(For BAC meeting on May 18, 2006.)
indicates there are potential issue(s) to be
addressed.)
Comments on this page may be sent to pehng@morris.umn.edu
indicates there are potential issue(s) to be
addressed.)
Comments on this page may be sent to pehng@morris.umn.edu
| Total number of responses: 46 (An unscientific (eyeball) summary ) | |
| types of issues mentioned | Number of responders who mentioned the issues. (Note: each responder can mention more than one issue) |
| In general, happy with UPlan or Medica | 17 |
| Mistakes or problems with billing & payment structure; more cumbersome in dealing with Medica Direct HRA's reimbursement structure compared with Definity | 10 |
| Lack of good in-network mental health therapists or chiropractor or physicians/providers/hospitals in the area | 8 |
| Communication problems; lack of clarity in explaining the specifics of the coverage or real costs; or having to spend too much time clearing up what is suuposed to be a simple claim. | 5 |
| High costs, co-pays or premiums | 4 |
| Lack of wellness incentive to subsidize health club memberships | 4 |
| Ineligible to choose a plan of her/his choice, resulting in higher costs | 1 |
| Unhelpful nurse line | 1 |
Issue: Co-pays and reimbursements
I remain at the mercy of Fairview and the insurer, as neither provides a detailed enough statement that there would be any chance of finding errors.
I haven't had any problems with disallowed coverage or anything along those lines.
(I understand that the pharmacy coverage is a separate issue. That's much more of a problem.)
Issue: Better explanation about payments
Issue: Insufficient communications before Open Enrollment to make a well-informed choice
Issue: Difficulty in finding a specialist and have decided personally to stop treatment!
Issue: Paying too much for, and more problems with, health care
Issue: Co-pays are too high
Things were SO much better last year with Definity!
Issue: Difficulty in dealing with a medical condition that requires
medical treatment (Medica), counseling (UBH), and special drugs (RX-Amer).
My concern is that to see a counselor, psychologist, etc., [as I did following major surgery which is not unusual] you need to go through United Behavioral Health. While they have been helpful, it did not state in our packet that this was required or how to contact them. It is an extra step in the process and one winds up dealing with numerous entities to maintain their health.
Right now I go through Medica for general concerns, UBH for counseling, Rx America for prescriptions, and another division of Rs America for special injectable drugs. It seems that it took a lot of time just to figure out all of the avenues for these procedures.
Issue: Difficulty finding a mental health therapist that is in-network with Medica's UBH;
having to deal with third parties for mental health and chiropractic
services makes
Medica too bureaucratic and cumbersome.
Background: I was a Definity user on the previous year's selection and was very satisfied. It was HRA, there were no referrals required (my doctor loved this also remarking that his office had full time people working just to process these), there were no co-pays, their web site was excellent, they had single point customer service. I did have to go out of network for some services, in particular the major service I required which was mental health for my daughter. This to was simple; definity paid 70%. The web site still had all the data on them.
The change required me to do alot of work to select a new system. To get information, I went out to Wayzata. I made it perfectly clear that I was a person from the university engaged in its open enrollment period and that I wanted to get some clarification their plans. The receptionist did not know what to do with me. Finally another employee happened by and got something going. I was directed to a waiting room. I waited a long time. When the person came we started our conversation but could not continue because the person said they were not the right person for me. A second came with the same result. And a third. The fourth person was helpful.
I googled Medica and found they they had to settle with Attorney General Mike Hatch. They signed what was call an MOU, Memorandum of Understanding.
I have found Medica to be very bureaucratic and cumbersome. The most important service for me was my daughter's therapy. Again, like Definity, her therapist was out of network. I had found this person after years of searching for someone that was effective. I had stayed within the managed health system and never found an effective person. Finally, I had talked with Professor XXX in our Family Social Science Department. He said I should get my daughter into therapy "right away". I responded that I had been trying for years without success. He gave me two names, and selected one. Bingo, perfect! But out of network. My daughter has been with this person for five years.
