Ask the Medicare Specialist

QUESTION:

From Mark: Yesterday I followed my doctor’s order and got shingles and tetanus vaccines at my Part D plan’s Preferred pharmacy. I nearly fell over when told the copays were $190 and $60. And, I have to go back for a second shingles dose that will cost another $190. I got the impression this is a common experience. If so, I can accept the unfairness, although I believe someone at the pharmacy should have told me when I completed their complicated pre-registration process about the costs. I want to ask you if this is common and if I should have done something differently? Either way, I was upset to say the least.

ANSWER:

I don’t blame you. Your question and concern remind me how important it is to ask questions of your medical, dental, and prescription providers prior to services and drugs being rendered or filled. You also need be aware of what your benefits are, how they work, the fine print, etc. It’s surprising how many people don’t know what it would cost if they needed chemotherapy or had a lengthy hospital or skilled nursing stay. There’s so much information regarding Medicare and insurance policies. No matter how much time we spend explaining the intricacies, it’s impossible to cover every scenario and easy for a client to forget or overlook something. It’s also uncommon for a provider to do the extra leg work to ensure there aren’t any surprises like the expensive one you got. You did nothing wrong Mark. And it is normal to pay high costs for Shingles and other vaccinations that are considered Part D drugs, not for those with Advantage Plans, but for people like Mark who have Supplements and must buy Stand Alone Part D prescription plans. Let me explain. Virtually all Stand Alone Part D plans are subject to a $445 deductible on Tier, 3, 4, and 5 medications, which Shingrix, the most common vaccine for Shingles is. Any drug in those Tiers will be the full responsibility of the insured until the $445 has been satisfied. Mark had not yet met any part of his deductible at the time of his vaccinations.

Should the pharmacy have disclosed the cost prior to Mark being administered his shot? In my opinion, yes. I’m sure Mark isn’t the first person to complain about being blindsided. But pharmacies are busy places. The employees working at the register may not be versed or experienced on the ins and outs of health insurance and Part D. They simply enter your insurance information into a computer program and then are fed back the dollar amount you owe. They don’t know if the drug is on formulary or not, if it’s an expensive Tier 4 medication, if you’ve met your deductible, or if you’re in the Donut Hole. We tell clients to keep our office phone number handy so if they ever show up at the pharmacy and are told the cost of their meds is hundreds of dollars, to call us first so we find out why. Once you’ve taken possession and paid for a medication, it can’t be returned. And if a drug isn’t on formulary, it doesn’t even count towards the deductible!

Doctors and pharmacies deal with so many different insurance plans and companies, which unfortunately can lead to surprise charges from time to time. Another we come across is a medical provider accepting one’s insurance card without making sure they’re actually in network prior to services being provided. There are now approximately 80 Medicare Advantage Plans available. The same company can have multiple plans that can be either in or out of network with the same doctor. The person who greeted you at the front desk recognizes the card as one that many of their patients have and doesn’t give a second thought to the doctor being out of network, an understandable mistake. It’s not until after the claim is denied by the insurance company that the patient finds out they’re on the hook for the entire bill. I’ve found that most doctor’s offices will work with the patient to get the charges reduced in this instance, but we’ve had others who won’t budge.

Here’s something I’d like to advise everyone who has an HMO or PPO Medicare Advantage Plan to do prior to having outpatient surgery; Ensure that all nurses who could possibly be administering anesthesia are in network! At times, even our largest health care systems must import anesthesiologists from out of the area who may not be contracted with your Advantage Plan. This can result in additional bills in the thousands of dollars. I just recently had a client who found themselves in this very situation. With a shortage of employees in virtually all industries including health care, I’m afraid it may become more common.

One other issue that can happen with Advantage Plan HMO’s or PPO’s is having a claim denied or a hospital stay cut short. Let me be clear, it doesn’t happen often, but does occur. Just this past weekend I got an email from a concerned daughter. Her mom’s Advantage Plan denied a Prior Authorization to have a Skilled Nursing Facility stay covered. We’ve had instances where clients were told physical therapy would be required prior to having outpatient surgery performed or getting an MRI. We’ve also seen claims for those services completely denied. Dental claims can also be denied or limited, which is happening quite a bit lately. Insurance is confusing. That’s the bottom line. And maybe none more so than health and Medicare, with so many moving parts and options, as well as the sheer number of times claims are made. There are bound to be issues. You have to advocate for yourself and ask questions such as: Is a brand name drug, test, or procedure really necessary? Is there a lower cost alternative?

Insurance companies with better reputations for providing excellent member services can be great resources. I take advantage of what they provide myself. Recently, I was disappointed in my PCP’s lack of concern about some long term COVID symptoms I’ve experienced. I called UPMC, explained the situation and asked them to refer me to someone. Turns out they have a “COVID Long Hauler Team,” as they call it. A nurse set me up with an appointment which occurred just two days later. I can’t tell you how pleased I was with the attention, advice, and information I was given. As I’ve mentioned in countless columns, we provide our clients advocacy and support for any issues or problems even remotely related to their insurance policies. We don’t accept answers such as, “I’m sorry, but that’s just how it works.” When we know a client has been a victim of an honest, or not so honest mistake, has something that wasn’t disclosed properly such as an anesthesiologist being out of network prior to a surgery, a claim that was denied when there indeed was medical necessity, among others, we get involved immediately and do not stop fighting with providers, insurance companies, billing departments, etc., until the issue is resolved to our and the client’s- satisfaction.