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Old 02-22-2016, 07:03 AM
 
Location: louisville
4,754 posts, read 2,014,098 times
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Quote:
Originally Posted by mathjak107 View Post
advantage plans are no different then any hmo's you might have used while not of medicare age .

they have all the red tape , review process and denials you have with any private insurer .

you have an an internet full of horror story's dealing with many advantage plans despite the fact they are supposed to cover what medicare does
Actually, they don't. They usually cover more, but there is also the contract aspect. It was part of the move to MA PFFS in 05 with a 3 years to build a national network and transition to HMO/PPO.

However, you are correct in regards to 'not being different' to any HMO/PPO. Contract takes precedence. Now, most providers do contract to medicare reimbursement which includes billing practices, fee scheduls, OPPS, IPPS, SNF, CMG, Rehab, LTC, MS-DRG Groupings, etc..., etc... etc... and an MA's population, or 'penetration, determines whether the rates are favorable to provider, or payor. They are almost never lower than 100% of Medicare but there are some instances... there is always an outlier.
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Old 02-22-2016, 07:10 AM
 
Location: louisville
4,754 posts, read 2,014,098 times
Reputation: 1713
Quote:
Originally Posted by Robyn55 View Post
Conversely - someone who is "on the inside" can miss how things actually operate in real life (I'm a retired lawyer who did a lot of insurance coverage litigation and my courtroom experiences have little to do with what has happened to me in real life when it comes to various insurance claims).

It's impossible to say how things work in all parts of the country - or even to generalize about things statewide in a state as large as Florida (both in terms of geography and population) - but the general trend here is for the better providers to drop patients who have less than good/great coverage. Whether you're talking about people who are uninsured - people on Medicaid - people on Medicare Advantage plans - or people with stingy pre-Medicare coverage.

And volume isn't enough to make a provider here accept a group of patients if the providers can't make money on them (you can't lose money on every patient and make it up in volume). The operative theory is along the lines of what an old lawyer once told me about accepting new cases. That he might be busy or he might be poor but he wasn't going to be both at the same time. Which is why - for example - our largest GI group here has severed its relationship with Florida Blue (largest insurer in the state IIRC):

Not True Blue

http://www.bizjournals.com/jacksonvi...ross-over.html

It is also why providers - especially primary care providers (whose reimbursement levels are pretty poor) - are increasingly refusing to see any Medicare patients (regardless of any insurance they have) and/or going to cash only/concierge practices.

OTOH - volume can be important when it comes to making the best use of things like expensive testing equipment. Like an MRI machine. If you have a machine that's in use from dawn until after dark - filling appointment spaces that would otherwise go empty - like filling empty airline seats or empty tee times - can be very efficient/profitable - even if the people filling those empty appointment spaces are paying less than the "going rate" (as long as the total income generated is more than than cost of operating/staffing the equipment).

BTW - since our main provider - the Mayo Clinic here in JAX - doesn't "accept Medicare" for Part B services - the check writing function is pretty important to us (because we have to pay the Mayo bills ourselves - and we - not Mayo - get the Medicare/Medigap checks). Both Medicare and UHC are excellent when it comes to paying us promptly - usually before we even get a bill from Mayo. Robyn
No disagreement at all on Providers not seeing new Medicare members, in some cases.

I 'left' the industry and work on the contract aspect... the last 3 were actually teaching and documenting the Fed Reg for legal teams for entities inside healthcare. That is ironic.

The point is not lost on 'not seeing the forest through the trees' in real life application of 'inside knowledge'. Being very intimate with the Florida Markets (Tampa/St. Pete, Miami/Dade, Jax, and Orlando), in my 'spare time', my parents would refer their friends to me to see if they should stay on Trad medicare, if so which gaps and/or part D, or look at the all inclusive MA Plan. There are some easy questions to ask people but, for an individual, it basically boils down to Out of Pocket Expense, yearly, how much Hospitalization and/or SNF has been used since Traditional Medicare does cap those days, and from a 'finance' standpoint: does one want to pay on the front end, or the back end.
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Old 02-22-2016, 12:25 PM
 
Location: Wisconsin
21,541 posts, read 44,039,638 times
Reputation: 15150
Quote:
Originally Posted by Stymie13 View Post
You have apparently never read the MA Payment guide. Actually, no, I'll leave it at that.
Huh?????

