Why Some Doctors Accept Medicare But Won't Accept UHC Medicare Advantage PPO

[JC]

Hi Gooch, and welcome to MyMedicareForum.com!

With Medicare Advantage you have to use a doctor that is in the Network as defined by the Medicare Advantage provider. Regular Medicare doesn't require you to use a doctor in any network, just use a doctor that accepts Medicare.

So I am thinking that the doctors that refused to accept your Medicare Advantage plan were not in the Network of your plan. If they are in the Network then you have a legitimate gripe. Complain to UNC. If they are not in the Network, I don't see how you have a complaint, you must use a doctor in the Network in order to be covered.

When you join a Medicare Advantage plan Medicare pays the insurance company to take over the responsibility of Medicare. Even though you have a PPO plan that does allow for you to go out of network it is still going to be up to the Dr to decide if they want to accept and bill your insurance company as an out of network. If they agree then you pay the out of network copays. If they don't agree you have to pay the full bill and get reimbursed through your insurance company for their part. Sounds like your drs are taking it as an out of network.

As a side not you mentioned that your Drs office told you that if you had an HMO you had to be reimbursed through the insurance company. This is not accurate as with an HMO they only pay for drs that are in network.

 

[gooch]

When you join a Medicare Advantage plan Medicare pays the insurance company to take over the responsibility of Medicare. Even though you have a PPO plan that does allow for you to go out of network it is still going to be up to the Dr to decide if they want to accept and bill your insurance company as an out of network. If they agree then you pay the out of network copays. If they don't agree you have to pay the full bill and get reimbursed through your insurance company for their part. Sounds like your drs are taking it as an out of network.

As a side not you mentioned that your Drs office told you that if you had an HMO you had to be reimbursed through the insurance company. This is not accurate as with an HMO they only pay for drs that are in network.

The doctors who make me pay upfront get the following: (1) the same amount of money (the insurance payment including the 20% charge for being out of network plus my payment) and (2) they don't have to submit a statement to me after they have received the payment from UHC, So it saves them paperwork and they get paid sooner. That is better for them but they now have PO'ed patient.

 

[JC]

The annual enrollment is coming up in the next couple of weeks. You might want to look at other PPO options that your Drs are in network with. Let me know if there is anything I can assist you with.

 

[gooch]

The annual enrollment is coming up in the next couple of weeks. You might want to look at other PPO options that your Drs are in network with. Let me know if there is anything I can assist you with.

This part of my retirement package so no change is possible. I have been able to convince at least one Practice Manager that what they were doing is not right and they agreed so I have one fixed.

 

[Constance]

I just called a specialist today that is listed as "in network" on my husband's UHC The Villages Plan1 HMO Website (I did a search for in-network orthopedic specialists). The receptionist told me her clinic in the process of discontinuing the contract with UHC because the negotiated fees are so low. She says the specialist is accepting new patients, but will not accept new patients with my husband's plan. She told me that many Florida doctors are doing the same. She recommended that I elect straight Medicare and purchase a supplement. She says the low fee issue is a problem with nearly all Medicare Advantage plans. Scary.

 

[JC]

I just called a specialist today that is listed as "in network" on my husband's UHC The Villages Plan1 HMO Website (I did a search for in-network orthopedic specialists). The receptionist told me her clinic in the process of discontinuing the contract with UHC because the negotiated fees are so low. She says the specialist is accepting new patients, but will not accept new patients with my husband's plan. She told me that many Florida doctors are doing the same. She recommended that I elect straight Medicare and purchase a supplement. She says the low fee issue is a problem with nearly all Medicare Advantage plans. Scary.

Unfortunately these receptionists don't understand you can't just simply change from one to another. There are only certain circumstances where you are guaranteed to be able to get a supp program, otherwise you have to qualify medically. Insurance companies and Drs are always in constant negotiations. I have seen it go back and forth over the years. Insurance companies want to pay as little as possible and Drs want to get paid as much as possible. The insurance companies need Drs so they are not going to let everyone leave the plan. Its like any other negotiations. If you need someone that can help look at all these programs and help figure it out let me know. I am more then happy to help

 

[Constance]

Thanks, JC. We are snowbirds (Central KY May-Sept, Daytona Beach Oct-April). I choose a Florida plan based upon our zip code because we spend more time there than in KY. The plan is well populated with FL providers (when we can find in-networks providers that will actually accept new patients with his insurance), but KY in-networks providers are scarce, and there are no participating hospitals in the state. These Medicare Advantage plans seem to be regional.

 

[JC]

Thanks, JC. We are snowbirds (Central KY May-Sept, Daytona Beach Oct-April). I choose a Florida plan based upon our zip code because we spend more time there than in KY. The plan is well populated with FL providers (when we can find in-networks providers that will actually accept new patients with his insurance), but KY in-networks providers are scarce, and there are no participating hospitals in the state. These Medicare Advantage plans seem to be regional.

so in those types of situations I usually try and make sure that we select a PPO plan from an insurance company that has dr networks in both states. If you want a supp plan (where you pay a higher premium and no out of pocket costs) that will allow you to go to any Dr that accepts medicare there may be a way to do that where you are guaranteed acceptance given the information you just told me.

 

[gooch]

When you join a Medicare Advantage plan Medicare pays the insurance company to take over the responsibility of Medicare. Even though you have a PPO plan that does allow for you to go out of network it is still going to be up to the Dr to decide if they want to accept and bill your insurance company as an out of network. If they agree then you pay the out of network copays. If they don't agree you have to pay the full bill and get reimbursed through your insurance company for their part. Sounds like your drs are taking it as an out of network.

As a side not you mentioned that your Drs office told you that if you had an HMO you had to be reimbursed through the insurance company. This is not accurate as with an HMO they only pay for drs that are in network.[/QUOTE

 

[gooch]

Well I am back. This time my wife goes to the ER and ER determines she needs surgery. A surgeon is called and the surgery is performed. She stays in the hospital overnight and released the next day. The insurance used at the hospital is United Healthcare Medicare Solutions PPO. In the discharge instructions, it says call surgeon for a followup appointment for a week after surgery. Called for an appointment and they refused because they don't accept United Healthcare. I guess I will just make an appointment and promise to pay cash.