New Medicare Program: Full List of Services That Will Need Prior Approval

[Ms. Toad]

36. If you are no standard medicare, your doctor is wrong.

Get a new doctor, or learn the rules yourself and educate them. Doctors pay very little attention to how the visits are paid for and their offices often work by a generic set of rules that are the most restrictive. My sarcoma specialist told me an MRI for suspected sarcoma would be delayed because I needed pre-approval. That is wrong. Under standard insurance - yes. Under Medicar Advantage plans - yes. Under standard Medicare - no.

We've been fighting for a week to get sensors for my wife's continuous glucose monitors. They are covered under Part B, not part D, and they do need prior authorization (their use is only covered by Medicare if you are on insulin, or in a few other limited circumstances). The first doctor we saw realized that, and knew her office used a particular provider for their Medicare Advantage providers - and insisted she needed to send the prescription there. Wrong.

Then she apparently didn't do anything. We called back to the office - and they said they would send it to CVS. We had an extended conversation about Part B coverage v. Part D coverage. I thought they had it straightened out - but sure enough the prescription was sent this morning to CVS without the prior authorization required, and the insurance under Part D was denied - since Medicare doesn't cover it like a drug.

Meanwhile, she had her first appointment with an endocrinologist - he re-ordered all her meds (including ones she just refilled, and including her sensor). He was unaware of any pre-authorization requirements - even though CGMs should be part of his bread and butter as an endocrinologist.

We has similar issues for blood glucose test strips - it took a month to straighten out.

So **IF** you are no standard Medicare your doctor is flat out wrong. There is no pre-authorization requirement for bloodwork. Your doctor may not know the rules - OR - he may be imposing his office policy on you. (If you don't like that policy, find a different doctor - or find out why he wants a same-day draw. There may be a medical reason for it.) But don't accept it because he is telling you it is a Medicare requirement - learn the rules and protect yourself.

Medicare Advantage, on the other hand, is an insurance program. They are permitted to impose prior-authorizations not required by Medicare. They are permitted to limit your doctors to a small list of doctors or providers, etc. If you have that - it was your choice not to get the full benefits of Medicare.