Medicare What's Buzzing

Medicare Advantage plan “prior approval” rules could stick you with huge medical bills

Written by Diane Archer

The Medicare Rights Center just released a report illustrating how people with Medicare who are enrolled in Medicare Advantage plans can get stuck with huge bills even when they use in-network doctors. They didn’t understand Medicare Advantage plan “prior approval” rules.

Medicare Rights Center’s client thought he was following his health plan’s rules when he received surgery from an in-network doctor. The health plan had told him he did not need a referral from his primary care doctor to be covered.  But, because his health plan requires “prior approval” for surgery–an OK from the health plan to go ahead with the procedure, which is different from a referral–and he had not secured it–he was stuck with a $12,000 bill.

People with Medicare have appeal rights, and most people who know how to appeal win. Had the client understood how to appeal the denial properly, he most likely would have won on appeal because the health plan did not tell him he needed prior approval, and the in-network doctor did not secure prior approval as he should have known to do.

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