I am Meredith Hirsch, and this is Working Healthcare. If you're approaching 65 or past that significant birthday, you know the ritual really well. The mailers stack up, William Shatner and Joe Namath beam from the TV. The radio promises free gym memberships if you call in the next 10 minutes. That's no accident. This fall's Medicare Open Enrollment window runs October 15th through December 7th. The brief season where every Medicare beneficiary can compare, switch, or drop coverage for the year ahead. It's the Super Bowl of insurance marketing, and you're the MVP. Here's the scale of what's at stake. More than 34 million people, about 54% of those on Parts A and B, are now in Medicare Advantage plans. That share has nearly tripled since 2007 and it's still climbing. Think about that. Most new enrollees are choosing private plans that promise coordinated care, simpler bills, and sweeteners like dental and vision benefits. And those ads you're seeing, they work because they sell the sizzle. 92% highlight extras like dental, vision, or hearing coverage. Two-thirds of MA plans charge no premium beyond Part B, and almost all offer those extras in some form. The message is simple. More benefits, less money, act now. The reality is more complicated once you need real care. Consider what rarely makes the commercials. Nearly 50 million prior authorization requests ran through MA plans last year. More than 3.2 million were denied. Only about 12% of those denials were actually appealed, and when they were appealed, 8 in 10 were overturned. If that sounds upside down, you're hearing what doctors and patients feel like at the bedside. Federal watchdogs have also found denials of care that actually met Medicare coverage rules, which tells you the friction is not just a paperwork headache, but a barrier at the bedside. Wall Street Journal reported, Wall Street Journal reporting from earlier this year found some Medicare Advantage insurers pumped up risk scores and leaned on questionable home health visits, driving billions in extra payments that taxpayers ultimately cover. The Justice Department is suing major insurers and brokerages over alleged kickbacks to steer seniors into certain plans and has secured settlements over false diagnosis coding, including a more than $62 million deal with Seoul Medical Group. Courts are a battleground. United Health recently won a key special master ruling and a long-running overpayment case. So enforcement is active but fiercely contested. This proves the golden rule. Your surgery gets delayed while offices chase approvals. Yes, you can make a one-time switch in the first quarter of the year if you pick the wrong plan, but leaving MA doesn't guarantee you a Medigap policy. In many states, insurers can still underwrite and say no. The stakes are high before you ever sign. Which brings me to today's guest, someone who sees this maze up close. Jamie Fiori is a fierce patient advocate and the practice administrator at Rheumatology Associates in Store, Florida. She consults with manufacturers, is a certified medical practice manager, and believe it or not, is a prior authorization certified specialist. I didn't even know that was a thing. Jamie and I have walked the halls of our state legislature together. She knows how policy lands in real clinics with real patients. So, as the ad blitz ramps up, let's ask what matters. If MA must cover what Medicare covers, why do so many people hit prior authorization walls? When almost every plan pitches free extras, what do those benefits actually buy when you're sick? And when millions of denials stack up each year, who is accountable? The insurer, the regulators, or the rest of us for believing the sales pitch. Jamie Fiori, welcome to Working Healthcare.
SPEAKER_01Thank you for having me.
SPEAKER_00I am so excited to have you here because you and I have known each other for a very long time. Very long. For those who don't know you, uh they're not in the rheumatology world, because you and I actually were part of the planning committee for the Florida Society of Rheumatology together. And that's where we first connected. Yes, many years ago. Many years. We won't say how many. Okay. So I really want to know what do you do day to day at rheumatology associates?
SPEAKER_01So I am the practice administrator. I, because we are a smaller office, I am tasked with handling everything from plunging the toilets to hiring and firing, prior authorizations, filling in when someone's out, answering the telephone, handling patients that have a less than a happy experience with their insurance company and are mad at us for some reason. Pretty much everything you can imagine falls under my umbrella.
SPEAKER_00Pretty much everything. And it's funny you say plunging toilets because people will say, that's not my job. And I'm like, well, yeah, who else is gonna do it? I mean, we can hire a plumber, but we need to teach our leady employees not to flush feminine hygiene products down the toilet. Um, when you hear Medicare Advantage, what's your gut reaction?
SPEAKER_01Yikes.
SPEAKER_00Why?
