Medicare Advantage PPO: See any doctor?
Can I go anywhere with my Medicare Advantage PPO?
Many companies are telling clients they can go anywhere with a Medicare Advantage PPO.
This sounds great!
I can go see any doctor or hospital regardless if they are in the network or not. That’s the flexibility I want!
But there’s a catch. And it’s usually buried in the fine print somewhere like an Evidence of Coverage document which is often more than 200 pages long.
Providers non in the network not required to treat you
Here is an excerpt from one company that touts your ability to go to any provider you want with their PPO Advantage plan:
“As a member of our plan, you can choose to receive care from out-of-network providers. However, please note providers that do not contract with us are under no obligation to treat you, except in emergency situations.”
That’s right. It says no obligation to treat you, except in emergency situations.
2 groups have to agree
Your insurance company is 1 part of the agreement that both have to say yes for you to get treatment covered out of network. It’s helpful that they allow you to do this.
But it’s only half the story.
The other party who has to agree is the provider. So if the doctor or hospital decides not to treat you, they don’t have to. Because we already know they’re under no obligation to do so.
So if they’ve had a problem with billing and getting paid from Advantage plans before then they may decide not to.
Which puts you in a tough spot.
Because if you don’t get treated, you aren’t getting the care you need.
What about submitting claims for reimbursement?
It’s true, many PPO plans allow you to pay for your services and then submit a receipt for reimbursement.
But if the provider won’t treat you, you can’t even submit a claim to your insurance company for reimbursement.
So this doesn’t help you at all.
And if they did agree to treat you, would you really want to pay the bill yourself. File paperwork to an insurance company and wait for them to reimburse you?
How long is it going to take to get reimbursed? I don’t know that answer, do you?
Also what’s the process for getting reimbursed? Well here’s something else buried deep in an evidence of coverage document:
“If we decide that the medical care or drug is not covered, or you did not follow all the rules, we will not pay for our share of the cost. Instead, we will send you a letter that explains the reasons why we are not sending the payment you have requested and your rights to appeal that decision.”
That’s right, if you did not follow all the rules, we will not pay for our share of the cost.
What are the rules? Do you know them all?
You better
What about emergency coverage?
Yes, emergency situations are covered as in network. And providers are required to treat you.
But in order for it to be covered, do you know the definition of an emergency?
Here’s one definition:
“A “medical emergency” is when you, or any other prudent layperson with an average knowledge of health and medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The medical symptoms may be an illness, injury, severe pain or a medical condition that is quickly getting worse.”
So life or limb emergency. Not just going to the emergency room.
What if the provider does treat me?
Great!
You are getting the treatment you need. But your costs for that treatment might be higher. Here’s more to read:
“However, if you use an out-of-network provider, your share of the costs for your covered services may be higher.”
So your costs could be higher than you expect.
What’s the bottom line?
PPO plans do you give you a lot of flexibility. But it’s not unlimited. So Medicare Advantage plans may not actually be cheaper than a Medicare supplement.
I think Advantage plans can be a good fit for a lot of people. But there’s key things you need to know BEFORE you sign up. And not after. Unfortunately, some people find out unpleasant surprises when they need their coverage the most.
If you need help sorting through this Medicare maze, please call me directly at 855-712-7316 or fill out the form below.