Problems with my Medicare Advantage Plan company

surprisedat65

I chose a Medicare Advantage Plan, which is like an HMO, because I felt if anything serious occurred I could cope with its annual out-of-pocket maximum. However, it has been a nightmare since my breast cancer was discovered.

I may only use physicians who are in its network, and when I make an appointment with such a doctor or lab, they must fax the request to my PCP's office, and that office submits the request to my insurance company which in turn notifies the PCP's office of approval and they have to notify the doctor or lab of the approval. The first alarm bell went off when I got a call from my BS's office telling me two days before my appt. that they still had not gotten permission from my insurance company, that they had called my PCP's office and been told that the request had been faxed to the insurer and they just had to wait. The BS's office suggested I, as the insured, give my PCP's office a call to nudge them so that my appt. did not have to be rescheduled. I was told the same thing, but I told them I apparently have BC and feel it's urgent to see the BS ASAP and couldn't they call the insurer to find out what was taking so long with the approval. That worked and so began my journey with the BS.

Subsequently the biopsy and the lumpectomy were all approved. Next it was time to see the MO, which visit was approved. Though all my nodes were clear, because there were two tumors in the breast she is thinking I should have chemo prior to radiation. She requested a PET scan, a MUGA scan and an Oncotype dx. On the Friday before the Monday PET scan I called the insurer to find that neither it nor the MUGA scan and Oncotype dx had yet been approved, the PCP's office was closing at 1:00 pm that day so even if the approval arrived no one would be there to pass it on to the diagnostic center, so we moved the PET scan back one day to Tuesday. Monday arrived and still no approval, so I called the company myself and was told they had up to 14 days to approve (!) but would see what they could do by the end of the day. Just in case, the PET scan was pushed back two more days. Meanwhile no one knew anything about the Oncotype dx.

This morning I learned that the PET and the MUGA had been approved but still no one knew anything about the Oncotype. By now my insurance agent was making calls on my behalf and told me that my MO's office told her they had only asked my insurance company for approval of the two scans which they now had received. I then called the MO's office manager who explained that they send the request for the Oncotype dx directly to the lab that's going to do it, and that lab is supposed to contact my insurance company which it apparently hasn't done yet. Further, while talking to the insurance agent, she tells me that these offices should first be making requests for approval of a required appointment or procedure and then scheduling the appt. after the approval arrives. Thank heavens this isn't emergency medical care!

There's little to be done about it now as I must wait till the end of this year to choose a different plan, but you can bet I'll be looking to make a change.

WinningSoFar

I'm sorry you're getting the runaround. I know this is a longshot, but might be worth trying: could you contact Medicare and see if there is some sort of special exemption so you can change plans now?

I'm on traditional medicare with a supplement, and none of these holdups happen, or if they do--I'm never aware of it. So far, I'm very pleased with my healthcare. I hope you get yours worked out as soon as possible. It helps healing to not have insurance hassles.

Spookiesmom

Sounds typical for some. I have Humana. I've been pleased so far. My rep tells me there are different plans within the plan I can switch to. If you want to totally change, you would need to move out of your service area, or wait till fall for open enrollment.