I called Medica about how this would be handled. They said that they did not handle mental health. They used United Behavioral Health. (It turns out they are under the same umbrella firm as Medica itself.) This is what I mean by heavily bureaucratic. The Medica folks do not handle all of their own business. I contacted UBH and they said they had a transitional period where we would not pay out-of-network charges for some time. It turns out to be quite otherwise. They use the period as a method of contacting the out of network provider and trying to recruit them. If they do not join the fold then no transitional period. In the case of my daughter's therapist they wanted her to provide her services at a rate of $70 per hour, more than a 30% reduction from her existing rate of $110 per hour. Neither she nor I thought that was appropriate so we could not take advantage of the transitional period. I might add that the observation that since the only therapists within the system are those willing to work for $70 per hour, that may explain why I never could find an effective therapist there.
I use chiropractic services to treat a condition called Morton's Neuroma. Physicians want to do surgery (with side effects) on this but I found that this chiropractor effectively treated the condition without surgery. With Definity the channel was direct: Chiropractor to Definity to Me. Under Medica, as with the mental health service a third party intervenes. Now the channel is Chiropractor to Intermediary to Medica to me. Mostly what the intermediary does in create additional paper work.
I mentioned that Definity did not require copays. I do not understand the reason these are imposed. They are inconvenient and impose costs on providers and patients attendant to tracking and reporting them. I doubt very much that they deter unnecessary use of medical help, which is, I suppose, the reason for them.
Since I use all of the same providers as before, I continue to be happy with the medical services that I receive. But the quality of the experience has fallen from an "A" to about "D-". To me I am involved with a enterprise that has had legal problems (Would it be in appropriate to brand them a corporate criminal?) and that has a cumbersome organizational structure that imposes significant non-monetary costs on me.
Thank you for this opportunity.
Issue: Difficulty in finding participating physicians.
As a consequence of a change in Delta Dental, (which we thought was similar to the Delta Dental we had) we have been stuck with a $1200 bill from our regular dentist who apparently is no longer covered under the new plan of the same name as before! Unhappily,
Issue: Plan is inferior to Definity - billing & payment structure for health and RX is problematic
Overall, I think that the Medica HRA system is very poor compared to Definity. I don't know why this change was made, as the amount I have to contribute has increased by $30 per pay period, and the service is much worse.
Issue: Plan is inferior to Definity - payment structure for health and RX is
problematic
I had to get a prescription filled recently and found out that I had to pay for it up-front and that Medica would re-imburse me. The prescription cost $73 and I only got re-imbursed $49 (3 weeks later). I don't understand why RX America couldn't bill Medica and have them take the money out of my patient care account like Definity did.
If I knew I was going to have to pay for everything up-front I never would have signed up for this plan. I had over $1,200 in my Definity account and thought with that rolling over I'd never see another doctor bill. It was never clearly explained to me how this new account worked and it's not easy coming up with the money to pay for prescriptions in full only to be re-imbursed less than what it cost.
Next year I will definitely sign up for a different Medica account and if I lose all that money in my so-called "patient care account" than so what - I don't seem to be getting all the benefits out of it now anyway.
Issue: Plan is inferior to Definity - billing & payment structure for health and RX is problematic
The first few months of Definity were quite a mess, but problems were quickly cleared up, and the web site and reports were quite complete and understandable.
No such luck with Medica. It is the end of April, and I just received 10 pages of gibberish reports that seem to state that I have overpaid -- but that I still owe. I know you don't want to hear about pharmacy, but I think the deductible amounts are supposed include pharmacy charges -- but they don't appear to. What I need is a summary of charges and payments, with balances. Ten pages of details that seem to be internally contradictory is really useless.
Medica seems to me to have been a big step backward. In its favor of course is that we are able to continue with physicians with whom we have long-established relationships. This is a benefit that gets more important with age, and one that is not so available with HMO type plans.
Issue: Bad explanations from UM Benefits about transitions from Definity,
misinformation on co-pays for RX, and changes in family status
I have the new Medica HRA plan. I have been happy with the coverage so far but Benefits has done a poor job of explaining the new system (I switched from Definity and it was supposed ot be the same). I had to do a great deal of calling between Benefits and Medica to iron out specifics like out of pocket maximums and in-network/out-of-network deductables. Medica and the University do not always seem to be communicating and that has been frustrating. I have had 2 denied Medica claims reversed already because the Univ plan was not clear and that has been frustrating.
