Healthcare is a Team Game

 By Marc Manor

Healthcare is a team game that includes everyone from the client/patient, to the provider, their staffs, coders, insurance companies and others. When one member of the team, drops the ball, it can result in wasted money and resources and undue stress on the part of the client/patient. Even the most talented doctor or dentist may lose client trust and waste their time (time is money) if they do not have a staff that can handle claims and referrals in an accurate and expeditious way.

Recently, I received a call from a client telling me his primary care provider referred him to a specialist. When he arrived at his appointment, he was told that the specialist was not in network and they would not accept his insurance. This exemplifies a break in the client’s “chain” of care that should never happen. Healthcare is a team game where every decision should be made with the client/patent’s best interest in mind. As a result, the specialist wasted an appointment slot, the client was inconvenienced, and the primary care provider ended up losing a patient!

In this case, the breakdown likely occurred somewhere in the office staff (team) at the primary care provider because of a broken link in the administrative chain when processing a referral or insurance claim. Clients or patients are not healthcare professionals and therefore, do not normally anticipate breakdowns in the system. I have contacted medical and dental offices about this in the past and been told “it is the clients responsibility to make sure these referrals are in network” - a totally unacceptable answer in my view. Fortunately, we were able to use our local resources and find another provider for our client in the above example (and others) who has an established track record for client centered care with efficient claims and referral processing.

 Here are some tips for putting together a strong healthcare team:

 - Seek the assistance of a local healthcare insurance agent to review your healthcare insurance plan. Your local agent can not only help you choose the right healthcare (also applies to Medicare and dental insurance) plan with your needs in mind. An experienced local agent will have knowledge of the local medical groups and hospital networks.

 - When you receive a referral from your provider, ask them if the specialist or other provider they referred you to are in your insurance network. If they don’t know or tell you to call them; red flag 🚩 - they should know.

 - If you have to call to make an appointment where your are referred, ask them if they accept your insurance as “in network.” If they say no or “I’m not sure”; red flag! 🚩

 - Call your insurance company “member” or “customer” service line. While the company may not have the insight or experience with the local providers, they will be able to let you know who is in network for your plan. If they don’t know; red flag 🚩 - call your local agent immediately!

 One last note on networks. Don’t worry about networks if you have an emergency. Go to the nearest emergency room or call an ambulance.

Doctors and medical staffs are people just like the rest of us. Most are dedicated professionals and many are extraordinary and go the extra mile for their patients.  In fact, their heroism has never been more evident than during the current pandemic. By-enlarge, medical professionals are some of the most competent and honest hardworking people in our community. We are blessed to have some of the best here in Northeast Florida. Just like a winning sports team, your healthcare team should operate like a smooth running machine; with you in the drivers seat.

Marc Manor is a 30-year military veteran who is now dedicated to teaching his fellow Americans how to make the most of their Medicare and healthcare benefits. As an independent agent, Marc has access to a wide variety of carriers with an abundance of resources to find tailored solutions. There is no charge for a consultation so call 904-222-0698 or email: marc@marcmanor.com.

Happy Medicare Advantage New Year!

Happy New Year and Congratulations if you have a new Medicare Advantage Plan for 2020!  I am very excited for the new year and I resolve to make sure all my clients make the most out of your Medicare Advantage Plans this year and beyond!  Here are some tips to help you make the most out of your benefits:

Photo by Jill Wellington from Pexels.com

- Be sure to let your providers know if you have a new plan for 2020 so they can properly process your claims.

- Be sure to stay in network!  PPO plans offer out of network coverage; however you will pay more so when you make your appointment, you should double check.  Most providers will "take" a PPO plan so be sure to ask if they are "in network".  If you have an HMO you must stay in network.  Your provider should know when they refer you as long as they have your updated insurance information.  HMO plans do not normally have out-of-network benefits so being sure you are in network is more important for you.