SPEAKER_01Because I have seen it in play for patients that have chronic illnesses and how they are told or assumed that it covers them, it covers their medication that they're on, and it's a better plan than regular Medicare. What they're actually hit with is roadblock after roadblock after denial, and the cost of actually receiving that medication that they need to be on to stay healthy is astronomical in most cases. When you're looking at a biological medication, a biologic medication, um, they're infused in the office generally. In rheumatology, we do a lot of um biologic medications. And, you know, the 20% with Medicare that they don't cover, you can usually get a supplemental plan for that. Medicare Advantage, you don't always have that option. You don't have that option.
SPEAKER_00So why do patients who are healthy think, but I'm healthy? When it really gets tough, I'll figure it out. What's the detriment?
SPEAKER_01So the detriment is uh trying to get back into the regular Medicare system. Um, it's difficult. It's very difficult. Uh oftentimes you have to go through underwriting. And if you have anything, any chronic condition from diabetes to cancer to rheumatoid arthritis, uh psoriatic arthritis, you have to go through that underwriting process. So you may not always be able to get that advantage, that uh supplemental plan.
SPEAKER_00So my son, my oldest son's girlfriend's father, if anybody wants to try to follow that, but he uh he said, I can't keep listening to your podcast, Meredith, and be on Medicare disadvantage. So so he actually tried to switch last year and he was denied. He didn't even get an offer for something that was unaffordable. He was flat out denied. And so I just saw him at Rosh Hashanah Services this past year and I said, So, what are you gonna do? Are you switching to Medicare or you're sticking with Medicare disadvantage? He's like, I don't know if I'll qualify. He goes, I think I will. I think I will. I spoke to my broker. I said, Why were you disqualified last year? Why were you denied last year? And he said, it was because he was hospitalized. And it was actually for really a non-issue type of thing, but it even for like a uh one-day hospitalization, insurance companies can deny you.
SPEAKER_01And we hear stories like this all the time, but it's not made public knowledge. I think there is a detriment to Medicare beneficiaries because they don't realize this. And I think this is what I'm glad you have this podcast because that's what we want to make public. There are rules and regulations to any plan you choose, and you have to make sure you're well informed of what you're actually getting into before signing that dotted line.
SPEAKER_00What do you think is the biggest challenge for patients who choose these MA plans? What is that one thing that you come across in your clinic that you're like, I I told you so? We don't want to say I told you so, but what is that one uh issue?
SPEAKER_01Care coordination, 100%. Uh, you know, you cannot always see the providers that you've been seeing for 20 years. They are not in the network. They don't have the administrative ability to handle the prior authorizations required to be in network. And, you know, you want to see the doctors that you've built a trust relationship with. That's not the case with Medicare Advantage. And um, we in my clinic, we don't take Medicare Advantage plans. I have to turn people away all the time. And we try to educate as much as we can, but there will be that one agent that gets them to sign on the dotted line saying this is the greatest thing since multicolored toothpaste. And ultimately they cannot see us um as their rheumatologist. And in my area, you know, the next rheumatologist is 30 miles away. And when you're already not feeling great, that drive is difficult. And does that rheumatologist take MA plans? I do not know. Well, I was just thinking I actually no, I don't think they do because we both know the rheumatologist.
SPEAKER_00Right, exactly. And I take very few MA plans, and it's not that I said, away with MA plans. And and my decision for choosing not to take these MA plans has been gradual over time. Because when we first started, I did take these MA plans. But either the insurance company like Florida Blue actually took 90% of rheumatologists off of their piano. So to find a rheumatologist in Palm Beach County, which I don't know if people are aware, you and I are in the same county. And how long did it take you to drive to the studio?
SPEAKER_01An hour and a half. Yeah.
SPEAKER_00And you and I are in the same county. Palm Beach County is actually the largest county geographically in the state of Florida, and we're a pretty darn big state. So for patients to try to get coverage is very difficult. So if they can't find a rheumatologist, where do they go?
SPEAKER_01Yeah, and you consider things like you know, things that could be more emergent, like cardiologist. You know, you're having a significant heart problem. You want to be seen that week at the very least, and coordinating care, and then do you need a prior authorization on top of that? It makes it very difficult. Is it going to be denied? Are they going to even allow you to see that doctor? Um, testing, denied all the time, medications that are necessary, denied all the time, uh, even down to the prescription drugs and formularies, which I'm sure we'll get into. You really need to do your research and know what you're signing up for before you sign the dotted line.
