Problems People Run into with Advantage Plans

This is a common issue. People often are quick to blame an insurance company for a problem.

Is it really the insurance company?

Sometimes but much more often is either the Beneficiary trying to do something incorrectly or the doctors office staff doing something incorrectly. What do we mean?

Here are some classic examples:

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My doctor says the insurance doesn’t cover a procedure but if I was on Original Medicare it would be covered

Plans have to cover everything Original Medicare covers. Translation to this problem is usually:.

  • Your doctor doesn’t know what they’re talking about. Hopefully unintentionally telling you it's not covered.
  • Your doctor can bill original Medicare more and is hoping you will drop your plan so they can make more money.
  • The procedure is covered but the doctor doesn’t take the insurance.

So what should you do?

Call the insurance company and ask.

So many people run into the office in a panic about a made-up problem. The first thing we invariably ask is; did you call the insurance company and ask?

The invariable answer is almost universally: no but my Doctor (usually meaning the incompetent staff) said so.

Who cares? Most clients never listen to any advice the doctor gives medically (the advice they should heed) but when it comes to insurance then the words are gold. Sent down through the doctor by the Almighty.

My Drug Isn't Covered

This can happen. Often a name brand drug will be prescribed but a generic alternative is covered. If you are unable for some reason to take the generic alternative then you must speak to the doctor about filling out a Formulary exception: You can request that your drug be covered if it’s not on the formulary.

Generally the company will only make such approvals if a Doctor states that the alternative drugs included on the plan’s formulary, the lower cost-sharing drug, or other restrictions wouldn’t be as effective in treating your health condition and/or would cause adverse medical effects.

Again: most beneficiaries go into a panic without ever actually asking the company anything. If you have a problem, calmly call the company and ask how to work it out. Remember the person on at the call center doesn’t know everything and doesn’t have the authority to authorize everything, either. Be patient and remember that it is a person on the other end of that phone and you are not the only person on earth. From experience we all know the rep will help a lot more if you are nice to them and not irritating and irrationally demanding.

I got a Bill and My Doctor’s office said the insurance won’t pay it

I hate to sound like a broken record but clients come running into the office in a panic. “Ahhhhh! I got this bill because the doctor’s office said the insurance refused to pay it.”

The first question is, did you call the insurance company and ask why?

“No. I figured you could tell me.”

Very rarely can the agent figure out why a bill is rejected. We have no access to the company’s internal information. If it is obvious, for example, the doctor is out of network and you are on an HMO. Yes, the agent can figure that out. But if the reason is less obvious, for example, the doctor’s office put the wrong billing codes are it was deemed unnecessary. Only the actual company can see that and give an answer.