PCP may not be able to refer a patient to that specialist.

Human warns prospective clients in its Provider Directory, under the heading Getting Care from Specialists that: "Each PCP may have certain network specialists they use for referrals. This means that the specialists you can use may depend on which person you choose to be your PCP.

If there are specific specialists you want to use, find out whether your PCP refers patients to these specialists. You can change your PCP at any time if you want to see a network specialist that your current PCP does not refer to."

The problem is, how to find out which PCP can/may refer to which specialist. Humana Customer Service can't or won't tell the client; is the client supposed to contact and query each of the 108 PCPs?

I contacted seven other Medicare Advantage providers and only one had a similar "capitation" arrangement.
Aetna: Any PCP may refer to any specialist (both within the same plan)

AvMed: Any PCP may refer to any specialist (both within the same plan)

BCBS: Any PCP may refer to any specialist (both within the same plan)

CarePlus: Any PCP may refer to any specialist (both within the same plan)

Coventry: Any PCP may refer to any specialist (both within the same plan)

HealthSun: Depends; if the PCP is part of an independent practice association (IPA) group, then any PCP may refer to any specialist within the same plan; otherwise similar to Humana, PCPs have limited options. However, HealthSun will provide a list of IPA PCPs upon request.

United Healthcare: Any PCP may refer to any specialist (both within the same plan)

IN-PATIENT COSTS

Humana and at least one other Advantage plan (Preferred Care Partners) offer $0 co-pays for hospital stays from Day 1 through discharge. Other plans charge from more than $100 to slightly les than $300 for Days 1 through 5. AvMed charges $0 for days 1 through 5, $80/day for Days 6 through 20 ($1,200), then $0 to discharge.

When I initially signed up with AvMed I asked about this and was told that typical hospital stays were 5 days or less. Two surgeries later, one "major," I have to admit the sales guy was 100% correct. (When the hospital over-charged, AvMed resolved the issue in our - AvMed's and mine - favor.)

It's a good idea to check costs for Skilled Nursing Facilities (SNF) as well; some plans charge for the initial days, other do not.

MEDICATIONS

It pays to check a potential plan's "Formulary" - list of prescription medications - before signing on the dotted line.

For two reasons:

One, to assure the medications are on the list and

Two, to see what LEVEL the plan lists for the medication. The "level" determines the cost to the patient and, in some cases, the amount of medication that may be dispensed at one time (e.g., 30 days or 90 days).

AvMed, for example, fails to list one of my medications, a Level 3 on Humana's list. It does offer an identical generic version, If I order the medication via AvMed's mail order pharmacy, my cost is $0 for 90 days. Mail order usually is slightly less expensive for the patient. (Some local pharmacies may offer some common medications, e.g., Metformin, gratis. It's convenient for the patient and a way for the local pharmacy to get the patient inside the store.)

Before signing on the bottom line, check with the prescribing physician to see if there are alternatives to your current medications and then check to see if the alternatives are listed by the plan's formulary.

Some plans include a small ()$5, $10) monthly allowance for Over-The-Counter (OTC) medications.

ADDITIONAL SERVICES

Most plans offer dental coverage; my experience is that this coverage usually is wanting; of little value.

Most plans also offer hearing services that cover exams and hearing aids. The plans I have reviewed seem generally the same.

Vision plans for optometrists and opticians are OK if your area lacks a "2 pair for $69 with a free eye exam" outlet. The plans cover the optometrist's fee and the cost of one pair of glasses or contacts. If you want "designer" frames or frames not made in China, expect to pay more at all opticians.

While podiatrists are covered, acupuncture and "alternative medicine" are not.

A number of plans offer patient transportation to and from specific locations; sometimes the number of trips is limited. If you lack transportation to a doctor's office or hospital, this may be a benefit to consider.

ANNUAL CHECK-UP

Unless you are employed by a plan provider - e.g., AvMed, Humana - it pays to annually review your current Medicare Advantage plan with other plans. It helps to put everything on a spreadsheet to compare plans item-by-item, side-by-side. In the Benefits column, add your PCP and specialists and your medications so you'll remember to include them. Conveniently, all Advantage plans follow the same presentation format (different from 2014), Select one and list the benefits as they are presented to create the Benefits column.

