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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Comments on Check the facts

Unhealthy insurance Humana and its docs Raise my blood pressure

 

I'm frustrated and my blood pressure, already high, is going to stratospheric levels.

Why?

Glad you asked.

I am a geezer on Medicare. My Medicare Advantage provider is, until December 31, 2014, Humana, specifically Humana Gold Plus (HMO).

My PCP is Leung Healthcare, a multi-office practice in Florida's Broward and Dade counties.

I signed up with Leung after my first Humana PCP refused to refer me to my long-time ophthalmologist who is a Humana practitioner. That boggled my mind - a Humana PCP refusing a referral to a Humana specialist.

IN ANY EVENT, last week I visited my PCP's office. I gave the office folks two pieces of paper.

One piece was a form from RightSource, the mail order pharmacy that contracts with Humana. The instruction was very clear - order ONE 30-day supply with two refills (total 90 day supply) of a specific medication. RightSource normally sends all 3 months in one package.

The other piece of paper instructed, in 14 point text that I needed three (3) separate, individual prescriptions for three additional medications. Each script (prescription) was to be for a 30-day supply plus two (2) refills for a total of a 90 day supply. I take the three meds I wanted prescribed on separate prescription blanks to local pharmacies; two of my medications are free from Publix, a local high end supermarket.

OK.

Leung's sole doctor - the nearby office is advertised as a two-physician practice, but this has not been true since early 2014 - has twice managed to mess up my meds. For that and other reasons I now avoid the practitioner and see a "certified" physician's assistant. In Florida, a physician's assistant is not required to be a registered nurse (RN). It's bad enough when a patient is seen by an Advanced Practice Registered Nurse (APRN) although, if truth be told, I've known some RNs who were better diagnosticians than the doctors for whom they worked. Still, a "PA" is a long way from an RN and even farther from an APRN. I wonder if Human is billed for a physician's visit.

About 5 days pass and the patient - this scrivener - calls the office to check if (a) the one script was faxed to RightSource and (b) if the three (3) scripts I will fill locally are ready to be picked up. (Never mind that the office should have called me.)

Because my meds previously were mishandled, the scripts no longer are in synch so I get the prescriptions filled when needed. (Insurance carriers make sure I do not get any meds ahead of time; no objection to that.)

When I asked about the three scripts that I specifically requested be written (again, 14 point text) I was told "I think they were ordered through RightSource."

I was told that I could call RightSource and check. I declined and asked that the practice office contact RightSource to find out where are my prescriptions. I didn’t send them to RightSource; I don't know who to contact at RightSource. Bottom Line: Not my job.

I TRIED to share this with Humana.

After all, Leung is a Humana practice and having the prescriptions filled by RightSource costs Humana more than having the prescriptions filled at Publix.

I can contact Humana several ways - via "social media" or through an on-line form. I don't have - nor want - Facebook or Twitter or similar "social media" accounts so that is out. I have managed to contact Humana several times via the on-line form, but not this time.

I tried with Chrome. I tried with Explorer. Neither could open the form. There was zero indication that Humana's system was sick and that I should try again in "n" minutes/hours/days. Click on Compose Message and nothing happens.

The end of the calendar year nears and I'm already looking for a new PCP and possibly a different Medicare Advantage carrier. So far I've found four (4) prospective Advantage providers - Aetna, AvMed, Cigna, and Humana. (The criteria is listing my vascular surgeon; if Jeffrey Hertz is absent from a provider's list, I move on.)

I have experience with AvMed; it was mostly positive and, had it not cancelled my former PCP's contract, I'd still be with AvMed. (To be fair, my former PCP's office staff never seemed to get anything night the first time; sometimes not the second or third time, either.) If I had a problem, I knew who - and how - to contact at AvMed; not so with Humana. I have zero experience with Aetna or Cigna.

I have reason to believe that Humana has a robot that scans blogs and "social media" for certain words - "Humana" being the primary word - so perhaps - perhaps - this rant will get someone's attention at Humana.

I know I can change my PCP at the first of any month, but since I anticipate visiting my current PCP's office only once more before year's end, I can (hopefully) "live with" Leung Healthcare's certified physician's assistant (in lieu of the second physician advertised for the local office).

One thing about Medicare: it's an education. I've learned there are many questions to ask both the Advantage provider and the prospective PCP. Although a patient can change PCPs every month (not advisable), the geezer is "stuck" with the Advantage provider (e.g., Aetna, AvMed, Cigna, Humana) from January to December.

MEANWHILE, if anyone has experience with Aetna or Cigna Medicare Advantage programs, please contact me via email: JohnGlennMBCI at gmail dot com.