The Kaiser Foundation is a great resource for information about Medicare. The foundation regularly issues reports and statements about Medicare ranging from its history, how it works, who uses it and how much it costs. They also regularly issue position papers to Congress to try to guide legislators to make informed decisions about Medicare.
For example, legislators have embedded in a recent law, H.R. 2 aka the "Doc Fix" law, a provision to eliminate Medicare Supplemental plans that are "first dollar payer" plans. Congressional representatives decided people who have such plans "go to the doctor more" and thereby cost Medicare more money. While it is probably true a small percentage of people who have such plans go to the doctor more, the root cause is likely because they are sicker. Maybe that's why they buy those plans which are substantially more expensive. But no one in Congress is doing root cause analysis nor reading position papers to find out if their hypothesis is correct. Our legislators just decided those plans cater to people who are hypochondriacs. There probably are some. But the notion that people buy "first dollar pay" plans to be able to frivolously use doctor services is not true. Who wants to go to the doctor? As a sample of one, I sure don't. Kaiser Foundation did advise Congress it was not true. Congress chose to ignore them. Amazing.
Anyway, the following report, issued in March 2015, by Kaiser is very comprehensive. It covers the history of Medicare, an analysis of the users of Medicare and the impact of the Affordable Care Act. It is a long report but I urge you to read it and become educated about Medicare because there is so much misinformation in the media. This report will help you separate fact from fiction and maybe even be inspired to push your Congressional representatives to act on real information instead of hypothesis:
http://kff.org/medicare/report/a-primer-on-medicare-key-facts-about-the-medicare-program-and-the-people-it-covers/
I also urge you to pay close attention to what legislators do to Medicare because the changes are subtle and buried in bills like H.R. 2. Remember, if a representative stays in office for five years they get federal health insurance coverage for life and don't use Medicare. They have no vested interest in keeping Medicare robust. My hypothesis is majority legislators are taking a back door approach to privatizing Medicare. This "first dollar pay" legislative change did not apply to Medicare Advantage plans. If it is bad then it should be bad for any insurance plan. Why not restrict Medicare Advantage plans from doing it? Do they want to push people to Medicare Advantage plans? As more people use Medicare Advantage plans, the original Medicare insurance pool will shrink until it becomes unaffordable for the federal government to maintain as an option. Is there is a slow drum beat to reduce Medicare insurance coverage by pushing seniors into private "managed care" insurance coverage?
Friday, April 24, 2015
Sunday, April 12, 2015
IBM Medicare OneExchange - Medicare information resources
Medicare is complicated. Medicare is constantly changing. Changes are usually small but can have a big impact. Some changes are great such as the gradual closing of the doughnut hole because of the Affordable Care Act (aka Obamacare). Some changes aren't really changes, they are just sudden enforcements of existing law. Nonetheless, these changes are confounding. One example is the current Medicare push to enforce drug denials for "off label" drug usage. There are no easy ways to find out about policy changes. AARP sometimes will highlight a change in their publications. But, typically Medicare recipients don't find out about them until they encounter the situation.
I volunteer on a help line at a non-profit organization called the Medicare Rights Center (http://www.medicarerights.org/). Recently, there have been a number of calls regarding the "off label" denial issue. My normal inclination is to suspect the insurance companies. However, in this case it is the Medicare administrative arm - CMS that issued instructions to insurance companies to do the denials. When part D legislation was passed into law in 2003, the insurance rules for drug coverage stipulated drugs are covered only for FDA approved conditions. The reason Medicare cares about what is covered is because Medicare subsidizes the insurance companies. For example, there is a pain alleviation drug called Lidocaine and it comes in patch form. It was approved in 1999 by the FDA to treat pain associated with shingles. However, doctors often prescribe it to help with muscle pain. That's an off label use. A woman called who had been using the patch for five years for back pain. Suddenly, her part D plan denied coverage.
There was no explanation in the denial notice about why this drug was suddenly denied beyond "not medically necessary". There is also no point in appealing the denial (unless the off label use is related to a cancer treatment - then Medicare is more flexible) since it is Medicare enforcing the off label restrictions - not the insurance companies. If you want more information about off label drug use rules in Medicare here is a link:
https://drive.google.com/file/d/0B83wVKnNLtjtYjZPZmo1OUpTUGs/view?usp=sharing
Unfortunately, doctors are as clueless as patients about an enforcement until they encounter it. Sometimes there are workarounds. For example, if you use a doctor that does not accept Medicare and that doctor orders a lab test at a lab that will accept Medicare, the test will not be covered by your Medicare insurance because the origin was from a non-participating doctor. The enforcement of this rule started a couple of years ago. Non-participating doctors now work with doctors who do accept Medicare to ask them to submit lab tests so that it will be covered. It's crazy to me to force people to only go to Medicare doctors for everything but that's how the law was designed.
The Medicare Rights Center has a great information data base you can search at http://www.medicareinteractive.org/ but it is unlikely you will find this type of information. I suggest when you encounter a baffling denial, call the Medicare Rights Center (1-800-333-4114) because they will know what is trending. They also have a great subscription (free) newsletter that often highlights these trends.
Of course, you can also always call 1-800-MEDICARE to ask questions. Did you know --- the Medicare helpline is available 24 hours a day, 7 days a week? The best time to call is late at night or early in the morning. I suggest you use the rule of 3 when you call Medicare. What is the rule of 3? Call 3 different times to ask the same question. Medicare call center agents highly vary in capability. It's not as bad as OneX. I am not sure that's a compliment.
Finally, if you think the Medicare "rule" is unfair, complain to your congressional representative. Tell them, if the rule is so great, why aren't they required to use Medicare when they retire from congress. Retired congressional representatives get federal health insurance coverage for life if they have been in congress at least five years. That's actually less then the eligibility for Medicare, which requires 10 years of work. Also, support AARP. It is a powerful resource as a Medicare lobby organization.
