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So what say you to this?
2 New Devastating Medicare Advantage Stories
- Thread starter Duaine
- Start date
- Thread starter
- #3
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If one of my prospects, or clients, wants an MA plan, I refer them to a friend who will take care of them.
Unfortunately for him, it has been quite some time since I gave him a referral. I know he misses the referrals and I miss the steak dinner I get for referrals.
Unfortunately for him, it has been quite some time since I gave him a referral. I know he misses the referrals and I miss the steak dinner I get for referrals.
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I had a prospect recently who had a very frustrating experience involving getting a Prior Authorization from her PPO MAPD. It seems her doctor wanted to send her to have a lung function test. He called in to the carrier's PA line and submitted the PA request. A week went by with no response from the carrier. So he called in again and submitted another PA request. Another week passed by with no word from the carrier. Finally, the member called in to see what the hold up was.
The carrier's CS rep explained that they could not process the PA request because it was not submitted by the PCP named on her application! She went ahead and formally named the Family physician who was treating her as her PCP. Of course, they made the doctor submit a new PA request for the lung test.
I checked the plan provider directory for the lady and saw that the doctor in question was an In-Network PCP/Family Medicine doctor for her plan.
What confuses me about all of this is, since when does a PPO plan require that only the member's NAMED PCP can submit a PA request? Especially if the doctor who submitted it is also an In-Network provider? Maybe someone who understands the ins & outs of Prior Authorizations better than I do can explain this. (Then again, maybe the CS rep she was stuck dealing with didn't know what he was talking about).
The carrier's CS rep explained that they could not process the PA request because it was not submitted by the PCP named on her application! She went ahead and formally named the Family physician who was treating her as her PCP. Of course, they made the doctor submit a new PA request for the lung test.
I checked the plan provider directory for the lady and saw that the doctor in question was an In-Network PCP/Family Medicine doctor for her plan.
What confuses me about all of this is, since when does a PPO plan require that only the member's NAMED PCP can submit a PA request? Especially if the doctor who submitted it is also an In-Network provider? Maybe someone who understands the ins & outs of Prior Authorizations better than I do can explain this. (Then again, maybe the CS rep she was stuck dealing with didn't know what he was talking about).
Where are all the MA experts on the forum who have decided not to address this question?
I think this is a damn good question.
ValeRosso
Guru
- 585
Anecdotal.
52-53 million people on MAPD. Are the vast majority facings issues like this? Or are the vast majority happy with their insurance?
Nothing on this planet is 100% certain except for taxes and death.
52-53 million people on MAPD. Are the vast majority facings issues like this? Or are the vast majority happy with their insurance?
Nothing on this planet is 100% certain except for taxes and death.
David Poston
New Member
- 18
As is usually the case, a balanced approach is necessary when handling MAPD. It is a really good product for a lot of people. But at times, it can be a frustrating POS. Both can be true. Just be honest with people.
