Some Medicare managed care organizations (MCOs) are telling
beneficiaries that they need to get a referral from one of the plan
physicians before they can get a mammogram. But that is not what the
law says. A woman can get an annual, routine mammogram without any
referral. William Scanlon, director of health financing and public
health for the General Accounting Office (GAO), says that a study the
GAO just did of 16 MCOs found that five of them erroneously stated
the mammogram benefit.
And that wasnt the only problem the GAO found after it combed
through the plan documents and contracts for these MCOs. There were
problems with the prescription drug benefit, too. Managed care
organizations offer outpatient drugswhich are not available as
part of Medicare fee-for-serviceas an enticement to get people
into managed care plans. Scanlon says that one plan stated in its
contract with Medicare that it would pay the first $1,200 a year in
name brand prescription expenses for each Medicare beneficiary.
However, the literature given to potential members by the MCO stated
that only the first $600 in name brand prescription expenses would be
Those revelations came out at hearings held by the Senate Special
Committee on Aging. Sen. Charles Grassley (R-Iowa), chairman of the
committee, says inaccurate information given to beneficiaries by MCOs
leads to appeals when benefit claims are then denied.