I volunteer on a help line at a non-profit organization called the Medicare Rights Center (http://www.medicarerights.org/). Recently, there have been a number of calls regarding the "off label" denial issue. My normal inclination is to suspect the insurance companies. However, in this case it is the Medicare administrative arm - CMS that issued instructions to insurance companies to do the denials. When part D legislation was passed into law in 2003, the insurance rules for drug coverage stipulated drugs are covered only for FDA approved conditions. The reason Medicare cares about what is covered is because Medicare subsidizes the insurance companies. For example, there is a pain alleviation drug called Lidocaine and it comes in patch form. It was approved in 1999 by the FDA to treat pain associated with shingles. However, doctors often prescribe it to help with muscle pain. That's an off label use. A woman called who had been using the patch for five years for back pain. Suddenly, her part D plan denied coverage.
There was no explanation in the denial notice about why this drug was suddenly denied beyond "not medically necessary". There is also no point in appealing the denial (unless the off label use is related to a cancer treatment - then Medicare is more flexible) since it is Medicare enforcing the off label restrictions - not the insurance companies. If you want more information about off label drug use rules in Medicare here is a link:
https://drive.google.com/file/d/0B83wVKnNLtjtYjZPZmo1OUpTUGs/view?usp=sharing
Unfortunately, doctors are as clueless as patients about an enforcement until they encounter it. Sometimes there are workarounds. For example, if you use a doctor that does not accept Medicare and that doctor orders a lab test at a lab that will accept Medicare, the test will not be covered by your Medicare insurance because the origin was from a non-participating doctor. The enforcement of this rule started a couple of years ago. Non-participating doctors now work with doctors who do accept Medicare to ask them to submit lab tests so that it will be covered. It's crazy to me to force people to only go to Medicare doctors for everything but that's how the law was designed.
The Medicare Rights Center has a great information data base you can search at http://www.medicareinteractive.org/ but it is unlikely you will find this type of information. I suggest when you encounter a baffling denial, call the Medicare Rights Center (1-800-333-4114) because they will know what is trending. They also have a great subscription (free) newsletter that often highlights these trends.
Of course, you can also always call 1-800-MEDICARE to ask questions. Did you know --- the Medicare helpline is available 24 hours a day, 7 days a week? The best time to call is late at night or early in the morning. I suggest you use the rule of 3 when you call Medicare. What is the rule of 3? Call 3 different times to ask the same question. Medicare call center agents highly vary in capability. It's not as bad as OneX. I am not sure that's a compliment.
Finally, if you think the Medicare "rule" is unfair, complain to your congressional representative. Tell them, if the rule is so great, why aren't they required to use Medicare when they retire from congress. Retired congressional representatives get federal health insurance coverage for life if they have been in congress at least five years. That's actually less then the eligibility for Medicare, which requires 10 years of work. Also, support AARP. It is a powerful resource as a Medicare lobby organization.
Wednesday, April 8, 2015
IBM One Exchange Medicare Insurance Denial Appeals & Provider Bills
When your Medicare medical insurance denies to pay for a service already provided by a medical practitioner, by law, you have the right to appeal the denial. Unfortunately, One Exchange aka Towers Watson will not help you as they have no legal requirement to help you resolve the situation nor have they contracted with IBM to provide such services. As I have written so many times before, they are just insurance agents. You are on your own. Any complaint you decide to pursue must be done via the the standard Medicare appeals process. It is a legally defined process and the process steps depend on whether you are using original Medicare or a Medicare Advantage plan.
It's almost always worth it to appeal an insurance denial. There are some obvious "not worth it" situations such as using a doctor who does not take Medicare or having a doctor preform a procedure not covered by Medicare (such as Lasik cataract surgery) and you signed an ABN (advance beneficiary notice) telling you Medicare might not cover it. However, the denial is more often associated clerical mistakes like a provider coding a procedure incorrectly. There are always instructions in the insurance denial letter on how to do an appeal. The instructions are reasonably good. Also, don't give up if you are denied a second time. Appeal again! The reversal rate is something like 50% for people who are persistent about appeals.
I learned something today that is important to know if you decide to do an appeal. Your provider cannot hound you for full payment of a procedure until all the levels of the insurance appeal are complete. That can be a lengthy process. As soon as you decide to appeal, call the provider billing department and follow up with a written letter telling them you are appealing the denial and not to bill you. They, then, (by Medicare law) can only badger you for the copay or coinsurance for the procedure until you complete the appeals process. If they threaten to send your full bill to collections, tell them it is illegal and you will file a complaint with Medicare if they do it.
It's almost always worth it to appeal an insurance denial. There are some obvious "not worth it" situations such as using a doctor who does not take Medicare or having a doctor preform a procedure not covered by Medicare (such as Lasik cataract surgery) and you signed an ABN (advance beneficiary notice) telling you Medicare might not cover it. However, the denial is more often associated clerical mistakes like a provider coding a procedure incorrectly. There are always instructions in the insurance denial letter on how to do an appeal. The instructions are reasonably good. Also, don't give up if you are denied a second time. Appeal again! The reversal rate is something like 50% for people who are persistent about appeals.
I learned something today that is important to know if you decide to do an appeal. Your provider cannot hound you for full payment of a procedure until all the levels of the insurance appeal are complete. That can be a lengthy process. As soon as you decide to appeal, call the provider billing department and follow up with a written letter telling them you are appealing the denial and not to bill you. They, then, (by Medicare law) can only badger you for the copay or coinsurance for the procedure until you complete the appeals process. If they threaten to send your full bill to collections, tell them it is illegal and you will file a complaint with Medicare if they do it.
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