You do the same thing with your health - you see your PCP at least once a year.

You probably do the same thing with your car and homeowner's insurance.

Plan benefits are "subject to change." (Case in point, AvMed dropped one of my medications from its 2015 drug list.)

NOTHING'S PERFECT

There will be surprises. The purpose of this rant is to help eliminate some of these surprises by knowing the questions to ask. If I never had Humana, I would never have known to ask about "capitation" or how to find out which PCPs referred to which specialists (I still don't have the answer to that). Capitation may not be an issue for you, but it's worthwhile to ask "Can any PCP refer me to any specialist listed on this plan's provider's list?" If the answer is "No," your next question is "How do I know which PCP refers to which specialists?"

You can change PCPs during the calendar year, but unless a plan is cancelled - and Medicare makes this difficult for the insurers - you are "stuck" with your plan until December 31. (You may do your homework and sign up for a new plan from October to Pearl Harbor Day for the coming year.)

MEDICARE IS A GREAT THING

Medicare is, in my opinion, a great - albeit not perfect - thing and if the politicians will stop chipping away at it, well worth the price.

Experience writes Medicare Lessons Learned

 

Funny thing about the Medicare "Select your plan" deadline: it falls every year on December 7th - Pearl Harbor Day, the day that then-president Franklin Delano Roosevelt said would "live in infamy." Infamy apparently is a very short time; ask a 20-something "What is the significance of December 7?" and all you'll get is a blank look.

I have had a Medicare Advantage plan for a number of years.

For most of the years I had AvMed. AvMed cancelled my Primary Care Physician (PCP) so I cancelled AvMed. Seemed fair at the time.

I did my homework and compared Medicare Advantage $0 cost plans - that's not exactly true, $0 cost, but that's what is claimed - side by side. Set up a spreadsheet and listed the categories in Column 1 and the vendors in the columns to the right.

At the time, and even today, Humana seems to offer the best economics with $0 co-pay for hospital stays. (There is at least one other plan that makes that offer.) Humana also could save me a little on my pricy prescription.

One of the selection criteria is the presence of my specialists on the plan list. If one or more of my specialists are absent, the plan is removed from consideration. If a person has no specialist relationships, this is a non-issue. I have such relationships.

Another selection criteria is in-patient hospital costs.

Humana, and at least one other plan, offers $0 co-pay from Day 1 to the end of the hospital stay. Many plans have a first days (typically Day 1 through 5) co-pay of more than $100/day to a bit less than $300/day.

Before I signed up with AvMed years ago I raised that issue with its sales person and was told that in most cases in-patient stays are 5 days or less - "no co-pay" days with AvMed. I think the sales guy probably was right; I have been an in-patient twice (open AAA repair and hernia repair) and paid $0 both times; the first time I was in the hospital 6 days (the discharge day doesn't count, so only 5 full in-patient days)). As it happened, the hospital billed me for two extra days and AvMed resolved that issue in my favor.

Still, having decided to "punish" AvMed for cancelling my PCP - a guy who I credit with saving my life - I compared other plans and settled on Humana.

WHAT I DID NOT KNOW ABOUT is a thing called "capitation".

Humana is about the only Advantage provider that utilizes capitation.

Translation: No matter if a practitioner is on a Humana plan's list of providers, you have access to that specialists only if the your PCP has that specialist on his or her personal referral list.

This came as an unpleasant surprise when I asked my first (of four) Humana PCPs for referrals to my specialists. The first told me to either use the specialist he used or to find a new PCP. He didn't explain that he choice of specialists was restricted by Humana. I never was sure if the restricted referral lists were the practitioner's choice or Humana's decision.

One PCP never addressed the issue; he simply made a referral to his (assigned?) specialist and ordered tests without consulting my specialist who wanted the tests.

My Humana plan lists 108 PCPs.

Bait and switch? False advertising?

