This episode features a Medicare expert’s perspective on healthcare from Danielle Roberts. She joined the Perspectives on Healthcare Podcast with Rob Oliver from Texas. Danielle is the founder of Boomer Benefits, a company that helps members of the Baby Boomer generation navigate the transition from traditional health insurance to Medicare. She is a member of Generation X.
Here are 3 things that stood out as Danielle Roberts shared a Medicare expert’s perspective on healthcare:
· Medicare brokers work with multiple insurance plans to provide health plans that fill in the gaps that Medicare doesn’t cover.
· There are over 1 million providers that accept Medicare. Your access to them depends on your health plan.
· HMOs and PPOs were the impetus for tipping the decision-making for a plan of treatment from the medical professional to the insurance company.
You can learn more about Danielle Roberts and Boomer Benefits through the links below:
Here is the transcript of Daniel Roberts: A Medicare Expert’s Perspective on Healthcare:
Rob Oliver: Thank you and welcome to another episode of Perspectives on Health Care. My guest today is Danielle Roberts. She is a Medicare expert and author. She is a member of Generation X. She joins us from Texas and where she is the founder of Boomer Benefits. Danielle, welcome to the podcast.
Danielle Roberts: Well, thanks, Rob. I’m so happy to be here. Thank you for having me.
Rob Oliver: You bet. So tell me a little bit about yourself and your role in healthcare, please.
Danielle Roberts: Okay. So I became involved in healthcare excuse me, when I got my life and health insurance license, which was way back in late 2004. And then I founded my agency in 2005, started helping individuals and businesses, helping them with individual health plans and group health plans. And over the next few years, we noticed that we had a lot of people who were asking about health insurance help for their parents. It would be something along the lines of, hey, you helped me with my insurance policy. I’m trying to help my mom. She’s aging into Medicare. And this stuff is really confusing. And so, sure enough, we took a look at it and found that Medicare is very confusing. What happens in America is you turn 65. In your whole life, you’ve had a company choosing your health care options for you, and suddenly you’re 65 and you’re thrust into this national health insurance program with all these different options. It’s very confusing. And so we were able to get in there and learn it backwards and forwards and become experts in the Medicare space. And over time, we shifted all of our business to where today, Boomer Benefits helps people when they’re navigating their entry into Medicare across the nation, people turning 65, they come to us.
Rob Oliver: Okay, so talk to me a little bit about are you offering supplemental plans? Are you offering plans that there’s a variety of Medicare plans that are available. And like you see, Joe Theisman is on TV advertising for all kinds of so what is it that you’re offering? Or what are you kind of counseling people about?
Daniel Roberts: That’s such a good point. Every time you turn on the television, there’s an aging sports start telling you about these amazing Medicare plans that come with all these freebies the kitchen sink, a peak Cadillac. We hear this a lot. These are, of course, ads designed to get people interested in certain insurance products. So where we come in as a broker is we work with 25 or 30 different insurance carriers. We know all the different medicare products, and we help people with setting up their medicare supplements or their medicare advantage plans and their part d drug plans. And these products fill in the gaps in medicare. So medicare, as a surprise to many people, doesn’t cover 100% of your health care costs in retirement. In fact, there’s a portion that’s significant that could bankrupt you if you didn’t have proper insurance to fill in some of those gaps. So what we do is we take medicare and educate people on what the federal government provides first so they understand what they’ve worked for all their life and how that works. And then we show them how the various products work so that they can choose one that will help fill in some of those gaps, give them some financial security in retirement and make sure that they have the needs. They’re choosing a plan that fits their needs and their budget.
Rob Oliver: Okay, so then let’s talk about quality health care. Okay, so what does quality health care mean to you?
Danielle Roberts: So in my world, working with medicare products, for me, what has meant the most in terms of quality health care is access. So in america, there are over 1 million providers that accept medicare, but your access to those providers will be dependent on which type of plan that you enroll in. So there are medigap plans and there are medicare advantage plans. Medigap plans allow people on medicare to see any provider nationwide. They don’t have to pick a primary care doctor. They don’t have to get a referral to see a specialist. Advantage plans have networks. And that’s very important then that you’re making sure your doctors are in the network and your medications are covered on the formulary. And so when it comes to quality health care, what I have seen time and time again over the course of my career is that when someone has a serious illness, they want to seek out the best specialist or the best hospital in the United states where they can treat. And having the type of coverage that will allow you that freedom of access, in my opinion, is one of the most important parts of being able to access very quality healthcare.
Rob Oliver: Okay, I’ve been dying to ask somebody this question, and you get to be the unfortunate person that hears it. Okay?
Daniel Roberts: Okay.
Rob Oliver: And that is, when did the power shift from doctors to insurance companies? And here’s what I mean. When someone goes and the doctor says they need this plan of treatment, the first question that’s asked is, what kind of insurance do they have? How do you navigate that? And what are your thoughts about that paradigm as the way that healthcare is delivered in the United states?
