Yesterday a customer service representative at OneExchange further explained the account setup for married couples who have both retired from IBM. I have never seen any documentation about why and how they setup those accounts.
The account is setup in the name of the person who is oldest. In my case, that is my spouse. The HRA subsidy for both people is put into one account. Because we each have power of attorney for the other we are both able to access the account.
The rep said there is huge benefit to having one account. The amount of money in the account is available to cover the bills and premiums of either person to whatever amount is in the account. So, it is possible to spend the entire account on just one person.
The rep went on to said if the accounts were separated then each person could only spend their own HRA money limit. The couple would not have access to each other's money - meaning if one underspent the HRA benefit the other could not tap into that remaining balance.
I have not seen that explanation written anywhere. All I knew is when the account was setup it was one account in my spouse's name. One customer service rep told me I could split it apart when I questioned it earlier this year but did not tell me the ramifications. I was concerned about what would happen when one of us dies but decided to not do a thing about it until next year.
This customer representative told me they will settle it out when one of us dies and it is no issue.
I haven't yet applied my rule of "ask 3 times" to be more confident that the answers provided are correct. Maybe later in the summer I will ask again.
Wednesday, May 28, 2014
Saturday, May 24, 2014
IBM Medicare part D Drug Insurance Formulary Exception Request
One of the aspects of losing the group health and prescription drug plans provided through IBM is we lost the help of the IBM HR employees that were assigned to shepherd us through various negotiations with insurance company claim denials. We are now on our own to figure out the myriad Medicare appeals processes.
My spouse's doctor just wrote a prescription for a new drug. When we took it to the pharmacy we were told it was denied because the brand name version of the drug is not on their formulary. The doctor was very specific - he wants the brand name version. As it happened, the brand name version of the drug was actually on the formulary until a couple of months ago. You may not know this, but part D insurance plans can change their formularies whenever they "want". Yes, they have to file paper work but then they can drop a drug they formerly covered "mid stream" in the plan year. Our illustrious congress passed laws in 2006 allowing them to do so. They also passed laws forbidding the government from negotiating with pharmaceutical companies to get drug discounts. The insurance lobby and pharma lobby are strong lobbies.
Anyway, what that means is even if you bought a part D plan that covers your drug - the insurance company can decide during 2014 to adjust their formulary any time they want and drop your drug from their list.
Because my spouse's plan dropped coverage for the brand name drug this year - they are required (by law) to provide a 30 day "transition refill" even though this is a new prescription for my spouse. If the drug were not on their 2014 formulary they would have just outright denied the drug. OK - so now what? In our case - the first step is to request an exception and ask that the brand name drug be covered for the rest of the year. The doctor had to write a letter for such a request to be even considered by the insurance company.
How do I put this politely? The letter the doctor wrote sucked. It didn't provide a compelling argument for why my spouse must take the brand name drug. I didn't tell the doctor it sucked as it would have been truly obnoxious - but I do believe the request will be denied because it was truly a lousy letter.
If the exception request is denied we will then need to go through the formal part D appeals process. If so, I will try to get the doctor's office to write a "better" letter at the next step. This might turn out to be a multi-step denial/appeal process. The truth is you do not get a fair decision until you get to the independent review board appointed by Medicare to review denials which will be the after the "3rd denial" for us. Insurance companies bet most people will give up after the first or second denial. DON'T DO IT. At least 50% of the time denials are overturned when they get to the independent review board.
How come I am so smart as to know a lousy doctor letter? Only because of the volunteer work I do at the Medicare Rights Center. Otherwise I would think it was just fine. Yesterday, ironically, I urged a caller to go back to her doctor to get a better letter for the next level of her appeal because the letter she read to me for her first appeal was truly lousy too. The Medicare Rights Center has a sample doctor letter:
http://www.medicarerights.org/fliers/Rights-and-Appeals/Part-D-Appeals-Packet.pdf?nrd=1
You would think doctors know how to write these letters - sorry to say - they don't. The compelling argument has to be that there are significant health (and cost) implications to using a generic version of a drug. What is interesting is doctors might even tell you those implications but when it comes to writing appeal letters they go brain dead.
So the bottom line of this post - we've lost IBM advocates to help us with an onerous appeals process created by our legislators that make the navigation of the Medicare maze very difficult. It doesn't matter what your party affiliation might be. Congress acts as one when it comes to satisfying lobbyists and maintaining campaign contributions. You have to become your own navigator and expert. It's not easy but it will save you a lot of anguish and money so - just do it.
