It’s difficult to find concrete information about the affected procedures, let alone data that supports reasoning for including the procedures in the program. The press releases from the administration state that real people will review, but they are prescreened by AI … so I assume any “real people” come into play when patients appeal. And many of us know how that works … old folks are likely to just accept the denial.
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A friend was finally able to get her husband off of a MA plan and back onto traditional Medicare because of the nightmare they went through with preapprovals. The example she gave was one took weeks and weeks and weeks to get approved and then apparently it came through on the Friday of a holiday weekend and when the staff returned on Monday to the doctors office the approval had expired.
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That page says that “The A.I. companies selected to oversee the program would have a strong financial incentive to deny claims. Medicare plans to pay them a share of the savings generated from rejections.”
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This. This. This. Argh.
That is awful.
I don’t blame you for being annoyed.
My husband scheduled a colonoscopy for Wednesday. He goes on Medicare on Monday.
The office called him about insurance, even though my husband told her, she didn’t understand that the insurance information she asked for wasn’t going to be his insurance on Wednesday. Told her again after she told us the insurance he will no longer have, won’t cover the colonoscopy as preventative
That’s correct, because he needs it because of a medical condition he has. But again, he won’t have that insurance with it’s $9000 deductible on Wednesday
Said she would call back in an hour. That was Tuesday. We called back today, no call back.
I told husband he needs to reschedule if they can’t figure out who to bill.
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My DH had a scan today b/c there is often a snafu as the systems input the new insurance
Going from a $9000 deductible to a $257 deductible, we decided to choose the $257 deductible.
It’s not an emergency, I think the procedure should be postponed. Because I’m the one who has to deal with any insurance issues
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There is a list of procedures and the reasoning is because of the large amount of medicare fraud associated with them.
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Neither my Aetna (2024 plan) nor United (2025 plan) require preauthorization for most things (both MA plans). Now the group I used under Aetna required my PCP to preauthorize/order specialist visits and tests, but that was their own system and Aetna never denied anything. While it was a little bit of a problem up front (took a few phone calls), I kind of liked it because I had everything in writing before the procedure. I’m paranoid that some test or procedure is not going to be covered so I usually check before I let them do it. When the office tells me “oh, that’s USUALLY covered” that’s not good enough for me and I want to make sure
I did notice that if I want shoe inserts, preauthorization MAY be required, and maybe for other things like PT. But for most everything else, including surgeries, it is the specialist’s office that wants preauthorization, not the insurance company.
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Then use AI to identify the providers who are supposedly perpetrating fraud & go after them. Give them huge fines and jail time. Deal with the real issue.
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Same for my husband.
You need to talk to the office manager
Posted this is Scam thread too:
I hope you’re doing well today. I am reaching out to remind you of the importance of keeping your eyes and ears out for scammers during open enrollment.
Medicare and health insurance scams are incredibly common, and scammers have gotten creative with new ways to steal your money and personal information.
Here are three signs of health insurance scams:
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Someone says they’re from the government and need payment or personal information - Government agencies do not call you out of the blue looking for information. If someone asks you for your social security number, bank account, or credit card over the phone, they are most likely trying to scam you.
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Someone wants your personal information in exchange for a price quote - Keep in mind that HealthCare.gov will only ask you for your monthly income and your age to provide a quote. If someone calls you and offers to “check your eligibility” in exchange for personal information like your social security number or bank account, they could be setting you up for identity theft.
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Someone asks you to pay for a quote - The Marketplace has trained assisters in every state to help you for free. You will never be asked to pay for services or help to apply for Marketplace, Medicaid, or CHIP coverage. If someone is asking you to pay, it’s a scam.
The bottom line is this: if something feels “off,” it probably is. If someone calls and pressures you to give out personal information or tries to rush you into giving over your credit card information, hang up immediately and block the number. If you receive a call you believe is a scam, you can also report it to the Federal Trade Commission.
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Sooo… we are temporarily caught in a loop with our insurance. BCBS is still showing as primary (and active) b/c apparently the benefits dept of my DH’s former employer only sends out notifications of the changes/termination/etc of the policy to BCBS every Monday, and last Monday was a holiday. So Medicare also still shows BCBS as our primary. This came up as I have PT for my back and they couldn’t update my insurance. The BCBS representative who stayed on line with us while we were trying to get Benefits to fast track it (per the BCBS’s recommendation) but BCBS said that it would be next Monday before it is (hopefully) addressed and then it takes “a few days” to process. In the meantime I got a message from PT that they need my PCP to write a new referral for PT. PCP office said they would be happy to, but they need the account to have my Medicare info before they can write it. I will update my account with my Medicare info, BUT it isn’t going to show as active yet until DH’s employer gets the changes to BCBS and BCBS updates their database. In the meantime I have another PT appointment next week. Sigh…..
It will get resolved… eventually… but in the meantime it’s a loop we are stuck in. It never occurred to us that the employer wouldn’t have notified BCBS when his (our) last covered day was.
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How frustrating. I’m not looking forward to the changeover. I have a dermatologist appointment this week under my ACA plan. I know I’m likely to need some follow up which will likely crossover into when I’m on Medicare. One thing I won’t need is a new referral for PT since my PT doesn’t take Medicare. My insurance agent sent a letter to Blue Shield canceling my plan as of the end of September. I don’t know if I’m going to have to set up a new online account with Blue Shield and hopefully set up autopay.
My prescription drug plan card came yesterday so now I have all three new cards. I need to figure out how to pay for all of them. Do I get a bill for the irmma?
H had the same issue after switching from BCBS to Medicare. We assumed it was because I was still on the BCBS policy, which due to his former employer’s rules, was in his name (I did not have a separate policy number), but maybe that wasn’t really the reason. We had 15 months of calls to insurance companies and Medicare, every time he went to a doctor. Fortunately, we never received a bill for anything we should not have. But it was frustrating!
H gave the doctors his Medicare & Supplement information, but the hospital system his doctors are with kept trying to bill through the previous insurance. Every customer rep was sympathetic, but no one could figure out how to prevent it. After I transitioned to Medicare, the issue went away. Given that he retired from a large corporation that provides subsidized retirement insurance that they cut off at the beginning of the month that the retiree/spouse turns 65, it made little sense. I assume many people had the same experience we had … you’d think fixing it would be a priority.
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I went to the website of the supplement and drug coverage company, there was a bill to pay and an option to go on autopay. Which I did.
I then went to Medicare dot gov. You have to pay for the first 3 months up front, there is also a way to sign up for autopay so I did that also. The first 3 months were $555.
This is if you are not drawing social security which my husband is not. No idea about the IMRAA.
I hope that’s the question you were asking. If not, never mind!
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Thank you! Clears up a couple of things. I got a bill for $555.00 yesterday but haven’t read exactly what it’s for. Glad it’s 3 months since I thought it’s pretty expensive for one month. I’m not collecting SS yet. My husband is younger and still working.
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