Avoiding the Medicare Penalty Box

by Marc Manor

Relative to most individual healthcare plans, many people find Medicare a significantly less expensive alternative with more coverage and lower deductibles.  After all, if you have been employed throughout your life, you have been paying into the Medicare system and have earned the Medicare Benefit!  If you have been employed for 10 years or more, it is likely your Medicare Part A will have no cost and your Medicare Part B will be only $135.50 per month* for most people (*Part B premiums are higher for higher income earners).   Medicare costs can be found here:  

https://www.medicare.gov/your-medicare-costs/medicare-costs-at-a-glance#collapse-4809

Courtesy of canva.com

To take full advantage of the value of your Medicare benefits, it is best to avoid late enrollment penalties.  There are late enrollment penalties for Medicare Part B and Part D and with so many low-cost options available, there are few reasons that would justify putting yourself in the Medicare “Penalty Box.”  Sometimes people seem surprised and are frustrated by the penalties.  They claim they just aren’t fair.  I understand how someone must feel but Medicare justifies these penalties because they base their rates and calculate their risk based on eligible beneficiaries in the pool of enrollees.  But you won’t care about why they penalize you for being late. So, let’s talk about the penalties and some ways you can stay within the rules and avoid them!

Dear Politician: Just What Is “Medicare For All”?

By Marc Manor

As we prepare ourselves for the onslaught of political rhetoric associated with the 2020 presidential and Congressional campaigns, we have all heard the term “Medicare for All” as a means to fix our healthcare system.  I must admit, the more I hear the talk about Medicare for All, the more questions I have.  As an insurance agent who works to place Medicare beneficiaries into appropriate coverage, I can tell you that most people I talk to do not really understand our current Medicare system when they become eligible.  Based on much of what I have heard from politicians, it seems to me they also don’t understand Medicare.

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I should disclose, I do have some personal interest in how Medicare for All would come to be.  Obviously, if commercial insurance companies were cut out your proposed system, me and thousands (if not millions) of people would have to find a new livelihood.  Having said that, I would support any functional system of healthcare over what we have now for people not eligible for Medicare.

Employee Group Plans vs. Medicare; When to Cut the Cord.

by Marc Manor

If you are coming up on age 65 and you are still working and are using an employee group health insurance plan you may be asking yourself if you should dump the employer plan to take advantage of your Medicare benefits.  If you thought that, you are not alone.  This situation comes up frequently and as an agent, I can only really answer by making a recommendation that you seek assistance from your company benefits advisor.

Seeking assistance from your benefits advisor is really the only answer because they should be the most knowledgeable about the group plan benefits.  Human Resource professionals earn their living managing employee benefit plans.  So, as you ask yourself the question of whether to part ways with your employee group plan to join Medicare, you need to go to HR.  You may be fortunate and get the HR professional that provides you with all the information you need to make an informed decision; or you may just be handed a form and be left on your own to make the decision.

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Either way, you need to know the questions to ask just in case you aren’t presented with enough information to make a determination best suited for your situation.  Here are some tips:

Changing your Medicare Plan - Should I Stay or Should I Go?

by Marc Manor

For a number of reasons you may be asking yourself if you should make a change to your Medicare Insurance or Prescription Drug Plan.  I am often asked, “what do you think about this company” or “which company is best”?  Because of Centers for Medicare and Medicaid Services (CMS) regulations, I am not allowed to impart my personal opinion in answering these types of questions.  Agents are only allowed to state the facts when it comes these questions and besides, the question should be which plan is best for you in your situation based on your doctors, ongoing medical concerns, and the prescription drugs you are currently taking.  When it comes to Medicare Insurance Plan performance, it’s all in the stars!

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Each Medicare Advantage (Part C) and Prescription Drug Plan (Part D) are assigned a star rating by CMS each year.  That is the objective criteria we as agents can use to let you know how that company performs.  The star ratings are assigned using a system of surveys that are compiled using information that is obtained from providers and members, among others.  But star ratings alone are not the only indicator of whether you should make a change or not.  Here are some things to think about before making a change:

Be Prepared for Long-Term Care with Clear Communication

By Marc Manor

Most of us are horrified as the prospect of being in a position of no longer being able to care for ourselves.  We are horrified for two reasons:  First, we don’t like the idea of not being able to carry out our own “Activities of Daily Living” (commonly known as ADLs) which are those activities required for one to adequately take care of themselves (bathing, bathroom, mobility, dressing, self-feeding etc.); and secondly, we really don’t like the idea of our spouse or children changing our diaper!  

