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Thread: Medicare Advantage Plans

  1. #1
    Senior Member
    Join Date
    May 2006
    Somewhere in the Rocky Mountains

    Medicare Advantage Plans

    I had the pleasure of having to watch a webinar at work today. It was all about the different Medicare Advantage Plans/PPO's and how to bill them and ensure that our hospital is getting paid.

    Some of the stuff the presenter said hit a nerve and I thought I would share it here.

    We all thought Medicare was doing us a favor by allowing private fee for service insurance companies offer better coverage including pharmacy for the same price as Medicare. Well these plans are "temporary" in the words of the presenter. They are a way to get us away from the government paying our medical bills and shift all insurance to the private sector. As it stands right now, any facility that recieves federal funding CANNOT turn down a Medicare or Medicaid patient based on whether the patient can pay. It is against the law. In other words, if you recieve any government funding then you can not turn down Medicare Medicaid patients. But in the next couple of years (now remember I am watching this as an employee of the hospital), the hospitals will have the option of either accepting these Advantage plans or not because they technically have nothing to do with the government anymore. Some doctors already do not accept some advantage plans. The hospitals will have to bargain with the advantage plans just like they do now with the likes of BcBS and other popular insurance. Contracts are negotiated and payment rates are predetermined by negotiation of a contract for BCBS at our hospital.

    That means if the hospital does not accept your insurance, they dont have to treat you as a patient and can literally turn you away. Now emergency situations and ERs will be different as no one can be turned away after triage with a life threatening situation.

    But all these urine tests and x rays we have to have will be at the mercy of your local hospital and whether they choose to take your advantage plan or not. Right now most hospitals just accept advantage plans because they are new.

    I have had several doctors offices turn me down for appointments because they dont want to navigate the red tape. Advantage plans still follow the same coverage rules as Medicare and if your test isnt covered by Medicare then your advantage plan dont pay it. The only thing saving us right now is that Medicare requires advanced beneficiary notice from the hospital when a test isnt covered. In order to make you pay the amount that is not covered by Medicae, the hospital is required to have you sign a form and they must tell you that you are responsible for payment before you have the services. The Advantage plans have not figured this out yet so the hospital just eats the cost of the non covered tests.

    I just worry about keeping my insurance. Private insurance does not provide the coverage that I get from my Humana Advantage plan. My AFO's are a fine example of that....BCBS wouldnt pay a dime of the $1,000 when I had it. I paid roughly $250.00 copay with my advantage plan.
    T12-L2; Burst fracture L1: Incomplete walking with AFO's and cane since 1989

    My goal in life is to be as good of a person my dog already thinks I am. ~Author Unknown

  2. #2
    Senior Member Broknwing's Avatar
    Join Date
    Mar 2004
    Central Florida
    interesting....this kinda explains the attitude I got from my endocrinologist office b/c they don't have a contract w/Humana anymore...Was my understanding that they still had to take me & bill Humana b/c it was a Medicare plan...They are currently refusing to even send me the forms to get the annual tests I need for a scheduled appointment b/c of this...
    L-1 inc 11/24/03

    "My Give-a-Damn's Busted"......

  3. #3
    Senior Member
    Join Date
    Jan 2008
    south central virginia
    THANK YOU!! for posting this information. an agent talked my elderly parents into changing over to an advantage policy and it has been a nightmare. they are much older and this agent was someone they thought they could trust so they didnt even discuss it with me before they did it. i have been trying to explain to them how serious the problems could be, as i know several doctors here who already refuse their policy (theirs is Pyramid). when i saw your post, i called them and told them what i had read. it was sooo good because it is written in a way that was easy for me to explain to them. so finally, they understand! they were going to start making calls this afternoon to try to go back on their original medicare. i wanted you to know that the info you posted helped them.

  4. #4
    Senior Member ChesBay's Avatar
    Join Date
    Nov 2001
    Coastal Virginia
    Thanks for info. I had to go back on Medicare after years of private insurance from work. So far Medicare has been good because all my regular doctors accept it and I'd like to stay with same health care providers.

    Sounds best to stay where I am w/ Medicare.

  5. #5
    Senior Member
    Join Date
    May 2006
    I'm covered by Medicare starting March 1.
    Thanks for the info, D. Daisy and others.
    I need to do more research.
    I was about to enroll in something called Keystone 65 Standard. Then, I decided to see if there were any more responses to the thread "changing from hmo to medicare". Spinky88 put a link to this page.

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