Daniel Roberts: Yeah, I love this question because there’s just no question at all that when the power shifted is when insurance companies began offering products like HMOs and PPOs. And so they go in and they create a network that you have to get your treatment from, or if you go outside the network, you may not have coverage or you may pay a lot for your medical services that you seek out there. And also, then what became part of that is, well, we’re an insurance company, and we’re busy to make money. We want to make a profit. So we need to make sure that we are controlling how much medical care that you receive. And in the Medicare world, this is a big, big conversation because you will find many doctors across the nation that won’t accept Medicare Advantage plans and don’t like those plans because the beneficiary has basically assigned all of their Medicare benefits over to this insurance company. Again, the insurance company is trying to deliver care, but also do it cost effectively so that they can make a profit. And doctors are frustrated by this. They’re very frustrated when they can’t get a referral to go through or if a prior authorization is taking time. And the doctor is like, look, my patient needs this procedure or this test, this diagnostic. They don’t like an insurance company to be holding up that care. And it is a problem. It is a problem that needs to be addressed in America, for sure.
Rob Oliver: Okay, thank you for not shying away from the question. Can you give me an example of quality healthcare?
Danielle Roberts: Yeah. So if I think about my own physician, I go and see him once a year. I’m a pretty healthy person, but he has time for me. So when I’m in the office, I’m not being rushed through because he needs to get in enough patience every day to make a profit. Or if he is doing that, he doesn’t make me feel that way. He spends at least 30 minutes with me every time I’m in there, and he’s going over a bunch of lab work that I’ve had done that is important for him to see, are there any problems going on? And I have an opportunity to ask questions. I can ask him for help determining a specialist. If I need something and you want to have that kind of access, you don’t want to have somebody being paid on the cattle call. How many people can we get in there? And one of the issues that we have with Medicare today is that a lot of times the doctor might accept Medicare patients, but they’re not taking new patients because Medicare reimburses less than what an under 65 group health insurance would reimburse. And so a lot of these positions can only take so many Medicare patients at a time, and this can cause access problems. We also will see certain hospitals, like down here in Texas, we have MD Anderson, one of arguably the best cancer hospitals in the nation, if not the world, and you can access care there if you have one type of insurance, but not necessarily if you have another type of insurance. And so we get back to that question of access. But we need to understand is that what people. At least my clients care about is when they do have an issue. They want to be able to get in and talk with their doctor and spend time with their doctor and have felt like they’re not just a number and that they aren’t being shuttled out quickly. That there’s a relationship there and that is all about developing quality health care in their minds. They want to be someone that is seen and heard by their doctor and not rushed through that process.
Rob Oliver: Yeah, okay. So I’m in Pittsburgh, and it’s interesting. The city of Pittsburgh is literally divided in half by health insurance. We have the University of Pittsburgh Medical Center, which has their own health insurance. And if you have UPMC insurance, you can access all of the UPMC hospitals. But then there’s another network that’s out there and Blue Cross, they offer their insurance, and UPMC doesn’t take that. And so you literally, when you choose your health plan, you choose which set of hospitals you have access to. And to me, I think it goes right to your point about access. And then the other piece. A lot of times I’m under the impression that insurance companies set the reimbursement rates and set them based on time, that a physician has 15 minutes per patient or something along those lines. Is that accurate or am I misunderstanding that?
Danielle Roberts: It might be maybe in some plans that it is, it might be also capitation. Like how many patients does this particular doctor see in this particular health plan and the way they reimburse them? We have seen Medicare and even some of the Advantage companies trying to make strides in that area to make sure that that is important to them as well as to the patients. But it’s hard to manage when you have a plan. A national healthcare program with 64 million people on it. Trying to make those strides in making sure that people have access to the care and that the insurance company isn’t the only one in that picture. And that the doctors aren’t being compensated for how many patients they conceived instead of what kind of value of the care that they’re delivering. It is on the radar. And I do feel like the Centers for Medicare and Medicaid Services is aware that this is an issue that we need to make initiatives on. But it is certainly something that takes time, and we see that down here in Texas, just like you’re talking about up there up north.
Rob Oliver: Yeah. Okay. And since I’ve got all kinds of questions about insurance, there are times that I feel like the insurance company’s incentive is to keep me right above not sick instead of at healthy. Right. Because sometimes there’s such a struggle to access things that are going to be beneficial for me from a health perspective. And the idea is you don’t want me to be sick, you don’t want me to be in the hospital. This is not you personally, it’s the insurance company that I’m directing that to. But do you have a similar experience or a similar understanding that sometimes there is a reticence to complete healthiness as opposed to non sickness? Does that make sense at all?
Danielle Roberts: Yeah. So we see a focus on preventive care, which is good, right? Because we want to have that care taking place and making sure people take advantage of it so that they aren’t in a position where they’re not using any preventive care. And now a problem develops and the cost of treating this health condition is going to be a lot more than if we had just prevented it in the first place. But we still see a resistance to doctors that come from a perspective of natural wellness and who really focus on wellness. And we see a lot of times those doctors are taking patients by cash because the insurance companies don’t necessarily want to invest in that. I know my mom sees a chiropractor and he’s got all sorts of things, supplements and homeopathy and massage therapy and natural raw honey. He’s got all of these amazing things and she loves him and enjoys seeing him and feels like all of those things are important, but yet you don’t see this in a typical MD style doctor. And so it would be wise, I think, for a lot of big organizations like medicare itself to consider that this is becoming more important to people, that they want to live healthy and they want to have an active retirement. And so maybe we need more than just a simple little annual wellness check. Medicare doesn’t pay for the type of routine physical that you and I are used to when we’re under 65 and we go and have blood work just to see if something’s wrong. They don’t have that. And so people lose that when they come into medicare and they might have to pay extra if there’s a blood work that’s done that’s not necessary for a diagnosis or to determine a problem. And I think that that is short sighted.