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It is hard to imagine ourselves getting to the point where we cannot function on our own, but assisted living and nursing homes are full of people who probably felt the same way just a few short years ago.  The reality is we are all just one accident or illness away from that horrible reality.  Some of us think about how we will handle the possibility of requiring long-term care, yet others don’t seem to think of this as a priority.  As someone who has dealt with this situation for both of my parents, I highly recommend discussing the possibility with those you love and trust and have a plan in case long-term care becomes a reality.  Some of the most well thought out financial and estate plans have been derailed because of long-term care requirements.  Here are some things to consider:

Tiers of Sadness...Tiers of Joy: Strategies for Medicare Prescription Drug Plans

By Marc Manor

The plight of those Medicare beneficiaries that take one or more high cost prescription drugs can be challenging; and as with anything in the Medicare Advantage or Prescription Drug Plan (PDP) world, the landscape can be foggy and difficult to sift through to find affordable solutions. Sometimes, it may be possible to save a few dollars if we take the time to research a few variables. Prescription drugs are categorized in “tiers” that relate to the coverage level according to the benefit schedule of each PDP. As a rule, the higher the tier, the more expensive the drugs will be for the consumer (and the plan). I say “as a rule,” because there are some exceptions to the rule if one digs deep enough and searches through several variables.

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Generic vs. Name Brand Drugs

Why Have an Agent?

By Marc Manor

With all of the1-800 numbers and websites loaded with forms and automation, why would someone need an agent to assist them with their Medicare or healthcare related insurance? When it comes to Medicare or healthcare related insurance, having an independent agent may be one of the best values in the universe!

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Where else can you get someone to research, analyze, and educate you on benefits as well as sort out the options across the vast horizon of the healthcare and Medicare insurance options? And all this without charging you a fee for these services! Now that’s value!

Of course, there may be a cost associated with insurance premiums and benefit schedules. However, independent agents almost always work to get you the best insurance plans that specifically meet your needs and budget. And yes, I realize there may be a few unscrupulous bad apples out there trying to “steer” or “up-sell” customers; but, there are several ways you can sift out these bad apples to improve your changes for a great agent experience.

Surprise! Surprise! Surprise! It’s a bill!

By Marc Manor

Those of us old enough to remember “Gomer Pyle”, can visualize the scowl on Sergeant Carter’s face when Gomer revealed his many surprises!  Surprises can be great but not when it comes to healthcare insurance claims, most of us want to our bills to be exactly what we expect – NO SURPRISES! 

Healthcare insurance claims are based on a long list of medical codes that are associated with each treatment, diagnosis, and/or medical procedure.   The codes are entered by medical data entry people to base them on a patient’s chart or doctors notes.  The codes have a variety of uses in the medical field but the codes that are probably most important to us as healthcare insurance beneficiaries are the ones correlated to our healthcare benefits.  The codes submitted to the insurance company will determine how claims will be processed.  Allow me to provide you with some examples that may help in understanding how the codes affect healthcare insurance claims:

“I received a bill for a recent lab test.  I thought lab tests associated with qualified preventive care was 100% covered!”

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Preparing for Annual Medicare and Healthcare Insurance Renewals

By Marc Manor

With Medicare Annual Enrollment Period (AEP) and Healthcare Open Enrollment right around the corner, I thought annual renewals would be a timely and appropriate subject for this week’s blog.  Many of our clients want to know what this means to them. People looking for healthcare or a change in providers want to know when and how they can make those choices when the time comes.  Because AEP and Open Enrollment  coincide with the holiday and shopping season, it’s important to have a plan before the throws of shopping and family consume us. Here are some questions to consider:

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Is my current Medicare or healthcare plan the right fit?

If your Medicare or healthcare plan is providing you with all the coverage you need, and it fits your budget, then you should likely stay with where you are.  Your provider probably already has the information they need and you have become familiar with the benefit schedule, co-payments etc.  If this is the case, you may want to just stay put and roll into next year with the same plan. 

I got a letter about “renewal” what does this mean?

Avoiding the Pain of Healthcare Privacy!