SPEAKER_00So it's interesting. Let's get into that now about the formularies. So at the end of every month, I get a report, which actually I'm going to talk about reporting at the rheumatology access network conference that you and I are both going to and flying out to tomorrow. Uh, but I am sharing these reports and I am and I reviewed September uh yesterday. And while I was reviewing it, I'm looking through as to there are four types of reports we keep. And one of the reports is non-starts. And so I'm scrolling through my non-starts and comparing it to those patients who were put on medication. And there isn't one Medicare patient who is on the non-start list and several either MA patients or those who are on traditional insurance because they're younger, like you and me, and we have to go through a formulary. So, could you explain what a formulary is for those who aren't familiar?
SPEAKER_01Absolutely. So, formularies, insurance companies put out a list every year, even sometimes twice a year, um, of what medications are actually covered or preferred with their plan. If your medication that that you've been taking for years is not on that formulary or drops off that formulary, I think that's very important that we say that because they can drop that medication mid-year, then they will not cover it. You can appeal it, you can appeal a denial, but like you say, it's very difficult to get the insurance to overturn that process.
SPEAKER_00Have you seen that patients were given a prior authorization for six months or an entire year and then their formulary changes mid-year?
SPEAKER_01Mid-year, yes, absolutely. We're starting to see that, which I think it's criminal. I honestly think it's criminal. I think in a lot of our patients are very sick, and we get them on a medication and they're stable after much trial and error, and it's finally working, they feel good, they can actually function in their day-to-day life. To have the insurance company then drop that medication that we fought so hard to find something that works. It's frankly, it's disgusting to me. So what happens?
SPEAKER_00Are you actually notified from the insurance company that the formulary was changed?
SPEAKER_01Not always. No. Sometimes we know after we get the denial when the patient's already got the medication. So what happens? So you appeal it and you don't get paid ultimately.
SPEAKER_00I mean So who's responsible?
SPEAKER_01It depends on if it's in office administered or if the patient's picked it up. The patient can be responsible if it's something they've picked up from the pharmacy. It can fall in their lap and they get that bill, which, you know, is that fair?
SPEAKER_00What do you do in your clinic for patients who they they you received a prior authorization, the insurance was changed mid-year, you go through the process of verifying that their insurance is active, because that's typically what we do. We don't go in to check that the prior off is still active. We see the dates of the prior off, but we check that their insurance is still active. We infuse them once, twice, three times, and then it's denied. And now there's a $30,000 bill. What do you do?
SPEAKER_01Yeah, you you start the appeals process right away, but I can tell you that a lot of times that is not successful because it falls back on the provider's lap. You should have known. You know, we we did the due diligence. We have the paperwork, we've been through the process, but ultimately they can do what they want and there's nobody holding them accountable.
SPEAKER_00Can you balance bill patients?
SPEAKER_01You cannot. You cannot. If the insurance denies it for lack of prior authorization, that it says provider responsibility right on the explanation of benefits.
SPEAKER_00So, what are the options for practices? Because I have a lot of physicians and practice administrators like you who listen to this podcast and listen to working healthcare. What are the options? You're $30,000? Are you kidding me? We're working on such small margins anyway.
SPEAKER_01Really? Well, ultimately, we're paying for the drug for the patient. We're buying their medication. And, you know, my doctor always says we don't work for free for insurance companies. We do free clinics for patients that need it, that have needs, because that's the type of people we are. But to work for an insurance company that should be, I mean, the patient's paying their premium to them, it makes it very difficult. And I've wrestled with that myself. What is our option? Do we just stop taking insurance completely? Um, you know, we want to help patients, but I I don't know what the option is, honestly.
SPEAKER_00So it's interesting you say that because I just ran a panel discussion for the coalition of state rheumatology organizations, and I was asking for feedback on LinkedIn, and I said, What is your biggest challenge with MA plans? And one rheumatologist who you and I know well, who's in a large group actually, said, I wish we didn't have to take insurance. I wish, I wish we could do a direct pay model. Is that feasible in rheumatology?