5/28/14 Update: A pleasant surprise! The exception request was granted! The insurance company left a message implying they talked to the doctor after getting the request so the letter wasn't an issue. My compliments to Express Scripts for making it so easy. The exception expires in May 2015 so we'll have to get another prescription plan in October to cover the drug unless Express Scripts is willing to extend the exception for all of 2015. At least we know it is covered for the rest of 2014. Nice.
My spouse's doctor just wrote a prescription for a new drug. When we took it to the pharmacy we were told it was denied because the brand name version of the drug is not on their formulary. The doctor was very specific - he wants the brand name version. As it happened, the brand name version of the drug was actually on the formulary until a couple of months ago. You may not know this, but part D insurance plans can change their formularies whenever they "want". Yes, they have to file paper work but then they can drop a drug they formerly covered "mid stream" in the plan year. Our illustrious congress passed laws in 2006 allowing them to do so. They also passed laws forbidding the government from negotiating with pharmaceutical companies to get drug discounts. The insurance lobby and pharma lobby are strong lobbies.
Anyway, what that means is even if you bought a part D plan that covers your drug - the insurance company can decide during 2014 to adjust their formulary any time they want and drop your drug from their list.
Because my spouse's plan dropped coverage for the brand name drug this year - they are required (by law) to provide a 30 day "transition refill" even though this is a new prescription for my spouse. If the drug were not on their 2014 formulary they would have just outright denied the drug. OK - so now what? In our case - the first step is to request an exception and ask that the brand name drug be covered for the rest of the year. The doctor had to write a letter for such a request to be even considered by the insurance company.
How do I put this politely? The letter the doctor wrote sucked. It didn't provide a compelling argument for why my spouse must take the brand name drug. I didn't tell the doctor it sucked as it would have been truly obnoxious - but I do believe the request will be denied because it was truly a lousy letter.
If the exception request is denied we will then need to go through the formal part D appeals process. If so, I will try to get the doctor's office to write a "better" letter at the next step. This might turn out to be a multi-step denial/appeal process. The truth is you do not get a fair decision until you get to the independent review board appointed by Medicare to review denials which will be the after the "3rd denial" for us. Insurance companies bet most people will give up after the first or second denial. DON'T DO IT. At least 50% of the time denials are overturned when they get to the independent review board.
How come I am so smart as to know a lousy doctor letter? Only because of the volunteer work I do at the Medicare Rights Center. Otherwise I would think it was just fine. Yesterday, ironically, I urged a caller to go back to her doctor to get a better letter for the next level of her appeal because the letter she read to me for her first appeal was truly lousy too. The Medicare Rights Center has a sample doctor letter:
http://www.medicarerights.org/fliers/Rights-and-Appeals/Part-D-Appeals-Packet.pdf?nrd=1
You would think doctors know how to write these letters - sorry to say - they don't. The compelling argument has to be that there are significant health (and cost) implications to using a generic version of a drug. What is interesting is doctors might even tell you those implications but when it comes to writing appeal letters they go brain dead.
So the bottom line of this post - we've lost IBM advocates to help us with an onerous appeals process created by our legislators that make the navigation of the Medicare maze very difficult. It doesn't matter what your party affiliation might be. Congress acts as one when it comes to satisfying lobbyists and maintaining campaign contributions. You have to become your own navigator and expert. It's not easy but it will save you a lot of anguish and money so - just do it.
5/28/14 Update: A pleasant surprise! The exception request was granted! The insurance company left a message implying they talked to the doctor after getting the request so the letter wasn't an issue. My compliments to Express Scripts for making it so easy. The exception expires in May 2015 so we'll have to get another prescription plan in October to cover the drug unless Express Scripts is willing to extend the exception for all of 2015. At least we know it is covered for the rest of 2014. Nice.
Wednesday, May 14, 2014
IBM Medicare and OneExchange HRA claims payment processing saga
HRA payment process seemed to settle down for me after a few blips in January and February. Unfortunately, it didn't last and today I spent 45 minutes on the phone with the claims payment department trying to resolve two claim denials.
I file my claims by filling out the OneExchange form and then faxing the form and documentation to them. I set up an email conformation of the fax. To set that up - go to the PayFlex site and select the notification option. I use faxes so that I will have a complete picture of what I have submitted every month. I attach my fax to the payment documentation when I receive checks to have a complete picture. It was invaluable to have this information for today's call because I could quickly reel off dates and payments.
The confirmation email tells me what has been processed and what is denied before the check arrives. This month they denied two claims. One was for our proof of medigap F premium payments. I provided a checking account statement I generated online showing the premium payment deductions from our account. It is exactly the same statement I have submitted for the same claim for the 3 prior months and all those claims were paid. This time OneExchange said there was not enough proof. The second denial was for a claim for a payment to a doctor that doesn't take Medicare. There was no proof it was not paid by Medicare.
