What's a common trick in Medicare marketing that hides restrictions on doctor choices?

Question

Diana Salisbury · Accepted Answer

You must check if your doctor accepts either a PPO or HMO with a specific plan.  All plans do not have to accept all doctors.

Melonie Wood · Answer

Unscrupulous agents will not check networks providers and tell members their doctor takes the plan.  This is why it is so important to meet with an agent in person.

Misty Bolt · Answer

They dont explain the difference between HMO and PPO plans. HMO means you have to stay in network and PPO means you have the flexibility to go out of network.

David Bell · Answer

HMO, PPO, POS, PFFS. I don't think it's a "trick." All plans have some restriction in who you can see. 
HMO- besides the rare exception, you have to see the providers on thier list or there is no coverage. 
PPO- the plan has a list of providers that are in-network but you can see the provider of your choice. If they are not in the network, you pay a higher co-pay. Sometimes much higher (this may be the "trick")
POS- is an HMO with an out-of-network option. It is slightly different than a PPO in that the "in-network list" is often smaller and you often need a referral to see out-of-network providers 
PFFS- you can see any provider as long as they are contracted with Medicare. 

Always review the provider list for plans you are considering. Most people don't want to chnage doctors so be sure yours is on the list. Don't bank on an exception.

Steven Bleicher · Answer

I'm going to use the choices that doctors make concerning a quicker
recovery due to a new prescription. The most frustrating problem 
today is the "over-use" of "PRIOR AUTHORIZATION" specifically by 
your insurance company. This is NOT your doctor's fault. This is 
extremely prevalent due to greater dollar restrictions nowadays. 
When being interviewed by a competent Medicare agent, it is an
essential topic to discuss "P.A."!  This is not something that any
agent can anticipate since it has become an overwhelming cause
for complaints specific to "MAPD" (in-Network) Advantage plans.

Be sure to recall that you have two choices with the RX copays 
that are a part of Medicare: A) you can use your Advantage plan 
as a means for the purchase of a drug at a "preferred" pharmacy,
or, B) you can use any US online discount website (the most
common is www.goodRx.com, singlecare.com, etc. ) which will
feature better copays for certain drugs. Moreover, their cheapest 
copay also may be at a pharmacy which you don't usually use. 
Thus, if it is a much better price, you must notify your doctor to 
re-send this new Rx to the "other" local drug store.  It is a quick 
double-check with these discount online websites to fill in the
long horizontal search box on the landing page. Be certain that 
you use their drop-down menus to specify the dosage and the 
frequency of the drug's (usual) 90-day use.

Fred Manas · Answer

A common deceptive marketing trick used in Medicare Advantage plans involves falsely assuring beneficiaries that their preferred doctors are in-network, even if they are not. This trick hides the restrictive networks that Medicare Advantage plans often have, leading to unexpected out-of-pocket costs when beneficiaries try to see their regular doctors. 
Here's a more detailed explanation:
Misleading Network Information:
Insurance agents may exaggerate the network of doctors a plan includes, falsely stating that a beneficiary's current doctor is in-network. 
Failure to Check Network:
Some agents may not verify the network status of a beneficiary's doctors before enrolling them in a plan, according to Medicare Agents Hub. 
Deceptive Marketing Materials:
Mailers and advertisements can be designed to resemble official government communications, making it harder for beneficiaries to distinguish between official information and marketing materials. 
Financial Disappointment:
When beneficiaries switch to a Medicare Advantage plan and discover their doctor is not in-network, they face the unexpected cost of paying out-of-pocket for those services. 
Limited Access to Specialists:
Medicare Advantage plans may have limited access to certain specialists, such as dermatologists or cardiologists, compared to Original Medicare.

David Christian · Answer

Medicare is so highly regulated and the punishment for an agent, broker or carrier to mislead possible clients is so high (loss of ability to sell or the license), it's not really worth it. That said, no matter what plan you are interested in, verify the doctor(s) you want are contracted with that plan. Notice I said plan. Some doctors or medical groups will be with a carrier with multiple plans, but not accept every individual plan. Hope that helps.

Answered by David Christian on April 9, 2025

Broker Licensed in CA & TX

Answered by David Christian Medicare Insurance Agent

Ellen Diehl · Answer

It's not as much a trick as a LIE. You should not work with an Agent who would LIE to you. You need a Broker who will put you in the best plan for you - not the best commission for them. If you have not made your selection yet please reach out to me for help. Ellen

Answered by Ellen Diehl on April 8, 2025

Broker Licensed in GA

Answered by Ellen Diehl Medicare Insurance Agent

Jack Mayer · Answer

I think for the most part it really comes down to the carrier, the available plans in your area that have the largest network of providers and going with a flagship carrier like United Healthcare for example. Also, Medicare Advantage PPO plans can offer less restrictions because there is no referral needed by your Primary Care Physician but the PPO plans are still network based and you will have more out of pocket! On the flip side a Medigap plan has no network and you are free to see any doctor, provider anywhere that accepts Medicare.

Answered by Jack Mayer on April 14, 2025

Agent Licensed in CA & NV

Answered by Jack Mayer Medicare Insurance Agent

Chris Prang · Answer

Funny. I just made a video that mentions this and my answer below. It will be on my Youtube channel within the next week. See here: https://www.youtube.com/@TheMedicareAnalyst

But to answer the question: I don't know if I would call it a trick, but it is something that occurs both probably intentionally and unintentionally. And that is "Ghost Networks." A Ghost Network will either have doctors listed as being In-Network, but aren't (this could just be a simple error on the insurance companies provider search, due to it not being updated), or they just aren't accepting new patients. 

From my experience, the more common thing that happens is, you search to see if a provider is in the plans network and they don't show up, so you presume they aren't in the network. You may even call Customer Service and ask them, and they search and don't see the provider. But lo and behold, they actually are. But the only way you find out is through the insurance companies provider relations department...which may be hard for a consumer to reach. But I do this all to often to find out, and in most cases a doctor that is not listed or "printing" as they say, is actually in the network.

If you have any doubt, the providers billing department should or better be able to answer the question correctly whether they are in the network with the particular plan you are interested in. Which brings up another point...a provider may not be in all of the insurance companies plans networks, so be sure to check your specific plan.

I hope that helps.

Have a GREAT day!

Chris Prang | The Medicare Analyst

Charles Mitch Winstead · Answer

In my opinion, most tv commercials don't cover topics like restrictions and choosing your doctor.  It's better to talk with or have an agent come to your house and discuss these things.

What's a common trick in Medicare marketing that hides restrictions on doctor choices?

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What's a common trick in Medicare marketing that hides restrictions on doctor choices?

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