When the Centers for Medicare and Medicaid suggested that a national network could save doctors millions of dollars a year, very few of us jumped for joy. We know those dollars won’t trickle down to our healthcare bills.
But there is something to celebrate in getting this topic to the front of the national discussion on Medicare. We can’t get done if we don’t get started and alas, we finally have started a conversation about Medicare Advantage doctor networks.
You, the American Medicare beneficiary, may have a private Medicare Advantage plan – PPO or HMO, or you may call it a C Plan. About half of all people on Medicare have chosen to enroll into a Medicare Advantage plan.
People typically express satisfaction with their plans, but there is one topic that gets people uniformly upset: doctor networks.
With a private Medicare plan, your insurance company will negotiate a contract with your doctor to participate in the company’s network. Your doctor agrees to a little pay cut (rarely a pay increase, but it has happened) to be in the network. In exchange, all the clients of the insurance company can see the doctor and pay a lower in-network co-pay. For PPO plans, if the doctor is not in the network, you must pay more to see that doctor, while many HMO plans don’t pay at all if you see a doctor who isn’t in the network.
Here’s where I come in, the insurance agent.
I will research all your doctors against all the networks of the plans in your county. In addition to matching your prescription needs to the plan’s offerings, I’ll search the extra benefits you see on TV: “dentures, food money, flex cards, etc.” For the very affordable cost of $0 (you don’t pay extra to use an insurance agent), I will recommend a plan that allows you to see all your doctors, covers all your medications, etc.
Here is the hitch: my research is flawed. Not because of my skills, but because there is no regulation of doctor networks. The contract your doctor has with the insurance company could expire on any given day. Agents have no way to know when you will suddenly receive a letter telling you it costs more or you’ll have to pay the entire bill to see your doctor (with some HMOs).
The government regulators can easily fix this by mandating that provider networks must be locked in for a calendar year. When a Medicare beneficiary buys a PPO plan, she is locked in for a year (unless there is a special exception, like moving). Doctors can also be locked in. This prevents what appears to be a classic bait and switch – agents telling you that your doctors all accept your insurance and two months later, your company informing you that is no longer true.
We get blamed as we are the face of the company. Yet, agents are never notified of when contracts are set to expire. Typically, you will receive a letter from your doctor’s office aggressively posturing you to pressure the insurance company to agree to new contract terms. Hospitals have taken out full-page ads in newspapers to complain about the looming contract expiration. No one wants to suddenly be out of network, so “call your insurance company now and tell them you must have us in network.” We pawns don’t understand what is going on, but the letter, emails, and ads are alarming.
It’s unnecessary theater that our regulators can stop.
The national provider network is the first step, and the goal must be to have provider contracts last for a calendar year. Stop leaving the insurance agents holding the bag.
Sylvia Gordon is co-founder of The Medicare Family, headquartered in Noblesville, where she educates thousands on Medicare and Social Security in all 50 states. You can learn more at TheMedicareFamily.com.