Insurance Plan Network Optimization Term Providers

The Impact of “Network Optimization” on Our Seniors, Retirees, and People With Chronic or Disabling Conditions

The Impact of “Network Optimization” on Our Seniors, Retirees, and People With Chronic or Disabling Conditions
The Impact of “Network Optimization” on Our Seniors, Retirees, and People With Chronic or Disabling Conditions

To Draw a Better Picture Here Are Some Examples to Show How Much of an Impact “Network Optimization” On Our Seniors and Retirees

Donna’s Medicare Advantage HMO plan allows her to see in network providers where she would have to pay a defined co-pay amount to see her specialists. Donna received an approval from her insurer to receive a specialized treatment at a vein clinic in New York City, where the clinic specialized in certain non-evasive procedures which are not available by any other clinic in New York.  Her provider received an approval to move forward with the procedure form 5/1/2021 – 10/1/2021. Donna received a letter from her insurer stating they are terminating their contract with the vein clinic effective 7/1/2021. The member is left scrambling to find another clinic to conduct a procedure which is only available at the Vein Clinic and now.

The member is now faced with the following limited choices:

  • If she can’t find another provider to conduct the procedure she would have to pay out of pocket
  • Donna can request an out-of- network exemption from her current insurer to continue specialized treatment at the vein clinic, but this does not always get granted by the insurer
  • Her other option would be to change her insurance, which is another headache, especially if she doesn’t have a special election to change her coverage and would have to wait until open enrollment 10/15-12/7 2021 – for new coverage to be effective the following year, which can cause unnecessary delays.

There Are Also Other Instance Worth Noting, Especially When it Comes to Receiving Specialized Surgical Procedures

David has a Medicare Advantage PPO plan, which provides out-of-network benefits. David received an approval from his insurer for a knee replacement surgery at a hospital the surgery is to take place on 6/1/2021. David is in the process of getting his knee replacement surgery at a hospital on 6/1/2021, but his current insurer terminated the contract with the hospital. The hospital was terminated from the plans network effective 6/1/2021.  Now that the Hospital is not longer in network, David would incure extra expenses for his surgery.

David is now faced with the following limited choices:

  • If David can’t find another in-network provider to conduct the procedure she would have to pay more out of pocket. Because he has a Medicare Advantage POS Plan, he can continue to get his surgery at the hospital, but would have to pay additional costs.
  • David can make a big case for his surgery and request an out-of- network exemption from her current insurer and ask not to pay any additional out of network fees.
  • David can also change his insurance, but would have to wait until open enrollment 10/15-12/7 2021, which can cause unnecessary delays.

What if Your Receiving Medical Services Such as Specialized Cancer Treatments, or Even Chemo or Radiation Therapy?

Here’s yet another important example related to a cancer patient. Christina receives ongoing cancer treatment at a provider who services patients in the hospital, which specializes in helping terminal cancer patients. She has a Medicare Advantage SNP plan for people who have Medicare and Medicaid. Her plan does not offer out of network benefits. She received approval to start her treatment April of 2021, and has being receiving services from the  provider at the hospital for the past few months.  She receives a letter from her insurer stating that the provider she receives her ongoing cancer treatment will not longer be in network as of May 1st, 2021, and that she won’t be able to get her continued treatment at the hospital and would have to find another provider that is in network.

Christina’s options are very limited because she receives specialized cancer treatment from a top hospital, and now she’s faced with the following:

  • Christina can request an out-of- network exemption from her current insurer to continue getting services by her provider, but again, this is not always granted.
  • Christina can try to find another in-network provider who works at an in-network hospital but is limited to her plan’s network.
  • Christina can change his insurance, that’s if she has a special election, or go on original Medicare once permission is granted from the Centers of Medicare and Medicaid.

In many instances, patients can end up paying thousands of dollars for out-of-network provider services if their current provider cannot be supplemented, if the request to see an out of network provider is denied, and for members who have a Medicare Advantage PPO plan, would be able to continue to be serviced with their current providers for a much greater out of pocket and deductibles costs.

“Network Optimization” impact seniors not only receiving services by family practice physicians, specialists, and hospitals, but also chronically ill or disabled people who also receive services from Home Care Agencies, Adult Day Care Centers, Physical and Rehabilitative Services in Nursing Homes, and Members receiving care from their doctors in Assistant Living Facilities.

Now that we can just grasp the type of impact “Network Optimization” has on our loved ones, finding good quality physicians, to replace your current doctor can be a very complex and strenuous task in New York.

Finding The Right Physician is Not an Easy Task, and it Certainly Does Not Come Without Limitations, Especially if You Require a Specific Accommodation

There are Fewer and Fewer physicians available to attend to patients needs in NYC. Just the rate for internal medicine specialists or family practitioners who serve as primary care doctors is 55 percent. Top quality, experienced, and board certified physicians are extremely hard to find.

Here are some limitations you should know:

  • Network Limitations: If you have a  regular Medicare Advantage, or an HMO plan, you are limited in only selecting physicians who are in the network with your current plan.
  • Physicians Not Accepting New Patients: You may find a physician you feel may be ideal for you, but lots of good physicians who run busy practices may be limited, and  no longer can accept new patients. Some very good physicians can no longer accept new patients due to their high demand and limited working hours
  • Unexpected Average Wait Time: Many physicians have  unexpected wait time to see them, especially if it’s a new Physician. Even when finding another physician to attend to your needs, getting a visit with the physician can be one of the most inconvenient experience, especially if you have an urgent matter and need to see a physician as soon as possible. It takes an average of 39 days for new patients to get an appointment with a family physician and 50 days to see an internist, as referenced in an article by the Boston Globe.
  • Language Limitations: Not all physicians can attend to someone who speaks another language, or have staff who is multi lingual who can translate for you and communication with you effectively.
  • Re-establishing Relationships: Establishing a long term relationship, similar to the one you had with your previous provider, with a new physician takes timemost people develop relationships with their primary care doctors that takes years to develop.
  • Transferring of Medical Records: Transferring all your medical records from one provider to another can be fast, or slow at times, depending on how busy the provider and his staff are. Filling out the required paper work can also take days, if not months.

To sum things up, the impact of “Network Optimization” on our loved ones comes at a great cost, affecting the health and well-being of our beloved seniors, retirees, and people with chronic or disabling conditions. In many instances, as described in this article, not being able to be serviced by a physician, medical practice, hospital, or other providers because the providers were terminated from the insurers network, can have life threatening consequences to members who are receiving services from irreplaceable providers, hospital, clinics, and community facilities. If you are a victim of network optimization, and are experiencing a situation where you urgently need assistance, support, or guidance in continuing your treatments with your current providers, feel free to contact us for live assistance today.



The Impact of “Network Optimization” on Our Seniors, Retirees, and People With Chronic or Disabling Conditions.

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Medicare Health Advisor

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