← Return to Any experience dealing with eviCore? Medical procedure denied!

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@hikerguy62

Well, that's very discouraging to hear about BCBS using eviCore as well. Insurance is a very seedy business. They're more than willing to take our money, but when we need expensive tests done, they find any excuse to block the procedure. Gotta make sure those senior VPs and CEOs can afford their million dollar homes and yachts.

Amazingly though, my wife got no push back on getting an MRI done recently when she twisted her ankle so badly she ended up with a hairline fracture (the xrays showed that). But they wanted to make sure no ligaments or tendons were damaged, so they are doing the MRI as well. We use United Healthcare through my wife's insurance that she gets from the government (known as GEHA). I still don't quite understand that relationship.

I'm only a few years away from Medicare and don't look forward to that.

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Replies to "Well, that's very discouraging to hear about BCBS using eviCore as well. Insurance is a very..."

The only thing I can say about getting to Medicare is that you need to understand the difference between the Medicare Advantage Plans, Medigap Plans, "wraparound" plans where you retain your employer's coverage after retirement and Medicare becomes primary, the insurer becomes the administrator.
I cannot repeat often enough "there is no free ride" - an Advantage Plan with a tiny, or no, premium, will definitely not offer as much as a Medigap plan, will have more restrictions, a preferred provider setup, and higher copays.. And usually, if you qualify, a wraparound where you keep your original insurance carrier tends to be best.

Sit down and do some future math. Try to look ahead 15-20 years - what afflicted your parents and older siblings may well come your way. Don't be swayed by shiny perks like "Silver Sneakers" - if they're in your "best fit" plan fine, but if you can't afford your meds, a gym membership is no good to you.
When I became Medicare eligible, it was clear that with a few health issues, we were going to continue to have rising health costs as we age. And an abundance of PT to keep my body moving would be needed.
So low copays were important - in good years we view the higher premium as a "down payment" on future needs. In bad years, we breathe a sigh of relief that we didn't have to dip into savings to cover medical bills.
We also planned to (and do) travel extensively, so we needed portable care - driving 1500 miles to get a lung infection treated is not an ideal situation.
Prescription copays and the most general possible formulary are important too. The meds you need at 80 are often much different than at 65.

Medicare may be the single greatest reason why the life expectancy of our WWII and Boomer generations rose so rapidly. My grandparents and their siblings only had the GP, who listened to their lungs, prescribed penicillin, and got $5 a visit.