Finding A Doctor In Your Health Plan Can Be Difficult

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Doctor and Patient

 “Is this doctor in my insurance network?” is part of the litany of questions many people routinely ask when considering whether to see a particular doctor. Unfortunately, in some cases the answer may not be a simple yes or no. 

That’s what Hannah Morgan learned when her husband needed surgery last fall to remove his appendix. When they met with the surgeon at the hospital emergency department near their Lexington, Kentucky home, Hannah asked the surgeon if he was in the provider network for her husband’s individual policy, which he bought on the Kentucky health insurance exchange. The surgeon assured her that he was. When she got home, Hannah confirmed that he was in-network using the online provider search tool for her husband’s plan.

But when she read the explanation of benefits form from the insurer, the surgeon’s services were billed at out-of-network rates, leaving the couple on the hook for $747.

The surgeon’s office later told her that he belonged to two different medical groups. One was in Hannah’s husband’s health plan network, the other wasn’t. Following multiple phone conversations with the surgeon’s office and the insurer, the in-network rates were applied and the Morgans’ share of the bill shrunk to $157.

“I did everything I was supposed to do,” says Hannah, 26. “You feel kind of hopeless. I thought I did it right, and there’s still another hoop to jump through.”

Consumers who use out-of-network providers can rack up huge bills, depending on the care required. Health maintenance organizations (HMOs) generally don’t cover any non-emergency services provided by physicians or hospitals outside the plan’s network of providers.

Preferred provider organizations (PPOs) typically do cover out-of-network services, but pay a smaller percentage of the charges, 70 percent instead of 80 percent, for example. Out-of-network services may have higher deductibles and higher out-of-pocket maximums as well.

Although it’s not routine, physicians may belong to more than one medical group, say experts. Surgeons, for example, may join a couple of medical groups to expand the number of hospitals where they are affiliated.

Even then, searching for in-network providers may not be straightforward. Just because a medical group is in someone’s provider network, consumers can’t be confident that all the physicians in the medical group are also in-network.

“Physician groups can be in-network even though individual physicians in that group may not be,” says Susan Pisano, a spokesperson for America’s Health Insurance Plans, a trade group.

That situation might occur if some of the physicians in a medical group agreed to accept the rates negotiated with an insurer, but others did not, says Dr. Jay Kaplan, an emergency physician who’s president-elect of the American College of Emergency Physicians. The physicians who didn’t accept the network rate would be out-of-network for a patient, even if other members of the medical group were in-network.

Consumer advocates say the lack of transparency is unfair to consumers.

“Federal law requires Americans to buy health insurance,” says Mark Rukavina, a principal at Community Health Advisors in Chestnut Hill, Massachusetts. “There’s something fundamentally wrong when you can only figure out what questions to ask after the fact.”

In addition to confusion about doctors who are part of more than one practice, consumers may also run into billing troubles if their doctor operates  practices in different locations and accepts different insurance plans at each, say billing experts.

A podiatrist may see patients at one office location two days a week, and at another office location the rest of the week. Each practice may accept different insurance plans, and a patient may be in-network only at one location.

If the physician’s office submits the paperwork to the insurer with the tax identification number for the wrong office location, the patient may get hit with an out-of-network charge. In that case, the patient may have to contact the doctor’s staff and ask them to resubmit the charges through the other practice. Generally that should solve the problem, experts agree.

Adding to the confusion is the fact that even if a physician is in a consumer’s insurance network, the hospital or clinic where she works may not be or vice versa. When undergoing a procedure or treatment, the patient could get hit with out-of-network facility and other charges.

More consumers may face out-of-network problems as health plans shrink the size of their provider networks in an effort to keep costs lower.

“Health plans work very hard to see that consumers have the information they need and resources to turn to when they have questions,” AHIP’s Susan Pisano said, noting that the Healthcare Financial Management Association and AHIP’s foundation have online guides to help consumers. Still, she added, “There is clearly also a responsibility on the part of providers to be more transparent.”

Consumers such as Hannah Morgan and her husband should not have to bear the burden when that is unclear, says Mark Rukavina.

Why Mom Went Back To Traditional Medicare

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Smiling LadyWhat ultimately changed to consider then convince my mother and me to disenroll her from a Part C Medicare Advantage plan. And why my mom’s story should matter to the thousands of private enrollees and the Medicare baby boomers.

If you’re newly eligible for Medicare or trying to decide whether to switch from traditional Medicare to a Part C Medicare Advantage plan (during the next annual enrollment period Oct 15-Dec 7 2016), you may want to consider this information as told by a daughter.