Last edited by Ariadne22; 02-22-2016 at 12:44 PM..
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Old 02-22-2016, 12:31 PM
 
Location: louisville
4,754 posts, read 2,014,098 times
Reputation: 1713
Quote:
Originally Posted by Ariadne22 View Post
Huh?????
It was in response to the 'obstruct' comment about MA plan 'not paying'... the MA Payment Guide is a publication CMMS puts out that Payors, those that offer MA plans, have to follow (in addition to submitting the plan to each state it operates in DOI before the plan can be offered to the public. That includes what is covered, premiums, etc..., etc... so, in short, each state approves all plans, commercial, group, individual, MA, before it's offered to the public. MA Payment guide is on CMMS.gov. It's public domain. One doesn't need access for it... same with fee schedules, rates, what's covered, whats not, so on and such forth).
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Old 02-22-2016, 12:46 PM
 
Location: Wisconsin
21,541 posts, read 44,039,638 times
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Quote:
Originally Posted by Stymie13 View Post
It was in response to the 'obstruct' comment about MA plan 'not paying'... the MA Payment Guide is a publication CMMS puts out that Payors, those that offer MA plans, have to follow (in addition to submitting the plan to each state it operates in DOI before the plan can be offered to the public. That includes what is covered, premiums, etc..., etc... so, in short, each state approves all plans, commercial, group, individual, MA, before it's offered to the public. MA Payment guide is on CMMS.gov. It's public domain. One doesn't need access for it... same with fee schedules, rates, what's covered, whats not, so on and such forth).
OK - you apparently missed my edit, so here it is:

Minn. attorney general asks feds to investigate Humana | Minnesota Public Radio News

The foregoing is NOT atypical in the Medicare Advantage world. 2sleepy cited upthread problems w/claims getting paid through Humana. I had the same thing with UHC - and I am a very healthy person who doctors rarely.

Are you saying the MA bottom line doesn't matter? It sure does - and there are bad actor insurers who set up UNBELIEVEABLE hassles and roadblocks to avoid payment. Consider yourself fortunate if you've not been a victim.

Based on my experience and that of far too many others on this board and all over the internet, it is all about performance. Rules/regs don't mean a thing if patient/customer/provider has to FIGHT to get the insurer to perform as it should.
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Old 02-22-2016, 01:29 PM
 
Location: louisville
4,754 posts, read 2,014,098 times
Reputation: 1713
Quote:
Originally Posted by Ariadne22 View Post
OK - you apparently missed my edit, so here it is:

Minn. attorney general asks feds to investigate Humana | Minnesota Public Radio News

The foregoing is NOT atypical in the Medicare Advantage world. 2sleepy cited upthread problems w/claims getting paid through Humana. I had the same thing with UHC - and I am a very healthy person who doctors rarely.

Are you saying the MA bottom line doesn't matter? It sure does - and there are bad actor insurers who set up UNBELIEVEABLE hassles and roadblocks to avoid payment. Consider yourself fortunate if you've not been a victim.

Based on my experience and that of far too many others on this board and all over the internet, it is all about performance. Rules/regs don't mean a thing if patient/customer/provider has to FIGHT to get the insurer to perform as it should.
What I am saying is things like that occur quite frequently, get reported, and then the 'why' is never explained by the media. I could write pages upon the why, but specifically, not being part of that investigation, nor resolving those specific issues, it's just another article.

Besides, Humana's MN member population is miniscule so that is suprising something like that would come from Minnesota vs. Wisconsin, or Illinois, or AZ, or TX, FL, GA, LA, KY.... states where they have huge populations.
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Old 02-22-2016, 01:38 PM
 
Location: louisville
4,754 posts, read 2,014,098 times
Reputation: 1713
Quote:
Originally Posted by Ariadne22 View Post
OK - you apparently missed my edit, so here it is:

Minn. attorney general asks feds to investigate Humana | Minnesota Public Radio News

The foregoing is NOT atypical in the Medicare Advantage world. 2sleepy cited upthread problems w/claims getting paid through Humana. I had the same thing with UHC - and I am a very healthy person who doctors rarely.

