One thing that isn’t mentioned is the use of temp MDs. I’m not sure whether this is still the case or how widespread it is, but some of my Kaiser lung patients told me they saw a different new lung doc every six months fit several years and didn’t feel they were getting the continuity of care they or their family desired.
I know when I got sick between my regularly scheduled MD appts with my internist, I could only be seen by urgent care. Because that new doc didn’t know me, we spent literally an hour talking about my medical history and figuring out what I should have done with my current symptoms.
She recommended and tried to pre-authorize a lung ct scan. I was able to be seen by my lung doc a day or so later and we agreed no lung ct scan was needed at this time and I was given appropriate treatment to clear the infection. The visit was much shorter and more productive because I have a long term relationship with the lung doc.
Does Medicare require a referral to a specialist? Such that PCP denying new Medicare patients also inhibits their ability to get in to see specialists?
I believe as long as your specialist accepts Medicare, you don’t need a referral. At least that has been our experience. I walked into an orthos office last year and made myself an appointment to see a doc regarding my knee. I had a partial knee replacement as a result of that visit. My PCP had nothing to do with this.
I’m thinking it is possible some Medicare Advantage plans might require a referral, but I’m not sure about that at all.
Traditional Medicare (Part B) and related Medicare Supplements (aka Medigap) do not require referrals. Traditional Medicare supplements can work like an open network PPO.
OTOH, if you choose Medicare Advantage, i.e., Part C, (generally most of the advertisements you see on TV), they have smaller networks and could requrie pre-authorization before seeing a specialist.
We have BCBS PPO private insurance plus Medicare A & B. H has no requirement to get referred from his primary for anything but his primary is happy to refer him if H wants a referral.
H can and has self-referred as well. His shoulder was bothering him so he went to an urgent Carr ortho place and then saw the head surgeon there who scheduled surgery for later that weak for his torn labrum.
Agree it depends on what coverage you have in addition to your Medicare as to whether or not a referral is requited for optimal coverage. Between H’s insurance and Medicare he generally has no copay or a very small one for some Rx and none for medical care. He could quit Medicare B (and just have BCBS family plan), but we don’t mind paying the premiums so we do.
Also if you have Medicare, it depends where you prefer to get care. If you choose an HMO like Kaiser, you need to follow their rules, which requires folks to see a primary and get referred.
The folks at the Dept of health, Office on Aging have an unit that helps provide good unbiased Medicare advice at no charge. They can help folks sort things out as it applies in their state.
As with many things in life and retirement, you have to go through a bit of a maze and information is power. Having experience with medical providers and understanding how medical care ‘works’ in your area and for your needs can be time saving, cost saving, and higher quality of care and medical outcomes.
For us, with DH having turned 65, we have less of those calls to get us into their Medicare ‘plan’. Some actually start a careful dialog to confuse the call recipient that they are Medicare/gov’t. Most know they never call but they obviously get some success by calling. Now I am starting to get mail plus the calls. Ugh.
But I am very excited for retirement and I can sign up in my Medicare window in a few weeks.
There are few providers and hospitals they don’t accept traditional Medicare. Switch to an Advantage plan, then you will need to travel and/or find a group practice that still takes new patients. I don’t think people understand how little advantage plans pay, at least in my area.
Yes, I think it’s a good idea to talk with the billing folks at your favorite providers and make sure they accept whatever coverage you plan to get when you start Medicare. No one needs expensive surprises. It shouldn’t be as complicated and confusing as it is for many folks, but sadly it is.
@bookworm in our area there is at least one Advantage plan that is an excellent provider - a coworker’s bed ridden mother is on it and it covers everything except for the Pick Wick system used to handle urinary incontinence (the family rents or has purchased the suction system and buy the disposable parts). It is a network in tandem with hospital employee insurance I believe - they pay first of the year deductibles and have no bills for anything. All care provided through the network.
But one has to be in a strong Advantage Plan area and also if not doing any traveling, like this woman.
Re: Medicare Advantage plans…they are NOT all restrictive and they are not all alike. I have a Medicare Advantage PPO plan. It’s through a very large group of retirees, and my Advantage plan is accepted by any doctor who accepts Medicare. There is no in and out of network coverage either. I don’t need to travel far and wide to find a doctor or hospital or anything. BUT I do understand that my plan is sort of the Cadillac of advantage plans.
I had knee replacement surgery. The anesthesiologist was not “in” my network but for my plan, that didn’t matter. Costs were paid. Total copays for the full year including my surgery, PT and my other doctors visits was $450.
Yes Advantage Plans have ‘widened’ in types of plan/coverage. Always good to have a top medical coverage plan if rates are affordable for the plan participants and give good services in-network.
The billing offices of departments can give the inside scoop about how well the plans are actually working for patients in your area. Sometimes plans that may look ok or good on paper are really a major pain to work with and constantly deny claims so providers opt to stop accepting patients covered by such plans. It’s worth asking if you don’t want to have to shop for new providers.
The price out of pocket between in network and not in network can be a lot of money!
Reminder to those approaching age 65. A few months before you have a lot of decisions to sort through. My husband (older than me) gladly took advantage of the services of a Medicare Broker … free to you, same rates as doing all the legwork yourself. Ask some local friends or financial planner for recommendations.
