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In physicians’ offices across the city, Medicare patients are receiving a rude awakening when they pull out their insurance cards for the co-pay.

They’re finding out they signed up for a Medicare Advantage plan that doesn’t include their physician, and the exam they just received will be an out-of-pocket charge. In fact, they find out, this new plan doesn’t include any of their physicians or specialists and may not even be usable at their hospital.

“When (patients) show up in my office, they have no idea they’ve enrolled in a plan we’re not participating in,” explained Dr. Keith Anderson, cardiologist at Sutherland Cardiology Clinic and president of the Memphis Medical Society. “A lot of them think they’re signing up for a supplement (to traditional Medicare).”

Seniors have been targeted by insurance companies, which are making claims that patients will be able to keep all the physicians in their network with lower out-of-pocket costs. Some of the sales and marketing directed toward seniors do not willingly provide physicians and hospitals with correct or current information.

This scenario has played out time and again as steps are being taken to inform patients about such misinformation. Bill Appling of J. William Appling and Associates, a physician management company in Memphis, worked with patients and physicians during the last quarter of 2007 to increase patient education and impede the efforts of insurance agents using deceptive sales tactics.

Some of the more questionable tactics include television and newspaper advertisements announcing meetings where patients can learn how to get improved benefits from Medicare, and receive free gifts.

“Many of these locations for information are in areas of Memphis where there are no primary care physicians, specialists or hospitals signed up, yet some of these companies are representing to these elderly Americans that they will see no change in where or who they see,” Appling explained, noting that some patients have even been approached at pharmacy counters.

The majority of patients Appling worked with did not realize they were selecting a Medicare Advantage program that replaces their traditional Medicare program.

“With all the Advantage plans being sold, not to mention seniors choosing Medicare supplemental plans and the pharmacy Part D plans, these poor people are more than confused. They’re outright misled,” said Appling. “Because these plans can sell their products without having a full panel of specialists that they would normally see for particular conditions that affect the elderly, many are left in the lurch.”

In fact, many Memphis physicians and specialists are reluctant to join Medicare Advantage programs due to restrictive guidelines and limited patient education about the plans.

Anderson explained that Sutherland Cardiology, which has a 45-50 percent Medicare patient base, is not enrolled in the Medicare Advantage plans because of the hindrance to care and increased costs involved with the heavy utilization review.

“To be able to take these plans, we’d have to hire more people to do the plans and right now that is not desirable,” maintained Anderson. “We’d be interested in plans if they could allow us to take care of patients without all this utilization review.”

In the meantime, Anderson is explaining to patients the realities of switching to Medicare Advantage plans.

“They may have less out-of-pocket but access is limited, and they need to know that,” he said.

A primary care physician with Medical Care Specialists, Dr. Jeff Warren, said his group has a 30-35 percent Medicare/Medicaid patient base. The group originally enrolled with Medicare Advantage a couple of years ago with the intention of offering more options to patients, but they soon found it was impeding care.

Warren’s group primarily refers to specialists and acute care through Methodist Healthcare, a system which currently does not accept any of the Medicare Advantage plans. This led Warren and his colleagues to reassess the impact it was having on their patients. They subsequently dropped all Medicare Advantage plans and sent letters to their patients.

“We don’t want to be unable to get patients to specialists or the hospital when they need it,” he said. “We’ll probably lose 5 percent of our patient base because of the Medicare Advantage plans (but) after looking at it, it’s not the best thing for our patients.”

The Methodist network does not include any Medicare Advantage plans, explained Bill Breen, CEO of HealthChoice LLC, because they were extremely skeptical of the marketing practices of start up insurance companies.

“We want them to value patient education,” Breen said.

Health Choice is waiting to join Medicare Advantage programs until they have the terms they want, which means greater reimbursement rates to physicians as well as patient education.

In response to reports about fraudulent sales tactics, large Memphis insurers voluntarily agreed to a new code of conduct to curb abuses by various private insurance plans. In Tennessee, BlueCross BlueShield of Tennessee, Conventry, Humana, Sterling, United Healthcare, Universal American Financial Corporation, and Wellcare agreed to cease marketing and sales abuses. However, federal law does not allow state insurance commissioners such as Tennessee’s to pursue Medicare Advantage plans for fraud, as they can with other private health insurers.

“Because of the money to be made by these private plans and the high sales commissions being paid to the sales people of many of these plans, these abuses of the elderly will continue until the federal government, who authorized these plans back in 2003, changes or more intensely monitors some of they ways these plans are marketed,” maintained Appling.

Appling has helped patients who did not want to lose their traditional Medicare re-enroll. The federal government is retroactively paying charges incurred on Medicare Advantage plans for patients who were misled or confused.

“The personnel at most physicians’ offices I’ve visited with have felt for these patients and have assisted as best as they can to help,” Appling concluded. “My hat’s off to the office people who truly show a sense of caring for these people.”

Medical staffers who encounter patients who believe they have been misled or are confused about enrolling in one of these Medicare Advantage Programs can direct patients to the Medicare help line at (800) 633-4227. Patients can also get impartial information on these Advantage programs, original Medicare, prescription drug plans and Medigap supplementary policies and compare cost and benefits at www.medicare.gov.



January 2008

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