Are you saying the MA bottom line doesn't matter? It sure does - and there are bad actor insurers who set up UNBELIEVEABLE hassles and roadblocks to avoid payment. Consider yourself fortunate if you've not been a victim.

Based on my experience and that of far too many others on this board and all over the internet, it is all about performance. Rules/regs don't mean a thing if patient/customer/provider has to FIGHT to get the insurer to perform as it should.
Being one who spent years fixing issues like that, it will be interesting to see what they find. However, I can flat out, 100% say this: if it were 'system' wide, knowing what I know, it wouldn't be specific to 1 hospital or system or something as small as 25 members. But, how I know that will require pages of technical explanations like provider selection logic, member selection logic, which clearinghouses were utilized, how the provider is contract,how the provider is loaded, what specifically were the services (inpatient, outpatient, IPPS, OPPS, SNF, HH) , how were the EOB/EOR's sent, was the G&A process even followed by the right team (I'm not saying that payors that employ 30,000 people don't have system/process issues... thats what I spent double digit years fixing), etc..., etc...etc...

The article was vague, which is to be expected due to Privacy, but as a person who has worked for multiple payors, some in MN, Big Fork System is not one I'm familiar with. But, most Hospital Systems operate under similarities. Unfortunately articles only cloud the issue vs. provide clarity. For example, if Big Fork had this going to their MAC Contractor (traditional medicare), the denials could still occur. At the end of the year, the MACS run an algorithm called 'settlement' that reruns all claims and balances paid amount vs. rate changes, etc... throughout the year. So, there isn't claim by claim contestation (although, MAC's first pass accuracy on claims is much lower than commercial payors, much of it because claims contestation).
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Old 02-22-2016, 02:11 PM
 
Location: Ponte Vedra Beach FL
14,628 posts, read 17,938,980 times
Reputation: 6716
Quote:
Originally Posted by Stymie13 View Post
No disagreement at all on Providers not seeing new Medicare members, in some cases.

I 'left' the industry and work on the contract aspect... the last 3 were actually teaching and documenting the Fed Reg for legal teams for entities inside healthcare. That is ironic.

The point is not lost on 'not seeing the forest through the trees' in real life application of 'inside knowledge'. Being very intimate with the Florida Markets (Tampa/St. Pete, Miami/Dade, Jax, and Orlando), in my 'spare time', my parents would refer their friends to me to see if they should stay on Trad medicare, if so which gaps and/or part D, or look at the all inclusive MA Plan. There are some easy questions to ask people but, for an individual, it basically boils down to Out of Pocket Expense, yearly, how much Hospitalization and/or SNF has been used since Traditional Medicare does cap those days, and from a 'finance' standpoint: does one want to pay on the front end, or the back end.
The network is also very important. Perhaps more important. FWIW - if you have family friends up here in the JAX metro area - we have an excellent agent here (doesn't cost more to use a good agent - and I encourage people to do so). Not only has he been in the business for a long time - he and his wife are on Medicare - and have friends on Medicare too. So he's very familiar with what's going on in terms of provider networks and the like. Also what is happening with traditional Medicare plans. Our agent works with individuals and groups all over the state - but I don't know if his knowledge about what's going on in other areas of the state is as good as his knowledge here (might well be - professionals in Florida like to gossip ). DM me for name/etc. if you'd like.

One thing I like about our agent is he makes "house calls". He also has the patience of Job - which he needed to convince my 97 year father to change his very old non-standardized Medigap policy to Plan F. Because he needs the "excess Medicare reimbursement" Plan F provides at Mayo.

Note that some people have to be more careful than others when it comes to networks. Especially if they need specialists in lower paid specialties like rheumatology. They can be hard to come by - no matter what kind of insurance you have.

On my part - if someone is dealing with a limited network (or thinking of doing so) - or simply picking a new provider - I always encourage them to stop by offices/facilities to check them out. What part of town are they in - what do they look like? Are the waiting rooms jammed to overflowing - or empty (both often bad signs). Do the places look state of the art - or run down? Also - when it comes to a new PCP - interview the doctor. This doctor will normally be the portal to your medical world - often for a long time - and it's important to "be on the same page" - get along. An important issue in Florida is whether a provider speaks English as a first language - or is fluent in English as a second language. Many here don't/aren't.

