Wednesday, December 17, 2008

Medicare Advantage Plans: A MOM's Perspective

[Welcome Insurance Forums readers!]
"MOM" in this case being Medical Office Manager Kelley Beloff (whose previous contribution here still gets hits). Over the course of the next few days, Kelley will be sharing with us her unique and helpful perspective on these "bad boys" of the Medicare Supplement (MedGap) world:
Part 1 The Medical Office and Medicare Patients
December usually brings thoughts of holidays, snow, egg nog, and a reprieve from the normal hectic days we all experience. As a Medical Office Manager, however, December brings thoughts of dread because between Nov. 15 and Dec. 31, all Medicare Recipients have the ability to choose a new Medicare plan. With this choice will come chaos into my office beginning January 1. How can a person practicing their right to choose a new insurance be a problem for me? After all, it is their insurance, and it has no effect on me, right? No.
Before Medicare Advantage Plans, all persons eligible for Medicare had one insurance carrier. Medicare was handled through the government and everyone had a “red, white, and blue” card. When a Medicare patient came into a Medical Office, you copied the “red, white, and blue” card (and yes, it is referred to as that in the biz.) Unfortunately, when the government designed Medicare Advantage Plans, the government did not get out of the health care business, and is still handling Medicare. Now there are two types of Medicare plans, Traditional Medicare (administered by the government) and Medicare Advantage Plans (administered by private insurance companies). This has led to an unbelievable amount of confusion.
There are three types of Medicare Advantage Plans: HMO, PPO and PFFS. The HMO and PPO plans have a deductible (not the government Medicare deductible) and co-pays (not the government Medicare co-pays). There are also in-network and out-of-network policies, depending on whether the provider is contracted with the insurance carrier of a Medicare Advantage plan. If a provider is contracted with the government (Medicare), this does not automatically mean the provider is contracted with the Medicare Advantage plan. Finally, one cannot purchase a MediGap policy to cover the costs (deductible, co pay, co insurance) associated with this new insurance. With Traditional Medicare, after the deductible is met, there is a 20% co-pay on each procedure performed in the medical office. In order to pay for these costs, many Medicare Recipients have a MediGap policy. This is a private policy purchased to cover the deductible and co pays.
The last type of Medicare Advantage plan is a PFFS. A PFFS is a great plan, so congress had to change it. Current PFFS plans are non-network policies: the patient can see any provider, as long as the provider agrees to the PFFS fee schedule, which is the Medicare Fee Schedule. However, some providers are not trusting of not having a network and will not see PFFS patients. These patients are welcomed at my practice, as I find the plans very flexible and always timely in their payments (reimbursements). As I said, Congress has changed these plans so that, in the next few years, PFFS plans will have to be network-driven.
This section deals with Medicare Advantage patients and the medical office. At the beginning of each year, medical offices collect new demographic and insurance information on their patients to ensure correct billing for the coming year. In the case of a Medicare patient, the receptionist asks if the patient has new insurance. In most cases the answer is "no, I still have Medicare." If the conversation stops there, the physician faces major billing headaches in approximately one month (I will cover this more thoroughly in Part 3). Why? Because the patient can have either Traditional Medicare with or without a MediGap program or a Medicare Advantage Plan. That plan is a HMO, PPO, or PFFS, and each plan carries its own deductible and co-pay. Hopefully, the receptionist will still ask for a copy of the patient’s insurance card, at which time the patient will drop two or three cards into the palm of the receptionist. The “red, white, and blue” card, maybe an old MediGap card and a brand new Medicare Advantage Plan card. Now the fun begins. The conversation usually goes like this:
Receptionist: “Ma’am/Sir, you have given me a Traditional Medicare Card, a Medicare Advantage Plan card and an expired MediGap card. What insurance do you have?"
Patient: “I have Medicare.”
Receptionist: “Yes, I know. Which type of Medicare: Traditional or a Medicare Advantage?”
Patient: “There is no difference, it is all Medicare." (Then they go into a monologue about being a longtime patient, never being questioned before, their other doctors don’t ask these questions, etc.)
Quiz: Has the patient told us type of insurance he/she has?
If you said no, you are correct, and this is what faces us in the Medical field every day. These patients simply do not understand that there is a difference between Traditional Medicare and Medicare Advantage Plans. The biggest problem is seniors do not understand that the “red, white and blue” card is not needed with Medicare Advantage Plans. On the day they turned 65 and received that card, they were always told that this was their insurance card forever. I have worked in this field for 5+ years, I am a Certified Medical Manager and I cannot convince my patients, or even members of my own family, that with a Medicare Advantage Plan, their “red, white, and blue” card is no longer active. I have actually told some members of my family to put their “red, white and blue” card in their dresser and never touch it again.
If you would like to read a more in depth piece on Medicare Advantage plans, here's the link to a 49-page workbook on this very topic. The one piece not covered in this workbook is how the receptionist at the physician’s office is to know which medical plan the patient has enrolled for this year.
In Part 2, we'll discuss the Government and Medicare Advantage Plans. Stay tuned.
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