Help me solve this problem!

[Family Man]

Unless Ive missed something OEP runs Jan 1 to March 31. Put them in an MA. Problem solved. Probably a quarter of my AEP apps were people fleeing Med Supps.

Half of all Medicare beneficiaries now have MA and about 1/4 have med supps

I believe OEP is for a like change (MA to MA), or drop MA to return to Medicare and Rx plan. On the other hand, it seems some call centers have the ability to change anybody to MA at any time.

 

[20th Maine]

I believe OEP is for a like change (MA to MA), or drop MA to return to Medicare and Rx plan. On the other hand, it seems some call centers have the ability to change anybody to MA at any time.

Yes sorry thats right. BUT there are dozens of SEPs and no one polices 62 million beneficiaries. We had a couple "Disasters" close by but not specifically in our area--and many brokers used the "Disaster" SEP.

With all the Horse**t CMS lets slide by--in my metro are large agencies with a trail of state complains, a history of EVERY agent scamming, obvious that they are trained to scam----and brokers and carriers alike complaining and CMS never acts---using an SEP is not a mortal sin

 

[shonceman]

Took my wife in for her final appointment with the pain clinic today. Turns out the reason the doctor wanted to stop taking OM was because they were denying every single claim for any procedure that required an injection. They also started requiring prior authorization for those procedures, which they never had before. None of the MA plans were giving them any trouble on that issue.

In any case, he apparently didn’t realize that the letters didn’t get mailed out in time for patients to switch to MA, so he’s reconsidering whether he should continue to accept OM at least for the near future.

 

[20th Maine]

WOW interesting. Were Med Supps denying as well?

 

[Chazm]

WOW interesting. Were Med Supps denying as well?

If Medicare denies a claim, it never gets sent to the med Supp.

 

[Yagents]

Oh boy.

Med supps don't deny claims. OM does.

Maybe the doctor has a history of high injection rates (ha) or wrong coding was submitted or it was not medically necessary for medical condition being treated.

 

[shonceman]

Oh boy.

Med supps don't deny claims. OM does.

Maybe the doctor has a history of high injection rates (ha) or wrong coding was submitted or it was not medically necessary for medical condition being treated.

I don’t know. He’s a pain and anesthesia specialist. Injections are kind of a big part of what they do. (My wife isn’t getting any injections, so it wasn’t directly affecting her care.) What was curious to me was that OM was requiring prior auth, but none of the MA networks were. MA also wasn’t denying any claims. I thought MA was more likely to want prior auth than OM. But there it is!

 

[LostDollar]

Unless Ive missed something OEP runs Jan 1 to March 31. Put them in an MA. Problem solved. Probably a quarter of my AEP apps were people fleeing Med Supps.

Half of all Medicare beneficiaries now have MA and about 1/4 have med supps

Which does NOT mean that OP might prefer to remain on OM + Medigap.

Does that mean that 25% of Medicare beneficiares are on OM only, or are there other options?

 

[LostDollar]

[EXTERNAL LINK] - Prior authorization (PA) program for certain hospital outpatient department (OPD) services

https://www.cms.gov/data-research/m...n-hospital-outpatient-department-opd-services

https://www.cms.gov/files/document/opd-services-require-prior-authorization.pdf

It looks like hospital outpatient departments were required to obtain pre authorization for some injections starting in July 2023.

Perhaps that requirement extends to physicians as well.

Beginning for service dates on or after July 1, 2023
Code Facet Joint Interventions
64490 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint
(or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or
thoracic; single level
64491 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint
(or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or
thoracic; second level
64492 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint
(or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or
thoracic; third and any additional level(s)
64493 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint
(or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or
sacral; single level
64494 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint
(or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or
sacral; second level
64495 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint
(or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or
sacral; third and any additional level(s)
64633 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging
guidance (fluoroscopy or CT); cervical or thoracic, single facet joint
64634 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging
guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint

 

[20th Maine]

For those with OM only they can also have VA, some corporate or union plan

Lots of people never get Part B to save the premium. Client of mine's Dad is in his 90s, very healthy, and never had B. Many people are just stoopid.