SPEAKER_01I think it's difficult because our medications are so costly, these biologic medications. And we have the large majority of our patient is the Medicare population. They're living on fixed incomes already to have them come up with this kind of money for their medications or even to wait to be reimbursed, it's just not feasible. It's not feasible from my standpoint.
SPEAKER_00So we're 80% traditional Medicare. Uh we do have some commercial carriers for our younger patient population, but only three, actually. Three that I can think of offhand. And we only cover one MA plan. And so 80% were traditional Medicare. What about younger people who need physicians? Where do they go?
SPEAKER_01Yeah, that's why I think they need to start thinking about this now. And they should actually look at their plan, whether it's commercial or Medicare, too, to see what's covered and what is the prior authorization process, what's on the formulary. And don't trust an agent. I mean, remember, they're a salesperson. They get paid by the insurance companies to, you know, not I don't want to say to steer you because they're not supposed to, but you know, there is some kind of in-game there. And, you know, talk to your physician, talk to the physician office staff, ask them, what is your biggest headache? What is the best insurance? You know, if I signed up for this plan, will I be covered? And they will give you an honest opinion if you ask. Um, ask your pharmacist, what these are my medications I'm on. What is the best part D plan to choose? If you're a commercial patient, what is what is the best plan when I'm talking to my agent? Where can I go with what I'm taking for my illness?
SPEAKER_00And there is an out-of-pocket max right now for Part D plans if you have that Part D supplement. So this year it's $2,000. Next year, I think it goes down to $1,500. I've heard multiple. I've heard $2,100, I've heard it's dropping.
SPEAKER_01I I don't think they've landed yet.
SPEAKER_00Okay. Well, I thought it was $1,500, but there is a cap. Unlike in past years where patients would hit a donut hole, they'd be responsible for the entire amount. And then it was 5% of the cost of the drug. And I've shared this before on the podcast. My mother-in-law, when she was provided or prescribed a drug, she does have traditional Medicare. She does have a secondary and she has a supplemental part D. And prior to this year, that drug would have cost her $18,000 additional. Wow. So it's crazy. That is crazy. So I'm sharing this because Patians have an option to go into traditional Medicare or an MA plan. And many will say, I can't afford traditional Medicare. Now there's a guaranteed cost for you on traditional Medicare. But why are the other reasons why Patians would choose a MA plan?
SPEAKER_01I think they're not considering the entire cost of care. Your glasses will be covered. But if you consider the traditional Medicare plan with a supplement, you're covered nine times out of ten at 100%, no matter what, without a prior authorization. The actual Medicare advantage, disadvantage plan, however you want to say it, there's going to be a copay for every doctor's visit. There's going to be a percentage that you're going to have to pay for medication if it's covered, if you can get it prior authorized. So the actual cost of care could be 10 times the amount that you're paying for your for your annual uh for your uh premium. So consider the entire cost of care and look at your family history and your health history. You don't know what's going to happen five years down the road. You may be relatively healthy now. No one expects to get cancer or expects to have a heart attack or a stroke or expects to be diagnosed with a chronic illness. All those things need to be taken into consideration before you sign up.
SPEAKER_00And I also think that when you're looking at The whole entity of traditional Medicare versus MA plans the biggest kickback I hear from patients is I'm on a limited income. Yes. But I say, do you get your hair colored? Right? Do you get your nails done? Do you go to brunch? Yeah, do you go to brunch? Do you go to happy hour? Do you go to uh the early bird special? Like, is there a way to decrease what you're spending elsewhere and make that your cost of living?
SPEAKER_01Absolutely. And this is one of the single most important decisions you can make. I mean, this is you're talking about your life, your health. And to have a middle person denying your care. So you can't get the care you want or need. Um, it's it's very difficult. You need to really weigh the cost before you choose.
SPEAKER_00So, what I learned interesting, even through this podcast, and I love the podcast because I'm always talking to people, learning from experts, learning more from you and others. And one item I learned when I had interviewed an insurance agent, because I wanted an insurance agent around last year for open enrollment, is that they are not licensed to sell every insurance plan. So if you have your best friend son who sells Medicare Advantage plans, he may only be able to sell United Healthcare plans.