The pharmacy plan is also not well defined. My co-pays are different with the HRA plan than the other plans and I was told I would receive a new card with the correct co-pays, I still have not received it. When I called Benefits they said I should be getting a new card, when I called Rx America they said I would have to use the card with incorrect co-pays and explain it to the pharmacy where I receive my perscriptions. Rx America said they would iron this out, that was 2 months ago.
I do have one other comment, I have been told by Benefits that when my family status changes (I am pregnant) I have to start completely over again on my deductables and out of pockets even if I keep the HRA plan. I think this is quite discriminatory since I will have already satisfied a significant portion of that deductable under my current 2006 single-coverage plan and I will not be changing plans. I will be a single parent and the assumption is that families would have already signed up for a family plan last year, I did not have that option, nor is this policy written anywhere in the benefits packages that I received when signing up.
Thank you for taking my comments, these benefit packages seem to be getting more and more complicated!
Issue: Billing mistakes
To the point. Today's mail brought an Explanation of Benefits that assigns to my wife and me a bill to come (the EOB is only the "explanation") of $4,672.77, $2,801.83 of which is for out-of-network out-of-pocket. The trouble is that it is for a Mayo Clinic claim and the Mayo is in-network. So I was assured when I signed up, so I was assured yesterday by the very able customer service person who took my call about another EOB, which she read as having mistakenly assigned to us an out-of-network event. She helpfully promised to send the EOB for "adjusting," I hope successfully. Today's customer service person, whom I called about today's EOB installments, made the same promise to try to correct the same mistake. Our fingers are crossed.
To vary the comedy, an additional EOB informed me today in code (53) and on the back of the sheet: "claim already processed; our records show we have already processed this charge." Since the claim numbers are different on the two EOBs although the event billed is indeed one and the same, I fear that we'll now get a replay of the multiple and identical RX America cards that began the slapstick. We already have had duplicates of this kind, especially at the beginning and usually in pharmacy.
I wish you well in your work on this important matter, and I genuinely hope that most of our colleagues have not met with difficulties similar to ours. If they have, however, the University should negotiate more carefully (and sooner) in the future.
Issue: Billing problems between Medica and clinics
Issue: Billing & claims problems with Medica
Issue: Unhelpful Medica Nurse line, and high copays
Secondly, because I was so ill and then later experienced subsequent asthma and breathing problems, I had to visit the doctor on MULTIPLE occasions. I think my doctor's office visit co-pays and Urgent Care copays cost me around $200 for ONE (granted, long) illness. I'm a Master's level therapist and have gotten very minimal raises over the many years I've worked for the U. It was a financial hardship for me and I hope the U will consider doing something to lower the copays.
Thanks for your consideration of my concerns. I appreciate your taking on the role of listening to insurance concerns!
Issue: Communication problem
Issue: Clearer explanation of true costs incurred
I would like to see the price lists for everything posted somewhere, like at a fast food restaraunt. Sounds silly, I know...here's why:
I purchased a walker for my husband. His doctor said he needed one with a seat and wheels. If you have wheels and a seat you have to have brakes. These kinds of walkers are expensive but not obscenely so. We went to Merwin Home Medical's showroom to look at options/get fitted. The sticker price on the walker itself, if purchased without insurance, was $365 or so. We paid for part of it in cash and the health plan covered the rest (so said the rep the clerk in the store spoke with to ensure we had coverage).
Later I received a statement from the health plan listing the prices
requested/negotiated by the plan and what was actually paid. Not only
did Merwin ask for more than the sticker price, it was approximately
$200 over the sticker price. No mention was made that we'd already
paid for half of the sticker price of the item! After the claim was
refused by the insurance company through a paperwork snafu (later
resolved), we received a bill from Merwin for over $600 for the item
and some mysterious "services" that we didn't receive (we walked in,
pointed at a walker, the person adjusted it, called for coverage,
rang it up and we were out the door).
What the...?!?!?!
I called Merwin. I called the health plan. No one cared (they flat out told me they didn't care). I explained that there appeared to be some "funny math" going on with the price of the walker and these "services" that were listed. Eventually someone explained that there is a negotiated price listed in a dusty volume somewhere, that "services" are always included whether received or not, and no matter the actual cost the provider asks for this book value. Then through what is apparently a random series of 20-sided dice rolls, an "actual" reimbursement amount is agreed upon that is significantly less. This is just silly.