By Marc Manor

Everyone loves the Health Insurance Portability and Accountability Act of 1996 (HIPAA), right?  I say that with a little more than a tinge of sarcasm because we all know that HIPAA is a necessary evil when it comes to protecting our privacy and, in many cases, our identity.

HIPAA seems like such a necessary requirement that I am dumbfounded it was not enacted until 1996!  I clearly remember the days early in my military career when we routinely plastered our social security number on everything we owned as a means of identification!  What were we thinking?  To think of all the sophisticated computer hacking that is done to steal someone’s information these days, while for many years, all someone had to do was pick through the garbage!  But I digress! 

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HIPAA is an essential part of the healthcare industry as well as affecting everyone who uses any healthcare service.  These regulations were enacted for your protection, and they are interpreted with only the slightest variation among healthcare providers and insurance companies.  Almost all err on the side of caution and interpret HIPAA with strict adherence.  Those who fail to comply with HIPAA guidelines are subject to fines of up to $50,000 per violation with a maximum $1.5 million annual ceiling. While this measure ensures compliance, sometimes it can make it difficult to have someone else act on your behalf with doctors, hospitals, or insurance companies. 

Medicare Myth Busters: Medicare Supplement (Medigap) and PPO Plans

By Marc Manor

Welcome to a series we call “Medicare Myth Busters”!  So much of what I hear about Medicare comes from word-of-mouth.  We know from our childhood, the game “telephone” can drastically transform an original message to something completely different.  Because I hear Medicare beneficiaries talk, I would like to help separate some fact from fiction on some of the most common Medicare misconceptions that I hear. We will insert the "Medicare Myth Busters" into the regular blog on occasion as we continue to advocate for our Medicare beneficiaries.  The first myth buster in the series is:

Courtesy Pixabay

“My Medicare Supplement Plan F is a PPO (Preferred Provider Organization) so I can go to any doctor that accepts Medicare and I don’t need referrals.”

Setting the Course for Your Medicare Voyage

By Marc Manor

You’ve already had that milestone birthday and reached the big six-O; you survived mid-life crisis and now you can access your IRA without being penalized!  So, before you ponder that next milestone birthday at age 70; let’s talk about that big 65^th!  Sixty-Five is really something to be excited about because that is when you will likely become eligible for Medicare. 

Photo by Pineapple Supply Co. from Pexels

Now you have reached the age of eligibility and you can look forward to the Medicare benefits you have been working toward all these years with your hard-earned tax dollars!  You are enrolled in Medicare Part A and B, and you have received that nice red, white, and blue card and are all set to go, right?  Not so fast!  Low and behold there is a fork in the proverbial Medicare road!  Do you stay on Original Medicare or Medicare Advantage (otherwise known as Part C)?

Medicare and Veterans

By Marc Manor

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One day I was in a Veterans Administration (VA) clinic waiting to be helped. I overheard a man complaining that he was charged over $1000 from the nearby military hospital for emergency services.  Of course, I had no way of knowing this man’s VA status or the history of his military service, but he looked to be a Vietnam era veteran.  While I did not really know anything about this fellow Veteran, I could not help but wonder what the circumstances were regarding this bill he received.  He returned to his seat next to me, and I asked him if he tried submitting a claim to Medicare or his healthcare plan.  He said he only received medical care from the VA and he did not have Medicare or any other healthcare insurance.  I did not question him further, but it seemed like he did not understand he could have Medicare while using his VA benefits.

What options do Veterans have when it comes to healthcare after become Medicare eligible in civilian life?

HMO Is Not a Four-Letter Word

 By Marc Manor

In the course of talking to people about Healthcare or Medicare Plans, I sometimes hear the words “no-way!” when the subject of HMOs or Health Maintenance Organizations come up.  In certain circumstances, after hearing why this immediate response was given, I totally understand.  Other times, I think these negative opinions are derived from “urban legends” or based on “what happened to my friend’s friend.”  Anyone could have a bad experience for any number of reasons on any type healthcare plan.  A healthcare plan is not necessarily bad just because it’s an HMO.  It may not be the right fit for some people; however, there are some things you should know before you just write-off a plan just because it is an HMO.