SPEAKER_01Right. That is true. And they are only allowed to discuss with you when they go into your home what you have asked it for to discuss in a pre-interview or that you have to fill out another form. That's the new regulations. So if you don't know what's out there, you know, your whatever's on that form is what you're discussing. So you don't have that full rounded picture that you would if you were to talk to your physician and your pharmacist and people that are actually in the daily grind of doing this. So that's why I think it's so important. Don't rely on the agent. Don't rely on your best friend. You know, talk to the people in the world of healthcare.
SPEAKER_00I like that because that's what we do in our practice. We will tell patients, especially our infusion patients, right? Who are considering we're we have a huge sign. Hey, ask us if your medication is covered.
SPEAKER_01Yeah.
SPEAKER_00Right? Absolutely. And so we will do that.
SPEAKER_01Do other practices do that? I would hope they do. We try to educate as much as we can, um, but we have to, there's a very fine line. We have to be careful. We aren't like agents, we aren't allowed to lead patients to a certain plan. So, you know, we can answer their questions honestly when they ask us. So, and then I think that's a good point too, knowing the right questions to ask your physician or your doctor or the or your doctor's office staff. You know, you want to to find out if your medications are covered. You want to find out, oh, does the formulary change a lot? You know, do I do I need to be worried about this? Am I going to be kicked off this medication after I started after two treatments? Um, those are the important questions to ask.
SPEAKER_00Yeah, but I'll say you don't know what you don't know.
SPEAKER_01Right. You're you're correct.
SPEAKER_00And so you don't always know what to ask. So that makes it really difficult. Is there a time when a denial really hit home for you and why you became such a fierce advocate for patients?
SPEAKER_01We had a patient that was very sick. She had something called Wagoners, and this was many years ago. There wasn't a lot of treatments for it. She'd already gone undergone a lung transplant. Um, I almost get emotional talking about it because she was very young. And to have her, she had one medication that would have kept her alive, and the insurance company denied it. My physician fought fiercely, wrote letters, called, spent hours on the phone. Ultimately, the patient passed because we could not get her on the medication, no matter what we did. And she could not afford it. She had not worked for years because she was so sick. And um, you know, having her come into the office and say goodbye to all of us, knowing it was the end, was so hard, so hard. And it and there was no reason for it. I mean, it wasn't even a that costly of a drug. And I think things like that, we see we see patients like this, and it's it's hurtful because you work in the surface industry because you want to help people and in the healthcare world, and you want them to get better, you want them out of the wheelchairs, you want them not crippled, and to live be able to tie their grandkids' shoes and and to grow old, you know, and and then to have a middleman step in and just completely flat out deny care.
SPEAKER_00It it's it's hurtful. And it happens even with patients who have been on a medication. Yeah. So I had Dr. Worse Bacari on the podcast, and he created a way to fight denials, especially AI denials, right? Because they're all using AI now. Um, you seeing AI to then appeal those denials. And he shares a story on the podcast that he's been on, he's an asthmatic, and he's been on this asthma inhaler for 20 years. And he lives in LA. So when the wildfires were going on, it was a crazy situation, especially exacerbating his asthma. He went in to fill his meds and it was denied. The inhaler was denied. He's like, I've been on this 20 years. And he's like, I'm just gonna pay it because I need it. And that, and and thank God he could. But then he went in and he created an algorithm to fight this denial and he won and got reimbursed. But that's because he created a darn AI company to fight denials. So what does the average person do?
SPEAKER_01Yeah, and I I think a lot of them either don't have the knowledge or the means to fight it. And then to your point, too, they don't have the financial means to pay for the medication. You know, so if it's denied, they're like, okay, I'll just go without. And sometimes they're even too embarrassed to tell the physician's office. And we don't know that they're not taking their medication. And and that's hard too, because how do we, you know, we we're wondering what's going on. They're too embarrassed to tell us they can't afford it. The insurance company's standing in the way of their care, you know, and but yet we're rated on quality. You know, so it's it's this like big filthy loop that we can't um we can't fix.
SPEAKER_00Right. And that's really interesting. I putting connecting the dots, you're right. We're rated on on cost. We're rated on not just quality, but cost measures. And we're like, okay, the person ended up in the hospital. Why? Because the insurance denied their medication. Their medication. And so you're like, okay.