Thank you for your time, and thanks for your service too!
Issue: worse than pref one
How much is my time worth? Original call, follow up call etc.
Issue: Lack of women chiropractors approved by Medica
Of the 18 chiropactic clinics in Alex, on(ly) 3 chiropractors take Medica. Medica has no women chiropracter providers in my area, only men.
Because I am not comfortable with the 3 who do participate, I have chosen to bear the added expense of paying for treatments myself, and planned this into my flex plan for this year. I resent the added expense and miss the $ that is taken out of my paycheck each payday, but prefer appropriate treatment from a provider who is not trying to sell me their personal beliefs on herbs, odd diets or overusing vitamins to line their own pockets.
Issue: Lack of chiropractors approved by Medica
Issue: too much referrals needed
All I need is an eye exam and new glasses--there should be a list of approved providers I can choose from to get this taken care of without having to go see a primary care physicians to get a paper referral. Come on!!
Issue: Lack of hospital choices and current choice worse than Definity
My former plan was with Definity. I was very happy with their plan. I think it was a colossal mistake to drop that plan, although now that I am no longera member and they have been acquired, it has become difficult straightening out billing issues left from last year.
With regard to open enrollment, I did not have a choice. My wife sees a doctor from one clinic, my girls have a regular doctor from a different clinic. Switch clinics? No way. My girls have access to a team of pediatricians. Changing clinics would move them to a sole family practitioneror to a clinic with a different hospital system 30 miles away. There was another plan that covered our current physicians, but I feel that I chose thelesser of two evils. The base plan was worthless!
The transition hasn't been pleasant either. I suspect that one of the clinicshas mixed up accounts again, such that my wife is no longer listed under my plan. It took months to straighten that out when we first switched to Definity. That isn't a comment on the plan so much as a plea for stability.
Under the Definity plan, it may have been a bit more expensive, but it was easier to manage and to keep track of services. Now I feel that I am writing a check every time I turn around. With Definity we actually had an incentive. Not it feels that we are being penalized for seeing a doctor.
Not all places have the choice of physicians that are offered in the metro oreven Duluth. When you get to smaller communities, that choice becomes a majorfactor. In that respect, I have to comment again that the base plan was worthless.
Issue: Lack of subsidy for Health Club membership
Health club memberships and other work-out related facility payments should be covered in "some" way, and not just by flexible spending accounts if prescribed by doctors. In the long run, this saves money anyway. With the obesity problem we have in our country today, this would simply be intelligent.
Issue: Lack of subsidy for Health Club membership
Issue: Lack of subsidy for Health Club membership
I have one comment- I believe that offering to reimburse employees for 1/2 of their month health club membership dues if they attend the gym twice weekly or 8 times monthly would be the best wellness incentive that there could be. The health benefits of working out 8 times a month is measurable and it sure beats the other rather lame incentives such as the "walk your way to fitness" incentives program a few years back with the free pedometers.
Issue: Would like gym membership dicount from Medica
Issue: Ineligible to choose Medica Choice
I want to thank you all for taking on this huge job and making it as affordable as possible. I think you've done wonders in trying to get the best deal and the broadest menu you can for us working stiffs. Especially for people like me who have a family and want the best care possible, with choice of physicians and Abbott Hosp. I also greatly appreciate the choice we now have of either single plan, spouse inclusion, or child and spouse inclusion. That is just excellent!
I may have complained in the beginning about having to choose a new plan "again", but I take it back. I know you try to keep the same choices if possible but also work to get the best deal without sacrificing quality. Thanks for your hard work
Comments on this page may be sent to pehng@morris.umn.edu
This web page is maintained by:
Peh H. Ng,
Associate Professor of Mathematics
Division of Science and Mathematics
University of Minnesota - Morris
Morris, MN 56267
email: pehng@morris.umn.edu
© 2006 by Peh Ng
Last Modified Friday, June 08, 2007
Page URL: http://www.morris.umn.edu/~pehng/BAC/medica06.html