Beware of Medicare Advantage Program Providers that are PPO and HMO plans as they are sold on basis of using their in-network providers. The "fraud" that I have found, as I resided in two different states, is that a Medicare Advantage Provider (Insurance Company) can enroll you in their plan that requires you to use their "in-network" providers yet no participating provider they have enrolled in their network has to provide services. This especially true in New Mexico where according to AMA, 48% of physicians have declared no Medicare patients allowed in their practices.
No matter that you may have paid an extra premium for the so-called HMO services to be provided. And, when you contact US Government CMS to complain they inform you all they can/will do is allow you to change plans. Even in mid year. But recovery of premiums paid for months of serves not received as all doctors in plan refuse to allow you in their office as one told me: it's socialized medicine and I'm opposed to it and will not participate." then a call to state Insurance office and Attorney general Offices gets this response: "We have no authority to resolve your complaint as Advantage is a federal program."
Finally, a call to the Insurance Company under contract with Medicare gets this response: "Our plan providers can refuse service to anyone at their discretion..." Thus, the only recourse is litigating premium losses as a tort claim against Insurance Company. Thus, irrespective of what our Government says. Irrespective of what an Insurance Company declares under a contractual obligation, you are on your own.
No agency or elected official will "fix" this rip off. The rip off being paying a premium for Advantage plan. The Insurance carrier getting a $1000 per enrollee from US Treasury. Laughing all the way to the bank while denying services paid for and even needed... And our elected officials refuse by acquiesence to "fix" it. I have been denied access with 2 Advantage companies I was duly enrolled in...
Presbyterian Health i2n NM, Carilion Health in Central Virginia... And no one on any level addresses this "fraud, " our own Federal Government is complicit. AARP solicited my input at public meeting they convened to gather information in general about Medicare experiences, and their program manager only shrugged his shoulders. Offering he was ignorant that went on... No matter that in NM such practice has been going on for past 7 years. And so it goes...
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