SPEAKER_01We appealed and did a peer-to-peer. And and by the way, peer-to-peers aren't always peer-to-peer. Even when you ask for somebody of equal caliber, you know, they will put a retired physician that hasn't practiced for years that doesn't even know what to mean. Yes, yes. Doesn't even treat adult patients or hadn't treated adult patients with rheumatoid arthritis. And and um, you know, we we fought for it, but they ended up in the hospital anyway because of the middleman.
SPEAKER_00And uh can you give me a story when you fought a denial and it actually was successful? I want to give hope. I and I want to encourage people to fight denials. Yes. A lot of times patients, and and I sh have shared the statistic many times, such a small percentage are actually fought. And a lot of times patients think that the doctor prescribed the wrong medication because the insurance company denied it. So there's you gotta connect the dots a little bit more. But when if you fight a denial, give me a story when it was successful.
SPEAKER_01There's a lot of them. But um, I think the one I rem that comes to mind first is a uh lupus patient. Yeah, she was on a medication and they they denied it after I think two treatments. And they said, you know what? You know, it's not our formulary anymore. This and she had been through other medications and this was the only one working for her. So we did the peer-to-peer thing, denied, denied, denied. Finally, I said, you know what? You need to make noise at the insurance company to the patient. The patient got involved and it wasn't our office. It was the actual patient that fought and got it approved after that. And I'll I'll real quickly I'll side note that I have a commercial insurance, my own personal medication that I've been on chronically for years. I threatened to take them all the way to the insurance commissioner and I got a call the next day. Oh, how can we help you? Did it get resolved? Can we appeal your can we uh approve your drug for you? So sometimes it takes the patient advocating for themselves and making noise and and pushing back, honestly.
SPEAKER_00I will say a hundred percent it takes the patient. I will go back to what Julie Bach said on my first ever episode. She said, I will stand shoulder to shoulder with you and fight this denial. But if you're not with me, I can't do it.
unknownRight.
SPEAKER_01Patients have to advocate for themselves. I mean, there are those patients though that that just don't have the strength to do it. I mean, I'm thinking of our cancer patients and stuff, which it puts us in a whole nother position. You know, we're we're we're trying to deal with all the other administrative burdens of getting prior authorizations for thousands of patients, but this one patient matters just as much as you know the rest of them. So um, you know, how do you spread a staff of 15 where only two or three of them do prior authorizations to your whole patient base? And and they're on the phone and you wait an hour when you call these insurance companies at minimum, um, and you're passed to five or six people only to be hung up on. So it's a difficult road.
SPEAKER_00When when I started 17, almost 18 years ago this month, actually, our nurse, I didn't even know what prior auth was. I was like learning this whole process and what a denial was. And as I got a little savvier and we had outsourced our billing at the very beginning, and then we quickly took it in about two and a half years later. But our nurses or our LPMs were the ones who are actually going through the prior auth and through the appeal process. That's what happened. Were we as successful? There weren't as many as there are now. We have three full-time people dealing with prior auths and appeals and denials right now.
SPEAKER_01See, and I I feel like I mean, I started 23 years ago in my office and it it did not take as long. You know, I I like you said, I don't think there were as many denials, and I don't think they they um they kicked them back as much. But but you're right, you have to have a full-time, you know, three or four people just to handle the volume. And the insurance company, they're just hitting a button. They're hitting a button on the on the computer. It's deny, deny.
SPEAKER_00It's insane. So if somebody picks an MA plan and they're listening to this after it was chosen, and they're like, oh man, you're right, this sucks. What do I do? How do you turn in the lemon?
SPEAKER_01So you can uh you you can disenroll in the Medicare Advantage plan. Um January through March actually is the Medicare Advantage, um, disadvantaged open enrollment period. You can also switch if your plan is not rated five stars, but that's to go to a different Medical. Okay, that's a game. They always rate themselves five stars. Exactly.
SPEAKER_00Or get it.
SPEAKER_01But during your open enrollment period, um, you can definitely call 1-800 Medicare, your best friend. That's what I say. 1-800 Medicare is your best friend.
SPEAKER_00But what is the hiccup that patients will face?