When it comes to Part D (or similar in a MA plan) - it's a no-brainer IMO because of the sign-up penalties that accrue if you don't sign up when you turn 65. Robyn
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Old 02-22-2016, 02:21 PM
 
Location: louisville
4,754 posts, read 2,014,098 times
Reputation: 1713
Quote:
Originally Posted by Robyn55 View Post
The network is also very important. Perhaps more important. FWIW - if you have family friends up here in the JAX metro area - we have an excellent agent here (doesn't cost more to use a good agent - and I encourage people to do so). Not only has he been in the business for a long time - he and his wife are on Medicare - and have friends on Medicare too. So he's very familiar with what's going on in terms of provider networks and the like. Also what is happening with traditional Medicare plans. Our agent works with individuals and groups all over the state - but I don't know if his knowledge about what's going on in other areas of the state is as good as his knowledge here (might well be - professionals in Florida like to gossip ). DM me for name/etc. if you'd like.

One thing I like about our agent is he makes "house calls". He also has the patience of Job - which he needed to convince my 97 year father to change his very old non-standardized Medigap policy to Plan F. Because he needs the "excess Medicare reimbursement" Plan F provides at Mayo.

Note that some people have to be more careful than others when it comes to networks. Especially if they need specialists in lower paid specialties like rheumatology. They can be hard to come by - no matter what kind of insurance you have.

On my part - if someone is dealing with a limited network (or thinking of doing so) - or simply picking a new provider - I always encourage them to stop by offices/facilities to check them out. What part of town are they in - what do they look like? Are the waiting rooms jammed to overflowing - or empty (both often bad signs). Do the places look state of the art - or run down? Also - when it comes to a new PCP - interview the doctor. This doctor will normally be the portal to your medical world - often for a long time - and it's important to "be on the same page" - get along. An important issue in Florida is whether a provider speaks English as a first language - or is fluent in English as a second language. Many here don't/aren't.

When it comes to Part D (or similar in a MA plan) - it's a no-brainer IMO because of the sign-up penalties that accrue if you don't sign up when you turn 65. Robyn
Some of the best consumer advice I've heard. And that is probably why your agent has been successful: for all the wonders of technology, personal touch still seals the deal, at least for everyone that grew up having to actually talk to people vs. being attached to their phone/twitter/facebook/instagram account.
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Old 02-22-2016, 03:04 PM
 
Location: Chesapeake Bay
6,048 posts, read 3,874,457 times
Reputation: 3502
Quote:
Originally Posted by Stymie13 View Post
Being one who spent years fixing issues like that, it will be interesting to see what they find. However, I can flat out, 100% say this: if it were 'system' wide, knowing what I know, it wouldn't be specific to 1 hospital or system or something as small as 25 members. But, how I know that will require pages of technical explanations like provider selection logic, member selection logic, which clearinghouses were utilized, how the provider is contract,how the provider is loaded, what specifically were the services (inpatient, outpatient, IPPS, OPPS, SNF, HH) , how were the EOB/EOR's sent, was the G&A process even followed by the right team (I'm not saying that payors that employ 30,000 people don't have system/process issues... thats what I spent double digit years fixing), etc..., etc...etc...

The article was vague, which is to be expected due to Privacy, but as a person who has worked for multiple payors, some in MN, Big Fork System is not one I'm familiar with. But, most Hospital Systems operate under similarities. Unfortunately articles only cloud the issue vs. provide clarity. For example, if Big Fork had this going to their MAC Contractor (traditional medicare), the denials could still occur. At the end of the year, the MACS run an algorithm called 'settlement' that reruns all claims and balances paid amount vs. rate changes, etc... throughout the year. So, there isn't claim by claim contestation (although, MAC's first pass accuracy on claims is much lower than commercial payors, much of it because claims contestation).
Thats all well and good. I guess.

However, if a person has done the research and decided that the MA plans are best for them, the next step is choosing the proper plan that best fits their needs. And that means skipping United Healthcare and any MA plans that they offer. Without exception.
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