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December 11, 2023

Medicare Advantage Plan Network Issues

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Question:  My sister is thinking of enrolling in a Medicare Advantage plan. In our practice, we have issues with pre-authorizations and denials. I’ve warned her about network issues. Is there anything else I should tell her?

Answer: I’m so glad you asked. I’ve had this conversation with my own family and friends.

Medigap plans

If you enroll in a Medicare Advantage plan and then want to return to original Medicare, you may not be able to get a supplemental Medigap plan. If you enroll in original Medicare when you are first eligible, you are guaranteed to be able to obtain this secondary coverage. But, unless you live in Connecticut, Maine, Massachusetts or New York, your application for a Medigap plan can be rejected for pre-existing conditions.  

This is a big deal. With Part B alone, a patient can have large out of pocket costs. There isn’t an upper limit on how high those costs can be. So, enrolling in a Medicare Advantage plan can keep you locked into Medicare Advantage because even if you want to switch to original Medicare, you may not be able to get a Medigap plan.

Low premiums, additional benefits, network issues

You may be locked in and not able to switch back to original Medicare, is that all that bad? There are low premiums and additional benefits that beneficiaries in original Medicare may not be eligible for.

One word: Network. Many Medicare Advantage plans are HMOs. That is, there are in-network and out of network benefits. If you’re diagnosed with a serious condition, will the physician you want to see be in network? What if you need care when you are traveling? There have been news articles about Medicare Advantage plans limiting access to rehab. 

Here is an example:

  • Feds Rein In Use of Predictive Software That Limits Care for Medicare Advantage Patients

Now is the time that cable tv is offering us great deals! Call now!  CMS is going to provide additional oversight of these ads. It’s about time.

You can read more about that here:

  • The Medicare Advantage Marketing Problem and Where It’s Headed

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Last revised October 17, 2023 - Betsy Nicoletti

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2023 E/M guidelines for hospital, nursing facility, home and residence services | Webinar

Effective January 1, 2023, the AMA has revised the definitions and guidelines for hospital and other E/M services, including ED visits, nursing facility services, home services, and domiciliary care codes. Also, coding for prolonged care services gets another overhaul with revised codes and guidelines. Watch this webinar about all these changes.

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Our mission is to provide up-to-date, simplified, citation driven resources that empower our members to gain confidence and authority in their coding role.

In 1988, CodingIntel.com founder Betsy Nicoletti started a Medical Services Organization for a rural hospital, supporting physician practice. She has been a self-employed consultant since 1998. She estimates that in the last 20 years her audience members number over 28,400 at in person events and webinars. She has had 2,500 meetings with clinical providers and reviewed over 43,000 medical notes. She knows what questions need answers and developed this resource to answer those questions.

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