The first representative I spoke to said she would stay on the line and bring in a funding department representative for a 3 way call. As soon as the funding representative came on the line the inital representative was gone! The funding representative said the medigap insurance problem was that I didn't provide a copy of the bill from the medigap insurer. I don't get a bill. She said I needed to get one. I said - but it was paid for the prior 3 months without a submitting a copy of a bill. She said the claims were never paid. I countered that they were paid and gave exact dates when the claims were paid. Then, she said she didn't know why those claims were paid but still insisted I needed a bill this time.
For non-Medicare doctor fee claim, the denial said I needed an EOB showing the claim had been denied. As an aside - I don't get EOBs - I am in original Medicare so I get MSNs. But I am quibbling. I told the representative the doctor doesn't accept Medicare so he is not going to even submit a claim to Medicare. Then, the representative said what I needed was a letter from the doctor saying he does not participate in Medicare. At that point I felt like she was making up answers.
I then asked to talk to a supervisor. The supervisor's analysis of the denials was completely different.
The supervisor said the claim denial for medigap premium was because the online bank printout I provided didn't include my name. The online generated statement only shows the last 4 digits of our checking account and does not show our names. I told her that the prior claims were paid. I also said the first time I submitted a premium claim I provided a copy of a check I wrote to the insurance company to pay the January premium and it did include both our names and account number. Nonetheless, she is now, in May, saying it may not be enough to generate a printout that has the last 4 digits of the same account that was shown on the January check for the follow-on months claims to be paid. She said maybe they were wrong to even pay for 3 months. She said she would send the May denial back to claims processing for a review.
The supervisor said for the non-Medicare doctor claim I needed to write on the doctor bill that he does not accept Medicare. I did write it on the bill but it was at the bottom. Apparently their fax machine cut off the bottom of that page. She could see some of the writing but didn't get it all. She said write it at the top of the bill and retransmit it.
I don't trust that she is right about the non-Medicare doctor claim solution. So, just in case, I went online to medicare.gov and got the form to submit the claim to Medicare myself and get an MSN denial. I am truly annoyed to have to do so - the IRS rules for HRA are quite clear - you just have to show you paid the doctor for the employer to reimburse the fee. If I am trying to cheat the system I will be the one liable - not IBM.
I continue to be underwhelmed by the knowledge and helpfulness of the OneExchange call center representatives. I feel they "make up answers" and want to just to get us off the phone. I suggest that if your claims are denied, when you call to resolve the problem don't trust the answers you are getting and, if it is at all complicated, ask to talk to a supervisor.
5/20/14 Update: The supervisor was right about the medigap F premium reimbursement. I resubmitted a different printout - a screen shot of the payment from my checking account that also showed my name. The claim was paid. However, she was wrong about the non-Medicare doctor claim. I did what she said but it was denied again with the same reason -- they want an "EOB" denial. I sent in the claim to Medicare so I'll get a denial MSN from Medicare in a couple of weeks and then I'll try to submit the claim again. I feel really lucky that I know what to do - OneExchange is absolutely clueless about giving Medicare administrative advice. I also get really aggravated that we have to jump through hoops to get our health benefit.
5/28/14 Update: OneExchange almost got the medigap F premium reimbursement right. They reimbursed one premium for May. However, the second premium was tagged as a duplicate even though they were the ones who setup an account to handle TWO people. I called yesterday and even the customer representative was baffled as to why the second premium was tagged as a duplicate. He said the easiest way to fix it was to just setup recurring premium reimbursement and sent me the forms to do it. I was perfectly happy submitting all my claims each month so I could easily track what I had filed. At this point - I just want to get it fixed.
6/7/14 Update: I continue to have trouble getting reimbursement for claims paid when the medical services are not covered by insurance. This time my claim was denied for dental services. They wanted to see an insurance statement because my dentist's bill showed he'd submitted the claim to MetLife and it was denied (of course). And, of course, I threw out the MetLife denial statement. Anyway, the answer du jour is doctor/dentist bills not covered by insurance can have NO reference to insurance on them. So, now I need a new bill from the dentist without the reference to insurance.
I file my claims by filling out the OneExchange form and then faxing the form and documentation to them. I set up an email conformation of the fax. To set that up - go to the PayFlex site and select the notification option. I use faxes so that I will have a complete picture of what I have submitted every month. I attach my fax to the payment documentation when I receive checks to have a complete picture. It was invaluable to have this information for today's call because I could quickly reel off dates and payments.
