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How to get the best care within the Medicare system

Coral Gables News - 6/26/2018

When I think of an insurance scams I think of companies who profess to assist in "sex addiction" (Who's not addicted to sex?), eating disorders (Really, Karen Carpenter still died.) or exhaustion (Who isn't?). But, now that I work with families in assisting their elderly parents/grandparents, I find the true insurance scam is against seniors.

The programs offered to Medicare recipients are normally HMOs (Health Maintenance Organizations) and PPOs (Preferred Patient Organizations). Under Medicare, HMOs are free whereas PPOs are usually between $25 and $30 per month. If you have an HMO your doctors must be chosen from their "organization," whereas you can choose your own doctors from a PPO.

I have a client couple, the Smiths. Mr. and Mrs. Smith have two very different needs as seniors. Mrs. Smith has dementia and lives in a nursing home. Mr. Smith, the elder of the two, lives in an assisted living center.

When I met them they had the same doctor and the same Medicare supplement plan. The physician who cared for them through their plan would speak loudly to Mrs. Smith and give her more medication to subdue her. If Mr. Smith had an ailment that she couldn't check off in her form he was sent to the emergency room for diagnosis. In one three-day period, Mr. Smith went to the emergency room twice (not the "nice" advertised ER - the one for Medicaid and Medicare recipients).

After the second stay they kept him overnight (It's the only way Medicare will pay for the second ER visit.) and diagnosed him with - ready for it - dehydration. Because HMOs need to make money from Medicare they find the least competent doctors, who in turn check as many boxes as possible to refer out to other medical practitioners so everyone makes more money.

This is why we always recommend PPOs for our clients. This allows our seniors choices in medical treatment. The healthcare improved but the insurance company does not. As part of our services we monitor the monthly billing. To date, we have had to call the insurance company more often than not for over-billing or wrongful billing.

Bottom line, you cannot expect an elderly person to actually understand insurance bills. Besides a "bill" in which money is owed there also are the more confusing documents titled "This Is not a bill."

The insurance companies actually make millions from wrongful billing because who has the time to decipher the bill ? or call and be on hold a minimum of 45 minutes with "customer service" (an oxymoron)? Then when the representative speaks he/she often does not know the answer, which means you hold, hold and hold to speak to the supervisor. Then the process repeats itself.

My way of thinking is that maybe it is easier to call yourself a sex addict, a food addict or exhausted. At least those companies know which box to check and someone makes money. Our seniors, who have added value to our country and society, certainly aren't reaping the "rewards of industry."

Frances Reaves, Esq., a graduate of the University of Miami Law School, spent 10 years as a litigator/lobbyist. Today, she Is an accomplished business woman who, when her parents could no longer take care of themselves, learned the ins and outs of senior care (or the lack thereof). She founded Parent Your Parents to assist seniors and their children through the myriad pitfalls and options of "senior care" in the 21st Century. If you have any questions or comments contact Frances at hfrancesr@parentyourparents.com.

 
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