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What Happens When an Insurance Company Misbehaves

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When the Centers for Medicare and Medicaid Services (CMS) took the rare step this spring of kicking Fox Insurance out of the Medicare Part D drug benefit program, it pretty much went unnoticed.'  CMS went after Fox, admittedly small fry in the pool of insurers, and said they couldn't sell any more stand-alone prescription drug plans to seniors.'  These plans are the kind that people buy to complement Medigap policies that don't offer any drug coverage.

It seems that Fox was improperly denying seniors access to medicines they needed to treat HIV, cancer, and seizures.'  Fox didn't tell seniors they would have to get prior authorization to use some drugs, or that they would have to use step therapy first; in other words, they'd have to see if a cheaper drug worked before getting to try more expensive medications.

When CMS said the company 'was unable to satisfactorily address compliance concerns, it terminated its contract to market Part D policies, the first such action CMS has taken since the Medicare drug benefit went into effect in 2006.

Fox Insurance surfaced again this week when the leaders of the Senate Finance Committee decided to find out whether seniors were getting their benefits and whether pharmacies were getting paid.  The senators want to know what the company has done with the $66 million the government paid to Fox in February and March.  They want to know how much of that amount Fox still held on June 1.  And they want to know how many claims received before the company got tossed out of Medicare on March 9 remain ' unpaid.  CMS spokesman Peter Ashkenaz says that Fox is arguing in court over paying outstanding claims to the pharmacies they've contract with to provide benefits, but that CMS is not a party in that case.

Watching what happens to Fox is instructive because it may offer clues to just how tough regulators and Congress will be in the new world order of health insurance.  Other companies, including big ones like WellPoint, have also had their marketing activities suspended for awhile because they were engaging in some unfriendly consumer practices that CMS regulators didn't particularly like. Will there be more?

The Fox case also serves as a reminder to seniors that they have to have a hand in policing the marketplace, too.  If you're not getting the drug benefits you believe you should have and have paid for, complain--- and loudly, too.  Call Medicare's helpline:  1-800-Medicare and tell the operator the problems you're having.  That will not only help you get what you need but will signal to the regulators that something might be wrong with a company's practices that are hurting others as well.

More Blog Posts by Trudy Lieberman

author bio

Trudy Lieberman, a journalist for more than 40 years, is an adjunct associate professor of public health at Hunter College in New York City. She had a long career at Consumer Reports specializing in insurance, health care, health care financing and long-term care. She is a longtime contributor to the Columbia Journalism Review and blogs for its website, CJR.org, about media coverage of health care, Social Security and retirement. As a William Ziff Fellow at the Center for Advancing Health, she contributes regularly to the Prepared Patient Blog. Follow her on twitter @Trudy_Lieberman.


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