Just because it is a PPO doesn't mean that the provider has to accept the coverage. The provider still has to agree to the plans terms and conditions. I have seen many places where they refuse UHC whether it's HMO or PPO. UHC is having network issues in NC with UNC and in SC with Prisma Health. Just moved a client today from UHC to Humana due to the UNC negotiations not looking promising.
I think were on the cusp of chaos in mapd networks as insurers and hospitals fight
- Thread starter DonP
- Start date
InsuranceGuy29
Guru
- 848
I understand that, but that's an outlier scenario. It's not common by any means. Does it happen sometimes? Sure, but it's most definitely not the norm.
EliseoRNCCM
New Member
- 9
I work in the Emergency department as a discharge planner. I'm also licensed in Life and health. Been a nurse for 30 years. I'm boots on the ground when it comes to dealing with all these network issues and it is getting uglier. Even original Medicare patients are being sent home with limited home care services. MAPD on hold for 2 hours for prior authorization and the calls just dropped. Forget about MAPD patients getting insurance authorization like on Availity during the weekend because of staffing issues from carriers who don't want to pay for nurse reviewers. On my days off I will be doing seminars to warn the public of what is currently going on. Having to deal with Medicare issues is not the end all be all. These elderly folks have dementia, substance abuse, no family and just plain stubborn in accepting help until it's too late to scramble for Emergency help from the office of Aging.
Welcome to the forum. You seem to be a wealth of information. Keep sharing!
UHC PPO has required a PCP for over a decade, at least now. Well, in FL they have. That's nothing new. Humana and Aetna don't.
Uhc/prisma in SC is ugly . They started suing each other back in July 6 months before the contract ended .Jan 1st uhc was out of network . I have at least 100 ppo dsnp's in sc . Uhc has 70% of SC dsnp mkt . I started getting calls left and right late last yr . Prisma started sending letters out bad mouthing uhc warning people to switch . They have been saying they refuse to take the ppo . There accusing uhc of stiffing them on out of network payments in the past . That said I've moved not one ppo dsnp and I've not gotten one call . There obviously accepting it and billing out of network.
If my client is to be believed, her doctor and hospital said that unless she changed insurance they won't schedule anything else with her. She has UHC MAPD PPO. UNC doesn't even want UHC PPO (granted, this is not coming from claims, it's coming from a doc to patient conversation).
This is the UHC/UNC fight here in NC.
But they have nice buildings (Prisma that is).
It's about $$$$$$$$$ on both sides. Prisma is greedy. UHC is greedy.
Jackson Taylor
New Member
- 2
You need to make sure that your clients understand that having a PPO does not guarantee that they can go to any provider regardless of network. Just because a PPO will pay out of network, doesn't mean the provider has to see the patient. Since they are not contracted with the plan, they are under no obligation to see the plan's members (except in an emergency). They can refuse to see the patient, the same way they turn away someone who doesn't have insurance. Or they can require the patient to pay up front out of their own pocket and then make the patient file for reimbursement from the plan.
I don't know. I've had UHC pay out over $18K for a client who showed up at an out-of-network hospital. But I guess they had to pay it because it was an emergency. He ended up passing and they charged back my $603 trued up commission. I thought that was wrong, but I didn't dispute it, on the grounds I shouldn't have moved him off his Med supp in the first place. UHC eventually paid, but everyone in that hospital kept reminding him and his loved ones, that he's not in network! To add that stress on top of losing a loved one, only for the bill to eventually cleared up in the end, is not worth leaving Original Medicare IMHO!
Similar threads
