Medicare members like you may be concerned about how their medical history or a preexisting condition will affect their Medicare Advantage eligibility. As with any major life decision, when selecting a healthcare provider, you may have many questions. This article aims to answer some of those questions and give you a better understanding of medicare advantage programs.

Accurate medical history information about allergies, illnesses, surgeries, immunizations, and results of physical exams is very important. They give a roadmap for doctors and healthcare providers to better serve you. 

Medicare Advantage providers cannot discriminate based on your medical history or preexisting conditions

A Federal Regulation(42 CFR 422.110) explicitly prohibits any Medicare Advantage organization from denying, limiting, or otherwise conditioning coverage to individuals eligible to enroll in a Medicare Advantage plan. This is on the basis of any factor that is related to health status, including, but not limited to the following:

(1) Medical condition, including mental as well as physical illness.

(2) Claims experience.

(3) Receipt of health care.

(4) Medical history.

(5) Genetic information.

(6) Evidence of insurability, including conditions arising out of acts of domestic violence.

(7) Disability.

Why would a provider review my medical history if I am guaranteed eligible?

Personal medical history may include information about allergies, illnesses, surgeries, immunizations, and results of physical exams and tests. It may also include information about medicines taken and health habits, such as diet and exercise. 

Knowing these medical history factors is important to ensure you receive adequate care in the future. An example of this would be to make sure your Primary Care Physician and their network are compatible with your healthcare needs.

How does a Medicare Advantage medical history review differ from a traditional patient-doctor review?

When treating patients, information gathered through a review will guide and direct care. Many initial visits with patients include asking about medical history, while additional visits may only require a review and update of the patient’s medical history.

Obtaining a medical history can even reveal relevant chronic illnesses and other prior disease states for which the patient may not be under treatment but may have had lasting health effects.

Are there any concerns I should have about disclosing past medical history with my Medicare Advantage provider?

Information is power when it comes to maintaining your health. It is important to realize that the medical history review process is meant only to benefit the patient. Disclosure to your medicare advantage provider, doctor, or healthcare professional is critical to receiving the right care for your needs. Be sure to let your Medicare Advantage provider about any conditions, accommodations, past surgeries, or medications you may have.

Will I be required to provide detailed records for my medical history review?

No, you can relax on this one. The process of medical record transferring is complex and handled by professionals with experience. The medicare advantage provider of your choice will work with the appropriate healthcare provider to collect the necessary medical records.

Should I expect my medicare advantage provider to conduct medical reviews in the future?

Yes, medical reviews are necessary for assessing the quality of care received.

Medicare Advantage providers regularly conduct reviews of healthcare providers’ records related to services rendered to patients. Medicare Advantage providers request access to medical records and billing documents periodically to conduct reviews. Upon request, the healthcare provider will provide detailed itemizations of charges to support the supplies and services billed.

This process not only aims to reduce fraud but ensures that members receive the proper care. It is important to remember that Medicare Part C companies are subject to federal law and are responsible for ensuring that members are properly taken care of.

We won’t go into any more detail on this here. For more information regarding Medicare Advantage review processes, please refer to Provider Payment Integrity Post-payment Review Policy and the Medicare Advantage providers Provider Payment Integrity Prepayment Review Policy.

Meadowcrest Family Physicians have resources to help get you started.

We have found that our patients are getting better benefits with Medicare Advantage Plans and strongly recommend that you explore your Medicare Advantage options.

At Meadowcrest Family Physicians our commitment to care goes much beyond our office. If you need additional information regarding Medicare Advantage we have resources to help. Please make an appointment with our in-office rep to learn your options.