It might be time to choose an Advantage plan…

If recent history is prologue, one of every three people newly eligible for Medicare will find the siren call of the Medicare Advantage TV commercials irresistible. And for some of you, a Medicare Advantage plan might be the way to go – at least for now. Some of them offer benefits not available through traditional Medicare, like vision and dental coverage, gym memberships and even hearing aids. But there are trade offs you need to be aware of.

I’m writing this while sitting next to my mother, who turned 91 a couple of months ago. I’m happy to report that she is a relatively healthy nonagenarian. The odds are pretty high, though, that Mom would not still be counted among the living had she not switched from a Medicare Advantage plan to traditional Medicare when she was critically ill a few years ago.

But it might be time to disenroll…

Here’s something you might not know: many Medicare Advantage enrollees do exactly what Mom did after a serious illness or injury, and the Medicare Advantage plans they “disenroll” from could not be happier to see them go. When a person goes back to traditional Medicare, the Medicare Advantage plans are off the hook for covering expensive care.

As I learned later, the circumstances that convinced my mother she would be better off in traditional Medicare were shared by hundreds of thousands of other elderly Americans. The evidence that my mother’s reason for switching back to traditional Medicare was far from an isolated case and came from two very credible sources in 2013: a researcher at the Centers for Medicare and Medicaid Services (CMS), and a team of researchers independent of CMS, led by a Harvard Medical School professor, who published their findings in the journal Health Affairs.

The CMS researcher, Gerald Riley, looked at the experiences of more than 240,000 people who switched from Medicare Advantage plans to traditional Medicare and compared them with beneficiaries who had always been in the original program. He found that in the six months after returning to traditional Medicare, the former Medicare Advantage enrollees used an average of $1,021 in medical services each month. Those who had never been in a Medicare Advantage plan cost Medicare just $710 a month.

Desperately seeking ‘unfettered access’…

Similarly, the study published in Health Affairs found that people who had returned to traditional Medicare from a Medicare Advantage plan were far more likely than other beneficiaries to report declining health.  J. Michael McWilliams, the Harvard professor who led the research team, was quoted as surmising that “beneficiaries who developed serious ailments might leave the Medicare Advantage plans to get unfettered access to physicians and treatments through traditional Medicare.”

The term “unfettered access” is especially important. It certainly was to my mother. After being hospitalized for a broken hip, Mom was discharged to a skilled nursing facility for rehabilitation. Her progress, though, was slow, and she was flat on her back much of the time. After several days there, she began to develop bedsores, and the staff at the facility wasn’t making progress treating them.

Before too long, the head nurse took me aside and told me that another nurse – not at the facility but at Mom’s Medicare Advantage plan – had come to the conclusion that the skilled nursing was no longer “medically necessary.” This other nurse – a so-called “utilization management” nurse – had never laid eyes on my mother, much less treated her. But she was able to insert herself between my mother and her treating physician and, for all practical purposes, determine whether or not she would get the care her doctor said she needed.

With my help, Mom appealed the utilization management nurse’s decision. She won a temporary stay of execution in the form of a coverage extension for another week of care. But that was it.

I knew that ending coverage for Mom’s skilled nursing care would be a death sentence, so, with her approval, I started the process of switching her back to traditional Medicare. At the same time, I also made arrangements for Mom to be transferred to a facility that not only had a good reputation for treating patients with bedsores but also, coincidentally, did not work with any Medicare Advantage plans, only traditional Medicare.

The administrators at the facility where I had Mom transferred had decided years before that they could not in good conscience continue working with insurance company utilization management nurses who could – and often did – deny coverage for further care despite the pleas of both patients and their doctors.

Private coverage can fall short for the sick or disabled…

Only in traditional Medicare can a patient count on getting “unfettered access” to doctors and facilities of their choice – and, in many cases, to life-saving care. The Kaiser Health News article that reported the result of those 2013 studies quoted Judith Stein, executive director of the Connecticut-based Center for Medicare Advocacy, a patient advocacy group, as confirming the disparity in access to needed care.

“Private Medicare Advantage plans work for people when they are relatively well, but fall short of traditional Medicare when they are sick or disabled,” she said. “This is particularly true for those with long-term and chronic conditions, many of whom also have low incomes. They are often denied coverage for necessary skilled care, or it is terminated before it should be, while the same coverage would be available in traditional Medicare.”

This article is to provide encouragement to keep all of this in mind as decisions are made during the Medicare annual enrollment periods. Depending on your age and health, it might be better choosing or staying with traditional Medicare and supplementing it with a Medigap private insurance plan.

And, it just might add years to your life.


The 5 Things To Do First When You Retire

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Smiling Couple of ColorThanks to an entire Internet worth of articles and advice, we generally know what to do in the years leading up to retirement. But what about immediately afterwards?

