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Medicare Advantage Ghost Networks
- Thread starter somarco
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Packerland
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StephanieCJ
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One of the bigger (but not great reputation with agents) companies introduced MAPD plans to my area a couple of years ago. I had pretty much determined that I would not be writing the plan except in extremely specific circumstances, but since I already had them for PDP, I would at least look at their plans. I emailed the broker manager for the state asking for more information, and he asked if he could call me. When we got on the phone, he was very excited about their Part B giveback, flex card, and other features. When I asked about network, they had 1 hospital from our area (a tiny hospital) and no cardiologists, but had somehow managed to get a plan approved. I bluntly told him that I couldn't sell a plan with a network like that but to get back with me if they had any changes. I still haven't sold that plan. I can verify that ghost-networks (didn't know that's what it was called but it makes sense) do in fact exist. The call-centers got a lot of people into plans with this company the first year using the TV commercials that we all hate. I received 13 referrals from one doctor's office during OEP that year to get their clients back into plans that covered the doctors and medications these people used.
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- #14
Ghost networks were new to me as well . . . but the title drew me in so I decided to offer it to the forum for those who have an interest in ongoing education beyond the required CE credits.
"Hidden providers" is a term that has been used more often, at least with insurance circles, and refers to folks who treat you (often in a hospital) but are non-par and the occasional opt-out provider. Hidden providers include P.A.R.E (sometimes rearranged as R.A.P.E.) claims . . . Pathology, Ambulance, Radiology, Emergency.
These are areas where you will most often encounter hidden providers who often are not hospital employees, but work for a firm that contracts with providers. I have a client that is an ER doc who works for such a firm. She covers 3 or 4 states and generally does 2 - 3 week stays at each hospital. The company she works for participates in Medicare but not MAPD.
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StephanieCJ
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- 660
So the "hidden providers" that you mention, such as hospitalists, ER docs, etc. don't generally tend to be an issue. For example, almost no anesthesiologist is in any network. If the HMO MAPD has a contracted price of $150 for an out-patient surgery, that is typically billed by the hospital where the procedure was done. The co-pay covers doctor, anesthesiologist, and facility. Patient should only get one bill because the hospital in that instance works out payment with the surgeon and anesthesiologist. ER visit of $90 covers the doctor at the emergency room whether or not they are in-network on the plan.
The big issue goes to fighting against agents/call centers signing people up for things they don't understand. Telling someone "since it is a PPO, you can go to any doctor that takes Medicare." While that may technically be true, the agents often don't cover the higher price for out-of-network care or the fact that a doctor is not obligated to see a patient enrolled in a plan for which he does not hold a contract.
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- #16
Amplification . . .
Hidden providers are indeed anyone who bills the patient, not the facility, and is non-par typically with ANY managed care plan (HMO, PPO, etc). These folks will not show up on any provider list provided by a carrier. Some take assignment for OM, some don't.
We ran into that a few years ago when my wife broke her hip, admitted to the hospital via the ER, and we got a number of bills from folks not on staff at the hospital and non-par with any managed care. There was a doc (don't recall if he was classified as a hospitalist or not) who "checked" on her every day. The radiologist that read her X-rays from the ER was another hidden provider, as was the assistant surgeon (who billed more than the primary surgeon). There might have been 1 or 2 others but those are the ones that stand out.
A ghost provider appears on a carrier list but they do not have a contract with the MCO so the patient THINKS they are a par provider but in fact are not.
Like the hidden provider, you may not find out their status until a bill arrives in the mail.
Preaching to the choir . . .
It's not just the cost differential with non-par providers but also the provider must agree to the terms and conditions of the MCO agreement if they want to be paid by the carrier.
Hidden providers are indeed anyone who bills the patient, not the facility, and is non-par typically with ANY managed care plan (HMO, PPO, etc). These folks will not show up on any provider list provided by a carrier. Some take assignment for OM, some don't.
We ran into that a few years ago when my wife broke her hip, admitted to the hospital via the ER, and we got a number of bills from folks not on staff at the hospital and non-par with any managed care. There was a doc (don't recall if he was classified as a hospitalist or not) who "checked" on her every day. The radiologist that read her X-rays from the ER was another hidden provider, as was the assistant surgeon (who billed more than the primary surgeon). There might have been 1 or 2 others but those are the ones that stand out.
A ghost provider appears on a carrier list but they do not have a contract with the MCO so the patient THINKS they are a par provider but in fact are not.
Like the hidden provider, you may not find out their status until a bill arrives in the mail.
Preaching to the choir . . .
It's not just the cost differential with non-par providers but also the provider must agree to the terms and conditions of the MCO agreement if they want to be paid by the carrier.