To Be Fair On Page 4 of Humana's Provider Directory, under the heading Getting Care from Specialists it states: "Each PCP may have certain network specialists they use for referrals. This means that the specialists you can use may depend on which person you choose to be your PCP.

If there are specific specialists you want to use, find out whether your PCP refers patients to these specialists. You can change your PCP at any time if you want to see a network specialist that your current PCP does not refer to."

Not exactly "small print", but based on a survey of seven (7) Advantage providers one of only two that need the caveat.

I queried Humana's Customer Service on more than one occasion, asking it to identify PCPs who could/would refer me to the specialists I named. I was told to direct my issue to another Humana department.

The other Advantage provider who uses capitation said that it has PCPs that are not "capitated" and that the insurer will provide a list of non-capitated PCPs upon request.

A THIRD QUESTION to consider when selecting an Advantage plan: If the patient needs a service from a specialist who uses modern methods - e.g., laser-assisted cataract surgery - or special devices - e.g., multifocal intraocular lens (IOL) - will the plan pay the basic, Medicare-approved fee and allow the patient to pay any additional charges, assuming, of course, that the specialist agrees to the arrangement.

Humana allows the patient-paid extra costs; AvMed prohibits it. (If a specialist is willing to take the additional payments "under-the-table" will AvMed, if it discovers the transaction, penalize the patient and/or the practitioner?)

A QUICK FEW WORDS about so called "$0" Advantage plans.

The Medicare participant must continue to pay his/her Medicare fee, for most people, roughly $105/month. Additionally, Medicare Advantage providers - the AvMeds and Humanas, and many others, receive additional taxpayer dollars for each person they sign up. Now you know why there is so much competition for a geezer's signature on the dotted line. Certainly $0 additional out-of-pocket cost is a good thing, but it's not exactly true; still for a person watching "pennies," it is a consideration.

There are other concerns to consider, among them

• Dental coverage (typically of little true value)
  
• Drug costs and specific drugs' classification
  
• Geezer health club membership
  
• Hearing services coverage
  
• Skilled Nursing Care facilities (like hospital in-patient days needs to be checked)
  
• Transportation to/from and how often
  
• Vision services coverage

When I signed up for my Advantage plan I didn't know the questions to ask; hopefully the above will give you something to consider before signing on the bottom line.

Unhealthy insurance - Part 2 The saga continues Mishandled Rx is SOP* AvMed, Humana: Are you listening?

 

This entry unfortunately is a continuation of the Humana and its docs rant posted Wednesday, August 6, 2014. This time Humana Customer Service gets a gold star.

WEDNESDAY, JULY 30, 2014

On Wednesday, July 30 I gave the people at Leung Healthcare in Hollywood FL - I can't write "my PCP's office" since I now am relegated to seeing a physician's assistant (PA) and no, PAs are not RNs - a request, written in large letters, for four (4) prescriptions. Each was to be for a 90-day supply. To my Edward Bear mind, that was a pretty simple request.

Apparently the request was too complicated.

I need four (4) prescriptions.

* Send ZXY prescription via fax to RightSource.

* Hand me the remaining three (3) prescriptions and I will get them filled locally.

Only one (1) prescription was to be faxed to RightSource, Humana's contract mail order pharmacy. I spent many years as journalist and technical writer so I believe I know how to write clear and unambiguous English.

Three prescriptions were to be handed to me so I could take them to my local pharmacy (Publix) which dispenses two (2) of my meds gratis; no charge to me or to Humana.

RIGHTSOURCE HISTORY

RightSource has received the Rx for one of my meds three times.

The first time the order (from another practice) was filled promptly and correctly.

The second time my then PCP, proving he either can't count or won't listen, ordered 240 capsules. I take four capsules a day. By my math, that comes to 360 (30 capsules * 4-a-day = 120) * 90 days =360 capsules).

WEDNESDAY, AUGUST 6, 2014

On Wednesday, August 6, 2014, I called the practice and asked if my three (3) prescriptions were ready.

To paraphrase, I was told: "Well, gee, I can't find anything. Maybe they were sent to RightSource. Why don't you (the patient) call RightSource and check?"

