Authorizations & Approvals – Understanding Medicare and Medicare Advantage Plans

Ashley Bills 00:07
Hello and welcome to Ask a NaviGuide, part of the Abundant Aging podcast series where we talk about aging and family caregiving and how to work through stressful situations with the help of the United Church Homes team of NaviGuides. Our NaviGuides have decades of experience helping families work through difficult situations. And today we have Robin, with us who will help us understand Medicare, Medicare Advantage and authorizations and approvals. Welcome Robin, would you like to start off by telling us a little bit about your background in the subject?

Robin Peconge 00:39
Sure. Thank you for having me. So I have about 20 years in the senior health care world where I was a broker, I worked in a little bit of claims as well as I ran a billing, I’ve managed billing departments for home health care for five years before becoming an APA guide. Awesome.

Ashley Bills 00:57
Alright, so today we’re talking about, like I said, Medicare and Medicare Advantage plans and getting approval or pre-authorizations for those health services. This might be something that most of the time we don’t think a lot about, because most of our interactions with the health care system are things like primary care visits, specialist visits, lab tests, and other things that just require copays and so on. But we know that situations may come up where you need more specialized treatments that require a pre authorization or approval, or you may be getting treatment and you didn’t know it needed a special approval until you incurred some unwanted charges. So Robin what sort of things that typically require a pre-authorization?

Robin Peconge 01:35
A lot of transitional care. So home health care therapies, skilled nursing facility visits, diagnostics, such as MRIs and ultrasounds, anesthesiologist experimental treatments, outpatient surgery, facilities, medical equipment, just to name a few.

Ashley Bills 01:58
Okay, so how do you find out from your insurance company that a pre-auth is something that’s required?

Robin Peconge 02:04
The best thing to do is to contact the customer service member number on the back of your insurance card? Unfortunately, they don’t always know the questions to ask or it doesn’t happen as planned. That’s where a lot of difficulties can arise. Yeah.

Ashley Bills 02:21
So what is the responsibility then of your healthcare provider to check whether a procedure is approved before or not you have it like is it on them? Or is it just on us?

Robin Peconge 02:35
Ultimately, it is our responsibility. However, ifit’s a plan, surgery, their billing departments are very good about that. It’s mostly an issue when it is unexpected. So if you’re at a hospital and the hospital says you’re not well enough to go home, you need to go to a facility. But let’s say the hospital had you you might have been there three days, but you were never actually admitted, you were under observation the whole time, that could present an issue on going to a nursing facility for rehab, you might have to get prior authorization here, that’s taking a couple of days and the hospital saying you can’t be here that can cause a lot of problems, a lot of anxiety for the patient and the families.

Ashley Bills 03:13
I can see that. So I guess you always think that, you know, when you call to get a preauth, at least in my experience, you always just presume it’s going to be approved. But what if you’re in the situation where the insurance plan is denying payment because of a previous authorization issue? Or, you know, what do you do if they just say, No,

Robin Peconge 03:35
That’s what happens. I’ve had residents that come even though they’re really not safe to be there. And here’s the next issue. So with home health care, Medicare says they have to come in within 48 hours of being discharged from the hospital. However, if your care really should have gone to a nursing home, and you need more care, and then what the home health care can provide, that wouldn’t cause liability issues. So they might not pick you up either for services.

Robin Peconge 03:59
And I mean, it’s just such a complicated system to navigate anyway, let alone you know, having not getting that what you need when you need it. So if there is an issue like that, what steps could you take to resolve it in your favor? Oh, my goodness, you might call the state health department. You might call your state insurance department and let them know that because of the issues that you’re having with the insurance company. Or call your company, you know, your insurance company yourself, but it’s just so hard for the families and the patients. I mean, when you’re meeting care, it’s just the last thing you want to think about.

Ashley Bills 04:36
Right? And so do you know if there’s a list or something online where you could check like if you know, something’s coming up just to see if your insurance company requires a pre authorization for that service?

Robin Peconge 04:48
Well, your Summary of Benefits always comes with Medicare Advantage plans every year they send you and even if you don’t switch plans, they will send you a Summary of Benefits and that is golden. It’s very easy to look through. Everything is just First line, you know, lined out first it goes by inpatient services, then it goes by outpatient, and so forth. So certainly having that handy, even if you don’t understand it, usually the discharge planner, if they’re looking through it, they may not know because as we’ve learned, if anything with the podcast is that there’s a lot of things that can go on a lot of auctions, and but usually, if they’re looking at that, they will understand the terminology a little bit better than you and they can help you find the answers to at least have a general idea of what to expect. But that’s really about all you can do. I mean, it’s just to try to be prepared. But then when you’re in there, again, having something like a navigation or if you know someone, and even an insurance agent will help you understand the terminology a little bit better and know where to go from there. So even contacting your broker might help.

Ashley Bills 05:47
It’s good information. It’s also helpful to listen to podcasts like this, right? Uncover these sorts of things that we don’t think about until we’re in the situation and it may be too late. So I appreciate you saying to have that information prepared and ready. So if you know something’s coming up, or if you have a certain health issue, you can kind of already be prepared in that way. So good information. Robin, thank you so much for sharing today. Thank you. And thank you for listening to this episode of Ask NASA guide part of the abundant aging podcast series brought to you by United Church homes. If you like today’s show, please share and subscribe. For more information about the Navigator Program, please visit uchnaviguide.org And for more information about United Church homes, visit unitedchurchhomes.org. We’ll see you next time!