Does a Medicare PPO Typically Notify when a Provider Becomes Out-of-Network?

Aug 5, 2016

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  1. wehotex
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    wehotex Guru

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    I know that an HMO does this (by necessity). If a PPO notices that mb has seen a provider in the past while on the plan, would the company notify the mb of the new out -of -network status of a provider who was previously in-network? It seems to me that this would protect the mb from incurring higher out of pocket costs if continuing with this now out of network provider. Or does the responsibility just fall on the provider to communicate this? Or is it the member's responsibility?
     
    wehotex, Aug 5, 2016
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  2. Josh
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    Josh Retired Agent, Current List Broker

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    Member's responsibility to check each time.
     
    Josh, Aug 5, 2016
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  3. yogooglethis
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    .UHC did this a few years ago when then they dropped alot of doctors in Fl.The members were notified if any provider they had seen while on the plan was being dropped.In fact because UHC requires a pcp to be selected on their PPO plans in Fl. members are always made aware of their PCP being dropped..
     
  4. WCMason
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    Fortunately we're likely to see less of this since the SEP was added allowing members to make a plan change if their MA Plan terminates a significant number of its network providers.
     
    WCMason, Aug 6, 2016
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  5. wehotex
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    wehotex Guru

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    How do they define "significant"?
     
    wehotex, Aug 6, 2016
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  6. vic120
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    I believe If it is granted it would have to be enrolled by medicare direct.

    I think I seen somewhere it is done on case by case basis.

    If this is true,I would guess there would not be a notice sent out, It would be done only If a client was knowledgeable enough to call medicare prove there was enough of His docs dropped and make enough noise to get SEP
     
    vic120, Aug 6, 2016
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  7. wehotex
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    wehotex Guru

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    Do they have to PROVE it or do they just take their word for it?
     
    wehotex, Aug 6, 2016
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  8. vic120
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    That part of my quote is just a guess

    "If this is true,I would guess "
     
    vic120, Aug 6, 2016
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  9. WCMason
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    They don't. Case by case and SEP plan change handle by CMS; no agent involvement.
     
    WCMason, Aug 6, 2016
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  10. yogooglethis
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    I believe it is the squeaky wheel syndrome in play mostly when it comes to granting this SEP .
     
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