MA PFFS horror stories

[Frank Stastny]

Slick,

A similar thing recently happened to my mother. She went in the hospital for a simple outpatient procedure. They ended up keeping her three days for "observation".

The hospital sent her a bill for $485 for medication they claimed they gave her, which she doesn't recall receiving, that isn't covered by Medicare when administered to an "outpatient". Medicare was correct, meds are not covered for outpatient treatment. This is the first time I have heard of a hospital considering a three day stay as "outpatient observation".

I have a friend who is a hospital administrator and he has never heard of this either.

She was not told that they were keeping her there as an "outpatient" for three days for "observation". She assumed she was there as an inpatient since she was there for three days. My mother is an RN and well acquainted with normal, accepted hospital procedures, that is until she entered "Rip Off Care Hospital".

She didn't find out she was an outpatient until she received the bill. I feel sorry for the person at the hospital that originally took her call. She is so mad about it she has asked an attorney to look into it for her.

The hospital apparently has figured out another way to further screw people and insurance companies out of even more money than they have in the past.

Now we have another thing to warn seniors of. The way it is going it is going to take an extra hour during an appointment to let seniors know about everyone who is out there that is going to try to screw them out of their last few cents.

She lives in Florida and has a supplement policy. I would never let her switch to an MA plan.

 

[honestagent]

I would like to hear some stories of bad experiences with MA plans. Stories you have heard from clients personally or from an agent you trust.

I have a story and here it is.

I met with a couple 2 days ago and they were telling me that when they were in Arizona, the wife went to the hospital. I'm not sure what she went for but she had the procedure done. IT was out patient I believe. WEll anyway they paid thier co-pay. They then recieved a bill later on. It said that the doc accepted the plan but the anestesiologist did not. They had to pay the $1300 anestesiologist bill outta there pocket and that does not count towards the Max out of pocket for the year.

I want to highlight a few things I've experienced with what constitutes within the guidelines of 'max out of pocket.' I will only refer to one carrier b/c this carrier I know for certain, though it will not surprise me if the other PFFS carriers operate similarly. I know with Secure Horizons, on their agent highlight sheets for all of their plans as well as in their summary of benefits booklet, it clearly states: 'for covered services in each calendar year' just under hospitilization. Okay, so when I first saw that (and the other agent hot sheets I have for the other carriers did not) I thought: "hmmm flag here! What the hell... so not everything is covered." And bam... no. Everything is not covered evidently and in all honesty, it's not like they enumerate a list of what is not covered.

The only thing I know at this point is to call the broker hotline of each carrier to inquire if 'what is not contributed to max out of pocket.' good luck if you attain accurate answers from these people. Also, consult with your upline if they know for sure. I know mine is not reliable. Sucks. It makes it so hard to do right and be well when we're given such limited info. and resources from where to pull.

Hence, another substantial reason why this board is invaluable!

 

[midwestbroker]

Great point honest. For the 2006 benefits, the only thing that Coventry counted to the MOOP (max out of pocket) was in-patient hospitalizations. For 2007 they fixed it to include a list of procedures.

I warn people that their co-pay will be reflected on how the procedure is billed.

Example: A blood test is covered by the co-pay at a doctors office. However, if you do to Lab One for a blood test, and the doctor does not bill it through his office, you will have a $5 co-pay.

3 day outpatient procedure. Ask a hospital billing clerk. I can see the answer now. Since she did in fact leave the hospital, we are billing this as outpatient. We know that she was here for 37 days, but she left, or is "out" of the hospital. Oh, and here is a bill for all the tests and meds that are only covered if she was an inpatient. Have a nice day.

 

[honestagent]

Great point honest. For the 2006 benefits, the only thing that Coventry counted to the MOOP (max out of pocket) was in-patient hospitalizations. For 2007 they fixed it to include a list of procedures.

I warn people that their co-pay will be reflected on how the procedure is billed.

Example: A blood test is covered by the co-pay at a doctors office. However, if you do to Lab One for a blood test, and the doctor does not bill it through his office, you will have a $5 co-pay.

3 day outpatient procedure. Ask a hospital billing clerk. I can see the answer now. Since she did in fact leave the hospital, we are billing this as outpatient. We know that she was here for 37 days, but she left, or is "out" of the hospital. Oh, and here is a bill for all the tests and meds that are only covered if she was an inpatient. Have a nice day.

Damn such a shame. Okay found something else out in relevance to the OP's post and what you said here Midwest. Call the companies you represent and ask them to mail you an EOC (Evidence of Coverage) booklet. In there, it will enumerate what is and IS NOT covered!!!! It was told to me that all of the carriers have this and mail it to our enrollees? Does anybody know if all carriers do this for certain?

 

[policy doctor]

My understanding is that Medicare Advantage plans pay just like Original Medicare.

Now Medicare doesn't pay everything either, just check your guide for exclusions. that includes electives, not approved services, experimental, typical jargon you find in major medical policies.

So if Medicare would pay on a procedure, so will the MA company.

As to the anesthiologist, my understanding is if they treat an MA patient, they have to accept the money. What happens behind the scenes I don't know, and I doubt the specialist has them sign waiiving an ma pymnt.

But i do know that with Medicare/and Med supps, if the specialist charged more than Medicare approved am;t, they were capped at the limiting charge. Hence the value of 'excess charges" Plan F or G.

 

[senior-advisor-indiana]

So I guess no one has any bad stories to share?

 

[midwestbroker]

I have stories about apps stuck in the Medicare system, doctors offices saying they do not take MA plans but they really do, clients being billed more then they should (but usually a phone call will clear that up), etc.

Honest - EOC should go out to clients. We have sample ones in our office. Humana is good about sending it's clients a rain forest of information. That is the problem, where clients just start throwing stuff away.

 

[SFMORROW]

Another Example

http://en.allexperts.com/q/Medicare-Medicaid-Insurance-992/medicare-advantage-problem-1.htm

 

[honestagent]

I have stories about apps stuck in the Medicare system, doctors offices saying they do not take MA plans but they really do, clients being billed more then they should (but usually a phone call will clear that up), etc.

Honest - EOC should go out to clients. We have sample ones in our office. Humana is good about sending it's clients a rain forest of information. That is the problem, where clients just start throwing stuff away.

Okay, I just posted another thread which overlaps with this: I am wondering, why they do not mail this to agents or make it so hard to attain for us to receive?!?!?!