I refused to call RightSource, telling the office person she should contact RightSource and get back to me before the end of the day. Today is Friday, August 15, 2014 and I still am waiting to hear from anyone at Leung Healthcare.

THURSDAY, AUGUST 7, 2014

Today, Thursday August 7, 2014, I received a package from RightSource.

And the snafu - that's accurate because this obviously IS the normal situation - continues.

Inside the package from RightSource were three (3) bottles of pills.

Two bottles contained a total of 180 pills which are taken one pill twice-a-day - a 90 day supply. (Yet, the bottle shows I have THREE (3) refills remaining.

The third bottle contained 90 pills of a one-a-day medication; a 90-day supply. This medication's prescription also was supposed to be handed to me. As with the earlier prescription, there are three (3) refills, so I'll be good for 120 days. According to Hozba.com there are less than 140 days until December 31; unfortunately that means one more trip to Leung Healthcare. Unless, of course, if there is another foul up not yet discovered- or I decide to skip 20 days between now and the end of the year.

The third "hand the patient the prescription" has yet to arrive.

The fourth prescription, the one that was supposed to be faxed to RightSource also was missing.

Did RightSource get the scripts? Will I get the remaining meds before running out in another few days.?

The first time RightSource sent a mail order it sent a 90 day supply - 3 containers, each with 30 days' worth of pills. (How did it happen that RightSource got it right? Different prescribing doctor; different practice.)

PAYING FOR LEUNG HEALTHCARE'S MISTAKE

Humana was charged $13 each for two prescriptions that I normally get for free - no cost to me or Humana - at Publix. While the $13 is not going to break Humana, the real issue , is that these charges get me very close to Humana's maximum annual allowance for prescription medications. (Humana's maximum is in line with other Medicare Advantage providers; the limit is not the issue - REACHING THE LIMIT is the issue.)

At the end of the day - the day being Thursday August 7, 2014, I am left wondering if tomorrow's mail will bring the rest of my meds and will the delivery contain a 90-day supply of two meds and, maybe, an 80 day supply of the medication for which I so far received only a 30 day supply.

TUESDAY, AUGUST 12, 2014

Letter to Dr. Gilbert Leung, the physician who owns Leung Healthcare, setting forth my problems with his Hollywood practice. I noted that I now am out of one critical medication (due to the pervious script's mishandling). I also related my communication with the office staff in trying to resolve the issue. This is my third (3rd) letter to Leung or his wife/administrator; none of which to date have received the courtesy of a reply.

THURSDAY, AUGUST 14, 2014

The third of he four medications arrive. As with the previous two (see Thursday, August 7, 2014, above), this 90-day supply shows "3 Refills before (date).

I still have heard nothing from Leung Healthcare - neither it's Hollywood office nor its owner or his wife; this cavalier attitude is most "off-putting."

How did "cavalier" morph from "horse soldier" to "don't care attitude?" (See bottom for Merriam-Webster's definitions.)

FRIDAY, AUGUST 15, 2014

HUMANA, in a response to a web-mail message I earlier sent, informs me that "RightSource does not have an active prescription for (medication) on file." RightSource got scripts for everything BUT the most critical medication, the one medication I told the people in the Leung Healthcare office to fax to RightSource.

Humana gets a gold star for tracking down what Leung Healthcare SHOULD have done two weeks previously.

Are all medical offices so badly run?

Last year I was with AvMed and I had an excellent PCP by the name of Edwardo (Eddy) Perez-Stable, a/k/a Dr. P-S. Unfortunately, the office staff almost never anything it right. (My wife still sees Dr. P-S - different insurance - and reports that the office still manages to mess up simple tasks.)

AvMed, in its questionable wisdom, dropped Dr. P-S' practice and, in a fit of pique, I dropped AvMed and signed on with Humana.

On first blush, I thought the practice where I reluctantly now go had a first rate office staff. A façade; this group is no better - and possibly worse - than the staff that is supposed to support Dr. P-S. (AvMed also lists Leung Healthcare.)

