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FW: Medicare Advantage Plan requires 2nd quote from prosthetic competitor?
Posted By: Anita Curtis on July 27, 2012
We are serving a patient who has coverage through a Medicare Advantage Plan who is requiring a 2nd quote from another prosthetic provider. More specifically, after initiating our authorization request including clinicals, the company sent a request to the patient's physician's office requesting a second quote from another prosthetic provider. When the physician's office did not respond they closed the case which we discovered when calling to get the status of our request. They explained that they have an internal policy in place that requires two quotes. They would not provide us with a copy of that policy. Has anyone had this same experience? Please advise.
Following are responses to the above post:
* Have not run into this yet. But what happened to pt's right to choose?
* You should also inquire with your state's insurance commission office and with CMS. Advantage plans are somewhat regulated, both by the feds and state.
* Never heard of this happening on a Medicare plan, most policies and benefits for these plans are online. Only thing you can do is tell the patient, if it's an inconvenience maybe he will switch plans.
* We're in Ohio as well, and to date, we've not encountered anything like this. We've had an issue with one Worker's Comp MCO, but the patient fought it. Sorry we can't be more help here. It would certainly be interesting to have the patient call them and inquire, and ask for it in writing. I'd be advising the patient to change plans as soon as open enrollment rolls around!
* I am pretty sure it is the case managers job to get that quote not yours. Workers comp does this as well on their own.
* This hasn't happened here yet, but this is a cause for AOPA in my opinion. Someone has to stop the bleeding. Even if you aren't an AOPA member, this is worth forwarding to them because they need to hear about this before word spreads around the country. Maybe your patient needs to complain too since they are the one that purchased this coverage. The patient needs to contact his/her state and federal legislators and if they can't do it, you should write the letter and have them sign it and tell them they won't get care anywhere if this continues. Good luck and keep us all posted.
* From a Florida practitioner - Yes, this has happened many times in the past with one particular Medicare Disadvantage plan, I mean advantage. When this happens, I ask the patient to get involved and contact the payer directly, bypassing the PCP. This usually takes care of the situation. Especially if the patient is adamant.
* I have not had that kind of situation with Medicare Advantage Plan. That is very interesting and scary.
* Try bringing the issue up with your congressman. This is an issue of what is most appropriate for a medical condition in order to prevent other more serious conditions from occurring. The cheaper option may result in knee, hip, back pain. It may increase the occurrence of falls. This may also be an issue for the department of insurance at the state level. Luckily, the Medicare Advantage plan is a federal pay source and they will probably decide fairly on the issue since it is not their money at stake. You might bring up the issue to their surgeon, since if this becomes a way to limit better services that may cost more, they will probably be affected in the future and may be willing to write a quick note on your behalf.
* I would file a complaint with the Ohio Insurance Commission and (CMS) Medicare. I'd ask the company if it is a policy that is in compliance with Medicare regulations, to provide a copy of the policy and the supporting documentation for their claim. If it is an internal policy, ask them who made the policy, on what date, and by whose authority. I think you'll get to the bottom of this issue much quicker going through these channels.
8517 N. Dixie Dr Ste 300
Dayton, OH 45414
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