How Medicare Advantage HMO's Limit Senior's Options
Today a friend of mine got a rude awakening about her father's medicare HMO advantage plan. She is the healthcare proxy and oversees all things medical. She hasn't had any problems until today when she was trying to get her father in to see the leading surgeon for a very specific rare surgery in Boston. Her father was suffering from compromised breathing problem of unknown etiology. Three doctors in the HMO network said it was nothing and would resolve with inhalers. My friend's sister working at another Boston hospital took the CT Scan and showed it to colleague who showed it to the specialist. Both immediately saw the cause and recommended surgery. There should be a big sigh of relief right now but the surgeon is out of network. The policy with Medicare Advantage HMO is no out of network. However, after my friend called the insurance company, she was told that if the PCP advocated for the second opinion and/or surgery, it would be approved. Another sigh of relief except when she called the primary's referral designee, she was told it was not possible and she should stay in network. In a panic, she called me and asked what her options were. This is what I told her.
1. Medicare law allows for a second opinion.
2. The reason the PCP office was not being supportive was by sending anyone out of network, they lose money from the insurer.
3. It is not the decision of the provider but yours. You can firmly continuing to insist on a referral.
4. Call the insurance company for further clarity. Take the name of the person you speak with and write down the answers. If you do not get a good explanation ask to speak with a supervisor. Always take the name and write down the answers.
5. Get a list from the insurance of alternative surgeons. Call these offices and ask how many of these specific surgeries have they preformed. This is way to show the insurance company why a specific surgeon is needed because of experience and training.
My friend did as I suggested by first calling the PCP and the referral person who continued to feel it was not going to be approved. She called the insurance company and ended up speaking with the supervisor. She was told to speak directly to the PCP and request he/she advocate for the referral. She verified the reason PCP's don't jump at the chance to be advocates is because they lose money with any out of network visit.
She is headed in the right direction but it took several hours on the phone and much anxiety. There is hope for her father. She was most concerned that three physicians from three specialties had misdiagnosed her father and didn't want to stay in network. Are seniors at risk from the rigidity of medicare advantage plans? Was "live with it" the prescription because of possible out of network loss? I believe seniors also deserve the very best care if available. I understand cost containment is important but denying a person the proper care for financial gain is not good medicine.
Posted by HealthCare Whisperer at 4/29/2010 2:13 PM 
Categories: senior, medicare advantage, HMO
Tags: senior medicare advantage PCP insurance HMO
Categories: senior, medicare advantage, HMO
Tags: senior medicare advantage PCP insurance HMO
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