 

Rx = Prescription, script (Yes, the graphic is deliberately upside down.)

SOP = Standard Operating Procedure

CAVALIER According to Merriam-Webster's online dictionary, "cavalier" as a noun means " a gentleman trained in arms and horsemanship" and dates back to at least 1589. "Cavalier" as an adjective id defined as "marked by or given to offhand and often disdainful dismissal of important matters"; this dates to at least 1641.

Wikipedia gives an interesting background on how the word was associated to Merriam-Webster's adjective definition.

Opuscula 1 + 1 + 1 = 0

 

In search of a decent medical practice

 

I'm beginning to think finding a decent Medicare Advantage plan with decent practitioners AND office staff is an impossibility.

For a number of years I had what I considered a good general practitioner, a/k/a PCP. The doctor was great and I credit him with saving my life (by correctly diagnosing a 7-cm abdominal aortic aneurysm or "Triple A" and quickly getting me into the hands of a surgeon to fix the problem).

Unfortunately, his office staff is clueless; a total disaster. Complaints, even repeated complaints, fall on deaf ears.
Despite the office staff's absolute incompetency my Spouse, on a different insurance plan, won’t abandon the doctor.

In any event, AvMed, for many years my Medicare Advantage provider, cancelled the practice. In talking with other practices, the opinion is that AvMed was "bleeding money" in my county and had to cancel practitioners who were failing to contribute as much to AvMed's ROI as it desired/required. Part of the blame might be laid to AvMed's allowing patients to self-refer to specialists. The was a two edged sword for the patient: On one edge, the patient could see an AvMed-listed specialist without waiting for authorization. The other edge is that the PCP and the specialist might never connect, and that is to the patient's disadvantage.

AvMed has since eliminated self-referrals and now is in line with most other Medicare Advantage HMO plans.

For whatever reason, AvMed cancelled my PCP. (It previously cancelled my long-time ophthalmologist. He was "reinstated" the following year.

AvMed's cavalier cancellations tend to prevent any long-term patient/doctor relationship, and even AvMed admits that relationship is critical for it's client's well-being.

 

Good bye AvMed, hello Humana

In a fit of pique, I went looking for a Medicare Advantage provider to replace AvMed. I looked at several and settled for Humana

Once I settled on Humana I went in search of a new PCP.

I found one who seemed agreeable and seemed to have a decent office staff; I notified Humana that when the 2014 calendar year rolled around, this gentleman would be my PCP.

January arrives and I visit the new PCP. During the course of the appointment I ask for referrals to my AAA surgeon (annual follow-up) and to my ophthalmologist. Both specialists are on Humana's provider list so there should be no problem.

But there was a problem.

The new PCP told me I had a choice: I could go to the ophthalmologist he preferred or I could find a new PCP.

No contest. I looked for a new PCP.

I was told that the reason the first Humana PCP would refer me only to someone on his personal list was due to "capitation." "Capitation" somehow relates to the PCP's bottom line. The truth of that is beyond my ken.

So I went searching for a new PCP - again.

 

New PCP Number 2

I checked out several and settled on one with what seemed to be a knowledgeable office staff. I thought this was a multi-physician practice; I was disabused of that idea today when I was told the person I thought was an MD/DO was actually a PA, albeit, the office staff told me, a "really good PA."

I made an appointment to see the MD and he seemed "OK"; off-shore degree, but conservative in his approach to medicine. So-so sign (off-shore degree) with positive sign (conservative approach).

My follow-up visit was pushed back two weeks - no reason given.

Meanwhile, I visited the local medical lab for blood work. The triglyceride results were off the charts.

I get a call from someone at the practice - not the doctor - who tells me to double a certain medicine. No one asked me for my history or if an anomaly occurred. Since I have had this test performed four times a year for many years, I knew the off-the-charts results were a fluke.

 

Strike 1

When I finally got to see the doctor, I tried to tell him that the lab results were not accurate and that I would like to retake the test. He arrogantly informed me that HE would decide if I could retake the test. The patient be damned. Even my surgeons are not that arrogant! It turned out his concern was not for my results but for an impact on Humana's and the practice's bottom line.