Rob Oliver: Understood. And you’re preaching to the choir. What do you wish people understood about your role in healthcare?
Danielle Roberts: Well, what I wish medicare beneficiaries and everyone understood is that when you’re working with an independent broker like boomer benefits, we offer multiple different types of insurance plans through various carriers and there’s no cost for our services. So what we see happen a lot of times is people will call 1800 number because that sports star said that this is a good plan and they enroll over the phone and something that they don’t have any time to understand. No one really looked to see if it was the right option for them. They’re getting a hard sell on the phone and they’re reluctant to reach out to brokers like us because they think there’s going to be a cost involved when in fact we offer the same exact insurance policies for the same price with the carrier. And let’s say you found a Blue Cross plan that you really wanted. If you call Blue Cross about that plan, you would get the same quote that you would get from us and there’s no cost to you at all. We get paid by the insurance company that you ultimately choose. We get paid a commission for introducing you to that company. But being independent means that we can offer all of the different products and help you find the one that’s going to be the best fit for you. So I wish people knew that there was access to the type of quality education that we provide and the type of service that we provide and what that is all about and realizing that it’s a thing that if you go and enroll direct with an insurance company, you lose all of that benefit of the person that could educate you on things you may not know. They could point out things about plans that maybe you haven’t considered and being able to access that person on the back end when a doctor miscodes the bill or, you know, these things that happen and people don’t know where to call because they didn’t work with a broker because they thought they were going to pay something when in fact the service that we provide is free.
Rob Oliver: Got it. What excites you about the future of healthcare?
Danielle Roberts: So I love the advances in technology and I was so excited that as a result of the pandemic, we now have Medicare kind of opening the doors to telehealth. This is something that is very important, especially for people out in rural areas that can’t get to their doctors as quickly. This is so important that we have access to that. And then also in the Medicare world, the inflation reduction act was just passed and this act in particular is going to create much better access and affordability for prescription drugs. So I love the strides that we’re making in areas like that that are concerned about what people are paying but also making sure that they have access to the medications and the health care they need, whether they’re there in person or not.
Rob Oliver: Last question for you what is one thing medical professionals can start doing today to improve the quality of healthcare?
Danielle Roberts: So in my world and where you have doctors accepting Medicare, one thing that they could do to improve the quality of their health care and the access for the patients is to understand how Medicare works. Many doctors and their office staff have been with zero idea about how to properly code things and Medicare has 70,000 different codes so they don’t understand how the billing works and they just send people off for a test. Medicare denies the bill and it’s because the doctor’s office and the office staff didn’t put the proper coding in it. Now, at my agency, we know exactly when that happens, like, what caused this and we can help people fix it, but most people don’t know that. And if the staff were better educated and how Medicare works, they could create a better situation for people. Because if that patient is coming in and every time they come to see you, they end up with a big lab bill, there might be a time where they don’t come in because they’re worried about what kind of bill they’re going to get. And so then they don’t access the care that they really need that would prevent this big health condition that’s lurking out here. And so if doctors in their office staff would learn diligently how to properly bill for Medicare, they would be able to head that off. And we see people all the time choosing not to treat because they’re so worried about what kind of bills are going to come in their mailbox, when in fact those things would absolutely have been covered had the doctor’s offices just billed them correctly.
Rob Oliver: Okay, where can they access that education? Because it’s a great point.
Danielle Roberts: I know. And with our clients, when they call in and they’re like, hey, I got this bill, I don’t think I owe this. I’m not sure, can you help? We actually outreach and we call the doctor’s offices and we educate them. And so I think your doctor’s offices should look for a local Medicare broker in their area who can come out and do a training session, spend an hour, they go and they have continuing education and all these types of things. Invite a broker out to explain to you how the billing works on the back end of Medicare and then develop a relationship with that broker so that when a question comes up about Sally Sue needs to have X test, how should we code this so that Medicare won’t just immediately deny it? You have a person that can hunt down that information for you or educate you or at least be involved so that if an appeal does happen, if a denial happens and an appeal needs to happen, the broker is involved and can be a resource for both you, the doctor, the office staff and the patient.
Rob Oliver: Very practical suggestion, and I appreciate you sharing that. Listen, Danielle, thank you so much for being with me today. I appreciate you sharing your thoughts. I respect you and I respect your perspective on healthcare.
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Disclaimer: All opinions expressed by guests on the Perspectives on Healthcare Podcast are solely the opinion of the guest. They are not to be misconstrued as medical diagnoses or medical advice. Please consult with a licensed medical professional before attempting any of the treatments suggested.