The confirmation email tells me what has been processed and what is denied before the check arrives. This month they denied two claims. One was for our proof of medigap F premium payments. I provided a checking account statement I generated online showing the premium payment deductions from our account. It is exactly the same statement I have submitted for the same claim for the 3 prior months and all those claims were paid. This time OneExchange said there was not enough proof. The second denial was for a claim for a payment to a doctor that doesn't take Medicare. There was no proof it was not paid by Medicare.
The first representative I spoke to said she would stay on the line and bring in a funding department representative for a 3 way call. As soon as the funding representative came on the line the inital representative was gone! The funding representative said the medigap insurance problem was that I didn't provide a copy of the bill from the medigap insurer. I don't get a bill. She said I needed to get one. I said - but it was paid for the prior 3 months without a submitting a copy of a bill. She said the claims were never paid. I countered that they were paid and gave exact dates when the claims were paid. Then, she said she didn't know why those claims were paid but still insisted I needed a bill this time.
For non-Medicare doctor fee claim, the denial said I needed an EOB showing the claim had been denied. As an aside - I don't get EOBs - I am in original Medicare so I get MSNs. But I am quibbling. I told the representative the doctor doesn't accept Medicare so he is not going to even submit a claim to Medicare. Then, the representative said what I needed was a letter from the doctor saying he does not participate in Medicare. At that point I felt like she was making up answers.
I then asked to talk to a supervisor. The supervisor's analysis of the denials was completely different.
The supervisor said the claim denial for medigap premium was because the online bank printout I provided didn't include my name. The online generated statement only shows the last 4 digits of our checking account and does not show our names. I told her that the prior claims were paid. I also said the first time I submitted a premium claim I provided a copy of a check I wrote to the insurance company to pay the January premium and it did include both our names and account number. Nonetheless, she is now, in May, saying it may not be enough to generate a printout that has the last 4 digits of the same account that was shown on the January check for the follow-on months claims to be paid. She said maybe they were wrong to even pay for 3 months. She said she would send the May denial back to claims processing for a review.
The supervisor said for the non-Medicare doctor claim I needed to write on the doctor bill that he does not accept Medicare. I did write it on the bill but it was at the bottom. Apparently their fax machine cut off the bottom of that page. She could see some of the writing but didn't get it all. She said write it at the top of the bill and retransmit it.
I don't trust that she is right about the non-Medicare doctor claim solution. So, just in case, I went online to medicare.gov and got the form to submit the claim to Medicare myself and get an MSN denial. I am truly annoyed to have to do so - the IRS rules for HRA are quite clear - you just have to show you paid the doctor for the employer to reimburse the fee. If I am trying to cheat the system I will be the one liable - not IBM.
I continue to be underwhelmed by the knowledge and helpfulness of the OneExchange call center representatives. I feel they "make up answers" and want to just to get us off the phone. I suggest that if your claims are denied, when you call to resolve the problem don't trust the answers you are getting and, if it is at all complicated, ask to talk to a supervisor.
5/20/14 Update: The supervisor was right about the medigap F premium reimbursement. I resubmitted a different printout - a screen shot of the payment from my checking account that also showed my name. The claim was paid. However, she was wrong about the non-Medicare doctor claim. I did what she said but it was denied again with the same reason -- they want an "EOB" denial. I sent in the claim to Medicare so I'll get a denial MSN from Medicare in a couple of weeks and then I'll try to submit the claim again. I feel really lucky that I know what to do - OneExchange is absolutely clueless about giving Medicare administrative advice. I also get really aggravated that we have to jump through hoops to get our health benefit.
5/28/14 Update: OneExchange almost got the medigap F premium reimbursement right. They reimbursed one premium for May. However, the second premium was tagged as a duplicate even though they were the ones who setup an account to handle TWO people. I called yesterday and even the customer representative was baffled as to why the second premium was tagged as a duplicate. He said the easiest way to fix it was to just setup recurring premium reimbursement and sent me the forms to do it. I was perfectly happy submitting all my claims each month so I could easily track what I had filed. At this point - I just want to get it fixed.
6/7/14 Update: I continue to have trouble getting reimbursement for claims paid when the medical services are not covered by insurance. This time my claim was denied for dental services. They wanted to see an insurance statement because my dentist's bill showed he'd submitted the claim to MetLife and it was denied (of course). And, of course, I threw out the MetLife denial statement. Anyway, the answer du jour is doctor/dentist bills not covered by insurance can have NO reference to insurance on them. So, now I need a new bill from the dentist without the reference to insurance.
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