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How Cigna Saves Millions by Having Its Doctors Reject Claims Without Reading Them, ProPublica March 25, 2023 - UPDATE: CIGNA IS BEING SUED OVER THIS!

Mary

Moderator Resource
Messages
17,335
Location
Southern California
Last edited:

Mary

Moderator Resource
Messages
17,335
Location
Southern California
From the above article:

A more market-driven approach would be better able to adapt to consumer needs. For example, in Medicare Advantage, seniors can choose between competing plans that often offer more benefits at lower costs than traditional Medicare.

This idea does suck a lot of patients in - the idea of getting more for less - until in actual practice one's claims are routinely denied without adequate oversight and patients are forced to file appeals to get claims paid (see Cigna article above). And even then there's no guarantee that claims will be paid.
 

perchance dreamer

Senior Member
Messages
1,691
I got on Medicare last year and did a lot of research to figure out the type of plan best for me. I got traditional Medicare with a good Plan G supplement. For the most part, it's been great. I haven't been challenged about whether I really need a test or treatment, and I don't have to get a referral to see a specialist.

My sister went for Medicare Advantage and really regrets it now. When she had covid, they didn't let her have Paxlovid until day 5. Another time, they denied her the RSV test although she had the symptoms. She wants to get off Advantage and onto traditional Medicare, but it is exceedingly difficult to do so.

Medicare Advantage was a gift to the private insurance companies granted by one of the former presidents.

Here's a New York Times article about Medicare Advantage corruption.

https://www.nytimes.com/2022/10/08/upshot/medicare-advantage-fraud-allegations.html
 

Mary

Moderator Resource
Messages
17,335
Location
Southern California
I got traditional Medicare with a good Plan G supplement. For the most part, it's been great. I haven't been challenged about whether I really need a test or treatment, and I don't have to get a referral to see a specialist.
I've been on Medicare for over 20 years (since I went on disability). I initially signed up for a Medicare Advantage plan, and then quickly discovered there no doctors I wanted to see who took Medicare Advantage plans. So I switched to straight Medicare and paid the 20% copay for many years, preferring that to seeing HMO doctors. And then last February I tried (second attempt) to get a Medicare Supplement plan to pick up the 20% copay and to my surprise quickly qualified, also a plan G. This was unusually fortuitous in that I unexpectedly ended up in the hospital for 2 weeks and needing a couple of surgeries/procedures the following month, after no hospitalizations or anything for years and years. And it's all covered now at 100%, no questions asked.

When she had covid, they didn't let her have Paxlovid until day 5. Another time, they denied her the RSV test although she had the symptoms. She wants to get off Advantage and onto traditional Medicare, but it is exceedingly difficult to do so.
Exactly - these are some of the pitfalls with Medicare "Advantage" plans. However, it's not difficult to switch to original or traditional Medicare - that part is very easy to do, though you might have to wait for the open enrollment period to do this - I'm not sure about whether you can only do this during the open enrollment period.

What can be difficult is qualifying for a Medicare Supplement (also called Medigap) plan. From the Medicare.gov website:

  1. The best time to get a policy is during your Medigap Open Enrollment Period.It’s the 6-month period that starts the month you turn 65 and you first have both Medicare Part A and Part B. During this time, you can buy any Medigap policy sold in your state, even if you have health problems.
    If you’re under 65, you may not be able to buy a Medigap policy, or you may have to pay more.


You can apply to enroll in a Medigap (Supplement) plan at any time - you don't have to wait for open enrollment. However, if this is done after the 6-month period referenced above when you first qualify for Medicare, your policy has to be underwritten. Being underwritten means you can be denied for pre-existing conditions, and you have to answer a series of questions about your health. So getting accepted all depends on one's health and the company providing the policy. I had initially applied for a Supplement plan about 4 years ago and was denied because of a Moh's surgery for basal cell cancer (skin cancer) - the best kind of cancer to get, it doesn't metastasize or kill you etc. And yet the company considered it cancer "surgery". Okay - I re-applied last January and this time the questions had changed and Moh's surgery no longer was a deal breaker, and they gave me a policy. And it was more affordable than I had anticipated - $100 a month.

I recommend using United Medicare Advisors (unitedmedicareadvisors.com) for applying for such a policy - I had a very knowledgeable agent, she was extremely helpful and even recommended I apply with the company which had the cheapest premium, to my surprise. She explained why they were better than some of the companies with more expensive policies (more financially stable among other things).
 

Rufous McKinney

Senior Member
Messages
13,251
Medicare Advantage was a gift to the private insurance companies granted by one of the former presidents.

Here's a New York Times article about Medicare Advantage corruption.

my plan was "a benefit I earned working".

on repeated occasions recently, health care experts indicated its not a benefit

It's my intention to contact my employer and point out these discrepancies in "benefit".

However, since I experience CFS, I may not know when I am getting around to "that" likely futile exercise.
 

linusbert

Senior Member
Messages
1,119
my plan was "a benefit I earned working".

on repeated occasions recently, health care experts indicated its not a benefit

It's my intention to contact my employer and point out these discrepancies in "benefit".

However, since I experience CFS, I may not know when I am getting around to "that" likely futile exercise.
the problem imho isnt the medicare insurance system but the tolerated corruption of insurance companies by the government.
its pretty obvious what they are doing, and they are just allowed to do that. in germany the same. my insurance company wanted tons of paperwork and justifications by doctor why i would need insulin, in their eyes its not necessary. at that time i had blood sugar of far over 200mg/dl and oral medication was already used.
i mean its a clean case, but they are allowed to annoy customers indefinetely.
its always the same, the law protects the criminals and corrupt. its not made for civilians.
 

Mary

Moderator Resource
Messages
17,335
Location
Southern California
Why is it just CIGNA?

My insurer denies every claim I have ever submitted, and every referral.
They probably all use the same damn algorithm!

You have a Medicare advantage plan right? If you do, they are so flawed. And people get sucked into them and then can be hard to get into a straight Medicare supplement plan because of pre-existing conditions.

Tho you can switch to straight Medicare (without a supplement plan) - It's very easy to do that, where you have a 20% copay for most things except for lab work is paid at 100% by Medicare. But getting the supplement plan to pick up that 20% can be difficult, depending on one's health etc.

I've never had straight Medicare deny me a treatment that was recommended by a doctor as long as it was covered by Medicare. I think this is a huge advantage over the Medicare " advantage" (disadvantage!) Plans.
 

Rufous McKinney

Senior Member
Messages
13,251
every referral.

maybe that was when I had HMO....(referrals were universally messed up and handled as rejected..you have to resubmit repeatedly)- now I don't often ask for any referrals due to having a PPO type thing.

My employer has to provide me insurance, and can't drop me so I am lucky there.

I'm leaving soon, and won't be accessing my insurance. Given its taken me six years to possibly move, not sure how readily I'll be bopping back here, to visit the doctor's office....