SPEAKER_01The hiccup is the secondary insurance and getting going through underwriting if you have to um to get that secondary plan, you know, it it can be difficult. Or like you your your son's future father-in-law, if I say that right. Perhaps, yes, perhaps. You are right. Maybe. Um, you know, sometimes they'll just flat out deny you and not let you uh enroll in a secondary plan, which then your you'll your cost care can go up.
SPEAKER_00Does that happen even if you make a blip at 65 and it's your first time?
SPEAKER_01It that it can. It can it it can, yeah, for sure.
SPEAKER_00That that's what I think is so appalling is that the first time you make a mistake, like you're you're not, it is a mistake because you can't backpedal. You're you're screwed.
SPEAKER_01Yeah. And and I have actually worked sat down with a f an elderly couple, friend of mine, and and walked them through the Medicare enrollment process. It was difficult. And I've done this for 23 years, but I'd never been on that side of it. And I'm thinking, if I didn't have like medical knowledge, this would be so hard. So, you know, there's a lot of states have ship programs where they go in through and help you, they're supposed to be not biased, and help you enroll. I would encourage you to reach out to those plans and and have somebody knowledgeable kind of tell you in layman's terms, what does it mean if I sign this, the for sign up for this plan versus this one? Um, and then also your part D plans too. Don't forget about that, because you, you know, your prescription drugs can be costly as well. And you want to make sure you're enrolled in a good Part D plan that covers the medications you're on. Exactly.
SPEAKER_00The medications you're on or the medications you you could be on, and sharing that or speaking to the pharmacist or speaking to your practice that you go to, right? The billing team. Hopefully they'll call you back.
SPEAKER_01Exactly.
SPEAKER_00I don't know about that sometimes. I know they will in my shop in person. Oh, I've had patients also show up because they were frustrated at the letter that their insurance company uh sent them. And Susan's great. She'll grab it and she'll say, Could I have a copy of that, please? So at least we have like more push and fight and we can share the information with everyone. You have been involved in advocacy. You know, you're my like groupie. You're we're a groupie of two. Um, you're my co-practice administrator who actually goes up to Tallahassee with me, which I'm excited about. And you were on our National Organization of Rheumatology Management Board and you're going back on the board again this year. If you had one minute with a lawmaker.
unknownOh my god.
SPEAKER_00I know. I'm putting you on the spot. One minute with a lawmaker, what what fix would you demand first? I'm only gonna make you choose one. But what fix would you demand?
SPEAKER_01Cut out the pharmacy benefit managers for sure.
SPEAKER_00That's a good one.
SPEAKER_01Yeah. They they are just they're destroying access to care. They are destroying access to care. And nobody understands, I don't think there's a comprehensive knowledge of how much they how much control they have in in the patient's actual care. And um, yeah, that would be number one. But I uh that would be a dream of mine.
SPEAKER_00I know, I know, a dream of mine too. And I know a dream of Dr. Maddie Feldman's because she's so anti-PBM. Um do you think it's possible to change the Medicare system?
SPEAKER_01I think it's possible, but it takes everybody working together. And and I think there has to be a real listening and understanding to actual patients and their stories and what they've been through and the hurdles that they've faced trying to get care. You know, as physician practice managers, we can go down there all we want. They're like, oh, well, yeah, you get paid. Yeah, you're you're paid for what you do. They don't understand how little. But um, but it's the actual patient that it affects. And until it happens to them or somebody in their family, I think it's it's um it's not an issue. It's not a priority, I should say, for most. I mean, we do have some great lawmakers too.
SPEAKER_00So bottom line, is there anybody who should choose an MA plan?
SPEAKER_01Um honestly, uh I'm I'm somebody who you never know what the future holds. I would say no. But you know, if you're completely healthy and you don't expect to have ever have any uh issues where you need any type of medication or to see any specialist, maybe it's the right plan for you. But the the 90% of the population, I think regular Medicare, traditional Medicare is the way to go. It's um tried and true. Um, you know what to expect. You don't have to fight to get care as much as you would with um, you know, these plans that are managed by a commercial payer that, you know, the CEOs are making billions.
SPEAKER_00Oh, yes, they are. What about somebody who is on Medicaid? So if they qualify for Medicare, Medicaid, should they stick with Medicare, Medicaid, or should they pick an MA plan?
