Expert: John Pedit - 5/13/2007

Question
QUESTION: As of Dec. 2006 I rec'd  medicare A & B due to a disability. I called BC/BS a few times to be sure my doctors were in network on the plan and to verify all coverage. I also checked with my doctors. After my doctors office's confirmed and BC/BS agents assured me more than once, I enrolled in the plan. As I understood it I was joining a medicare advantage plan.  When I needed a nebulizer for breathing I went through a lot. First I was told there were no DME providers in my area and that they were working on contracting with someone. I called again and was told medicare pays for the nebulizer since I have part B. I still don't know what is right.When I had to go to the ER for a pinched nerve and asthma attack I was told medicare pays part and BC/BS would pay the balance.  Well no one is paying and I can't afford it and shouldn't have to. I began to get denials from BC/BS saying they paid $0 to the doctors because they were out of network. I called BC/BS and was told to disregard the letters as my doctors were in-network. More denial letters came and I called again.  I was told again they were in network and to disregard. I told the agent (named Jason) something was wrong and after a while I heard "Oh, No, now I know the problem". He told me this plan must be new and is very confusing and my doctors were not in-network and never were.  Every time I called to check, when they saw the doctor was in-network for Medicare Advantage they assumed that was the plan. They had never heard of any other medicare advantage plan and neither did my doctor.  I now have $5,000.00 in medical bills I cannot and shouldn't have to pay. I put in complaints to medicare who sent letters to BC/BS to fix the problem but all they will do is tell me which doctors are on the plan I have. I am told I have to stay on this plan until open enrollment in November. Yet, if I have no savings then I could qualify for extra help. If a person qualifies for extra help then they can change their plan whenever they want. I have no rights and BC/BS has all the rights. Other plans cost only your part B premium. I wanted to be sure I had the best plan so not only to I pay the part B premium but I also pay and extra $50.00/month. I need eye surgery but none of the doctors my doctor referred me to are on it. My eyes are getting worse,and I am not going to go to some doctor I know nothing about. Most of the doctors are not even in my area and driving is hard for me. I cannot go to the asthma/allergy doctor anymore because he is not on it and the only one is in St. Petersburg. How can it be that if I have no money I can switch whenever I want but if I am misled and lied to, I have no recourse. PLEASE PLEASE PLEASE  any help you could give me would be great. On top of this I am dealing with taking care of my mom just diagnosed with cancer and my own severe daily pain. Plus they won't pay for a generic medicine I take for pain even though I was told beforehand it would be covered.


ANSWER: Paula

What State are you in?

If in Michigan where do you live?

John

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QUESTION: I live in Pinellas county florida
ANSWER: Paula

Sorry===more questions.

There is more than one type of Advantage plan.  Do you know which you have?  A HMO     PPO    or Private Fee For Service?

When you were enrolled di you receive or get mailed an information packet called Certificate of Coverage?

When uou go to the doctor, does he bill the plan and then you psy co-pays?

Or do you pay co-pays and also a  percent of the bill?John

---------- FOLLOW-UP ----------

QUESTION: I don't mind answering the questions. Sorry I didn't give all the info you needed.  I was told I had Medicare Advantage PPO, my card says BlueMedicare Medicare Advantage PPO. I don't recall getting a certificate of coverage. When I go to the doctors they just have me pay a copay because they say they are in-network and that I only pay a small copay and nothing else.  I really don't understand why they won't do anything when their people gave me the wrong info many times, especially the person who signed me up for the plan and gave me the wrong info. I called one doctor about the bill and they said they were sorry, they are on most all BC plans, they thought this was a regular medicare advantage plan, they never heard of this plan, but that I have to pay the bill anyway. Do you know what would happen if I stopped paying the extra $49 month? I ask to speak to someone higher up but they won't let me.  Thanks for any advice.

Answer
Paula

Check the plan out.
A Call 1-800-Medicare and request info on plan
B  Or go to Medicare.gov.  Click on Compare Plan, State of Florida, Advantage plans. PPO plans and check them out.
C or go to local Social Security Office and get copy of Medicare and You 2007.  Go to back of book and check for them under Advantage plans.

Re Medicare and You 2007:  In back of book is phone nymber for the
state Health insurance Assistance Program.  You can contact thwm for assistance> If you do tell them you were referred by their counterpart in Michigan.

You are in a PPO.  You should have received information on appeals etc and also a list of netwqork providers.  You do not need referrals to got to a doctor.  It appears that when you go to a metwork doctor, there is no problem.  Problem comes by going out of network.  A PPO allows you to go out of network.  However the cost is usually with higher copays.

It is not unusual for the out of network provider to request payment up front.  Request the out of network to make a demand billing to the PPO.  When the PPO pays their portion of the bill the provider should return the amount paid to you.

john