I did walk out with scripts for my four meds.

 

Strikes 2 and 3

Unfortunately, despite telling him I take two tablets-a-day of one med and four capsules-a-day of another, his prescriptions called for one tablet-a-day and two capsules-a-day.

I discovered this situation the other day when I started running low on the two-a-day pills. My first thought was that Publix, where I get most of my meds, shorted me. Then I looked at the script and saw that my now "previous PCP #2" ordered 30 pills for 30 days. Publix was fine; the now former PCP was not.

The the four-a-day meds arrived (they come from a mail order pharmacy). I received two (2) bottles of 120 capsules/bottle (and was charged for three bottles). If you do the math. 120 capsules divided by 4 (capsules-a-day), you have 30 days' worth of medicine. The delivery of 240 capsules would last 120 days (four 30-day months) on a two-a-day consumption.

I take my health seriously, but doctors and office staffs have put it in jeopardy for too long.

I hope the PA that works with a good office staff and who can refer me to my specialists "prn" (as needed) will work out. If not, I will be interviewing PCP candidates again.

Just for the record, both of my former Humana-listed PCPs also are listed with AvMed.

Time will tell.

NOT ERM-BC-COOP Black Holes

I loathe the telephone.

I particularly dislike the telephone when I have to talk to a customer service representative (CSR) about an issue - not necessarily a problem but any issue.

For much of my "professional" life I was a writer: newspaper reporter and technical writer; even when I lacked "writer" in my job title, written communication still was a major component of the job. I am accustomed to setting things forth "by the numbers."

Add that to the fact that contacting a CSR by phone often - usually - means tying up the phone for more than a few minutes listening to music-I-don't-like-on-hold until a CSR finally answers the call. Never mind that I think about the menus I'm forced to navigate or the really aggravating "Press 1 for English." I'm calling from the U.S. to - supposedly - a call center in the U.S.

1. This is the situation.
2. This is what I want to do/have done.
3. This is how I would like you (my correspondent) to respond.

I try to deal with the CSRs via email - either from my own email service or via the CSR's "communicate via the Web form" function.

Usually this proves highly satisfactory.

But lately . . .

I repeatedly sent emails to two organizations and repeatedly failed to get a response.

Humana (Medicare)

I'm new with Humana Medicare. My previous Medicare provider, AvMed, delisted my Primary Care Physician (PCP) forcing me to find a new PCP. I decided to also find a new Medicare provider. (Apparently my AvMed PCP's practice failed to make its required Return on Investment - ROI - to satisfy AvMed so his practice was delisted. Great doctor but an office staff that was sorely lacking.)

When AvMed was my provider, I could, and did, communicate via Web mail; I would send a message via AvMed's Web site and get a response to the site (requiring me to log on to AvMed to access the mail; inconvenient, but "secure").

I naturally - and foolishly - assumed that I would have the same reasonably efficient communications with Humana, my Medicare provider du jour.

I wrote and waited.

I wrote again and waited.

I wrote a third time and noted that if Humana failed to respond this time I was taking the non-responsiveness issue to Medicare.

FINALLY I received an email telling me that Humana answered my query and that I should log on to my Humana account to read the response. I logged on and - no response. I wandered all over Humana's Web site to no avail.

Defeated, I called Humana's call center. A nice sounding CSR heard my complaint - WHERE'S THE EMAIL? - and told me she couldn't help me but she would transfer me to Humana IT. After about 15 minutes of ring-no answer and commercials for Humana I gave up.

I went back and logged on again to Humana's Web site, tried multiple options and finally the elusive response email appeared. "Sorry we didn't answer before; we were busy." In the end my question - asked at least 3 times - was satisfactorily answered.

Painful.

netTalk

Still, Humana's much delayed response was better than netTalk's.

NetTalk is an Internet telephone provider, a VoIP (Voice over Internet Protocol) service.

Based on netTalk's Web site, the service meets all my requirements. I did some additional checking and found that netTalk's customer service was less that five star.