SPEAKER_01I stick with Medicare, Medicaid. You're covered. I mean, there's no reason to go outside of that because you know because you're gonna have co-pays, you're gonna have, you know, extra expenses if you choose a commercial plan. You're essentially going from something that's a sure thing, 100% coverage, to something that does not have 100% coverage. And um, no, I say stick with traditional Medicare.
SPEAKER_00And then if you, and I don't know this answer, hopefully you do, if somebody has Medicare Medicaid and is prescribed a medication, is the medication going to be covered?
SPEAKER_01Usually under the, I mean, I'm I I don't work a lot on the pharmacy benefit side, but I know with a lot of our biologic medications, and anyway, there's a cap that they pay, you know, three dollars for a medication. Um, but yeah, nine times out of ten, I I have not seen it not covered. Okay.
SPEAKER_00So are you ready for a lightning round, Jamie Fiore? Oh, good.
SPEAKER_01Put me in a hot seat.
SPEAKER_00I know this is your hot seat, but this is gonna this is gonna be easy. This is gonna be great. So what is the first insurance term you learned that made everything click for you? I think coordination of benefits and what that means. Okay. One myth that Medicare I'm sorry, one myth about Medicare that you correct most often. That you're 100% covered all the time. So what do you think is the biggest generational gap you see in how patients navigate insurance?
SPEAKER_01I think that um our older generation, they expect it to be covered. Um, whereas we're so used to, like I want to put myself in the younger generation, the younger folks, they uh they tend to expect to pay something because they're used to it coming out of their paycheck, their premiums. So I think there's a a diff difference in generational there.
SPEAKER_00So what do you think Zoomer patients do better? These are the not Zoomer patients. I'm gonna say Zoomer advocates do better. They're 28 and under, than boomers do when it comes to advocacy.
SPEAKER_01I think they Google a lot more and use Chat GPT and they take advantage of the technology.
SPEAKER_00Aaron Powell Paper forms or portals, what slows down care more?
SPEAKER_01Um I I honestly think. I'm gonna say paper forms in my office because there's a lot of back and forth and they never get it.
SPEAKER_00So prior off in one word.
SPEAKER_01Administrative burden. That's two words, but burden.
SPEAKER_00We'll hyphenate it. Yeah, burden. The moment you knew you had to be an advocate, not just an administrator.
SPEAKER_01I think it's going back to that patient with wagoners that needed care and couldn't get it.
SPEAKER_00What is the one question every patient should ask a broker before picking a plan?
SPEAKER_01Are they paying you to lead me to this plan? That's great. Are they paying you? Are they paying you and how much? And if I stay enrolled, are you getting a check every month?
SPEAKER_00What is the single insurance tactic that you'd overhaul right now? Oh, I that's a tough one.
SPEAKER_01Single. Um I think the the formulary thing, the form changing formulary.
SPEAKER_00Mid year.
SPEAKER_01Mid year.
SPEAKER_00Yeah. So I'm gonna give you 30 seconds because I want to give you uh I want you to speak to a patient and give them a pep talk on how to push back on a denial. So what is your 30-second pitch as a patient to push back on a denial?
SPEAKER_01I'm the patient or I'm the counseling. Counsel the patient. Okay. Mrs. Jones, I see that they have denied your biologic treatment. You've been on it for a long time and it's worked for you. We've been through many medications before we got to this point. Our office has done everything we can do. You're the one paying your insurance premium. It's time for you to stand along. We'll stand with you, but it's time for you to call your insurance company and fight for your medication because we can't do anything. They won't listen to us. We're not the ones paying the premium. And I think the patient advocacy thing is huge.
SPEAKER_00Yes, I love that one. So I am gonna end this podcast the same way I end every single podcast, Jamie. And I know you listen, so you know. And I've asked you a lot about changes, but looking at the entire American healthcare system, what is one change that you think or would like to create now?
SPEAKER_01Let the physicians be physicians. Cut out the middleman. Um, yeah, the administrative burden has gotten in the way of actual patient health care. And doctors just cannot be physicians anymore. They have to do it all. And it's not fair. It's not fair to the patient, it's not care to the physician who just wants to care for the patient.
SPEAKER_00Jamie Fiore, thank you for being on Working Healthcare.
SPEAKER_01Thank you for having me.
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