Here’s five things we’ve learned that you must do upon leaving the workforce for good — and one you should wait on. It turns out that celebration, preparation and even hesitation go a long way.

Look before you leap is definitely the mantra. Retirement can be a wonderful period of life — a time of tremendous fulfillment and enjoyment, and planning will make your ability to enjoy it so much greater.

  1. Treat Yourself

First things first. On the way out the door of your office, buy an expensive bottle of wine. You’ve retired! Congratulations! Take a moment to savor the feat, reminisce and look forward to the future you’ve been working towards for years.

And the next day? Take a special vacation trip or visit someone. This will make the transition from work to retirement go smoother. The break with the routine is not so abrupt.

Another advantage to the trip: It gives you the breathing space before you return to the work of deciding how you want to spend your time for the next twenty or thirty years. If you’ve always dreamed of spending a week exploring Iceland, there’s no better time.

  1. Review Your Income Streams

Now that the party’s over, it’s time to get down to business. Ideally, you should have an income strategy before leaving the workforce, including a blueprint for withdrawing Social Security. Once you actually retire, however, you must double-check where your finances stand, and confirm that all plans are up to date.

Make sure you have your cash flow in order. Know how much income you will have and where it will come from (a pension, Social Security, retirement accounts or perhaps a part-time job).

While you’re reviewing, be aware of the potential volatility within your portfolio, the tax implications of all your different revenue streams — and disregard CNBC and Fox Business channels.

During the initial phase of retirement, it’s best to ignore the 24/7 news cycle. News outlets are vying for attention and as a result, their headlines are designed to appeal to an investor’s emotion rather than logic. Hold the course on the financial plan you have set for yourself in retirement.

  1. Start Tracking Your New Daily Expenses

Now that you’re not working, your daily expenditures will change, possibly drastically. It can sometimes take a year or two to adjust to retirement and really know what you will spend on average, and you need to know what your retirement income can support, even in bad market years.

So, from Day 1, prepare a reasonable outline of your monthly expenses now that you are living on your post-retirement income and retirement savings. A rule of thumb is that you shouldn’t pull more than four percent from your retirement savings each year.

While a pen and paper always works for this, financial software can significantly ease the burden of bookkeeping.  You may want to use Quicken and automate your expense tracking so that you know where your dollars are going and can find ways to save money if needed down the road.

  1. Revise Your Estate Plan

As we age, illness and incapacitation become more serious concerns. With that in mind, update your estate plan. Chances are you haven’t looked at your will in years, perhaps decades. Your adult children likely wouldn’t appreciate having a guardian anymore.

Your will (living and otherwise), insurance beneficiaries, medical directive and power of attorney should be reviewed and then reassessed every three or four years after that. That is, unless something significant happens — such as if you move to a different state or there’s a change to any kind of marital status in your family. In that case, start drawing up new documents immediately.

One special note: Checking your estate plan review is vital for retirees who want to spend significant time abroad. Accidents happen overseas and it’s much more difficult to coordinate critical documents and directives from a distance.

  1. Fill Your Calendar With Meaningful Activities

Why did you retire? Now is the time to discover the real reason. Find your passion. Sometimes, too many individuals retire ‘from’ something and not ‘to’ something. While it takes everyone time to get used to retirement, you have to find a reason to get up in the morning, whether it is volunteering, gardening, finding a part-time gig, etc.

Whether your passion lies in genealogy or card games, make sure it involves the following key elements:

  • Connecting with others: Get involved in meaningful activities that will keep you connected to friends, family, and the community. You’ll feel valued, and stave off the loneliness [and related health issues] that can accompany retirement.
  • Making concrete plans:  Many are surprised that their goal of golfing in retirement still leaves significant empty space on the calendar. It’s encouraged for people to consider an exercise where they [fill in] a blank weekly calendar, hour by hour. Seeing that schedule gives you a realistic view of your commitments, provides specific events to look forward to, and prevents aimlessness.

Don’t Make Big Decisions

Retirement is a big change and new retirees should expect to spend some time adjusting. While downsizing and making other lifestyle changes can be a fun and sometimes a necessary part of retirement — to lower the cost of living — this is something that can be put off for a year or more to ease the adjustment period. Instead of buying a new place or paying off the old one in one fell swoop, it’s suggested taking time to consider your new needs: Do you still need to live in a spacious home? Should you downsize to help with your retirement expenses, move to be closer to the grandchildren, relocate to a sunny locale or a less-expensive state?

Another big decision to put off?  Making large cash donations to your children and grandchildren. [Postpone] contributing to a grandchild’s 529 plan or other form of gifting to your grandchildren. Make sure you have your personal finances under control first.