I sent netTalk an email with two questions.

No response.

I resent the email.

No response.

Finally I sent a third and final email to netTalk: "Since you can't respond to a person who wants to buy your product, I don't want to think how you treat people already signed up for your VoIP service."

NetTalk's VoIP service MAY very well be an excellent product; certainly the price was right, but if a potential customer cannot get two simple questions answered, I would be foolish to sign up.

I'm "stuck" with Humana for a year; hopefully our two-way communication will improve, otherwise, despite some financial benefits offered by Humana will be sacrificed for better customer service.

As for netTalk, it lost a customer even before it had the customer's business.

The price was right and it sounded like a perfect product, but lack of customer service was the show stopper.

ERM-BC-COOP: AvMed letter raises Customer ire and BP

I have been an AvMed Medicare Advantage customer for several years. Over all, it has been a satisfactory relationship - at least for me.

But this year, 2013, AvMed's communications with its clients has left more than a little to be desired.

For example AvMed sent me two documents in one envelop.

The outer document told me my plan was cancelled.

The inner document solicited my continued patronage with a new plan.

It seems AvMed cancelled one plan and substituted another.

One letter stating "Your plan [Plan ID] has been replaced with [Plan ID]. The only differences between the plans are listed below: " would have sufficed AND avoided confusion.

Remember. This is a Medicare plan, and that means a plan for geezers who (a) know how to read and (b) usually don't make assumptions.

The previous two-letter package pales in comparison to the letter I received yesterday in which I was informed that "Your enrollment in has been cancelled. This means you don't have coverage from AvMed Medicare."

The only date in the missive was the date the letter was printed.

Since AvMed delisted by Primary Care Physician (PCP), I looked at plans that listed my PCP. None of the plans favorably compared to AvMed. But since I already was looking at other vendors' plans, I decided to look at plans that omit my PCP from their list of providers.

I found such a plan and, surprise, it was better economically for me. AvMed was good, but Humana had a more wallet-friendly plan.

By the way, there is no such thing as a "$0 premium" plan. Medicare charges a Part B premium of about $104/month (sometimes less, sometimes more, depending on income). An advertised "$0 premium" plan means there is no additional premium paid to the vendor. On top of the $104 (plus or minus) from Medicare, the U.S. government kicks in much more, which is why there are so many vendors vying for a geezer's business.

OK, I know that on December 31, 2013 AvMed and I will part company, but to get a letter that states that I "don't have coverage" - and given the wording it has to mean I don't have coverage as of the letter's date - causes panic; the blood pressure soars and my normally calm disposition is rattled.

I call AvMed's Customer (dis)Service number and a Sweet Young Thing answers. I give her my name, rank, and serial number and finally she allows me to tell her why I am calling. She pulls up my file and assures me that I am covered through 12/31/13.

So what, young lady is your name if I need to refer back . . .

She gives me her first name and, when pressed, the last initial of her last name.

Not satisfactory. I can anticipate the response if I call back and say that "Miss [CS person's first name and last initial] told me … " I'll likely hear either (a) "We don't have anyone by that name, or (b) "We have a number of people with that name and it's impossible to know which one spoke with you."

I demanded to speak to a supervisor and was told all of her supervisors were busy. (How many supervisors does one person need?) She said she'd send an email to a specific supervisor and that person would get back to me.

A day later the supervisor did call - and explained that AvMed has a 24-hour window to return calls, something the first person failed to mention.

By now I'm thinking like a Risk management practitioner.

How can I give callers a CS person's ID without compromising their privacy?

Bingo: Employee ID. John110 or Judy10.

AvMed, the supervisor tells me, instructs its CS people to give their telephone extension. That may work IF the called notes the day/date and time of the call; I'm reasonably certain the extension is shared during the call-in hours.

Since AvMed and I are quits on the last day of the year, I suppose I shouldn't let this bother me, but it does.

AvMed generally is a good company, but of late it has had a serious problem with communication. I sent letters to two company executives, noting that I do not want a response - I think I've had enough blood pressure-boosting letters to last for awhile.