By FRANK LEAHY
This is the second of two pieces. The first told the story of “Rick,” a 77-year-old Humana Medicare Advantage member who nearly lost his sight in a months-long runaround over a retinal detachment. This one asks what his case reveals, and what would help fix it.
The runaround was exhausting – the hold times, the repetition, the new voice on every call. But the most disturbing moment wasn’t any of that, and it wasn’t a denial. It was a justification. The claims that paid his surgeon $0.00, a Humana representative explained, were “paying correctly based on the contract loaded.”
Hold onto that sentence, because it reframes everything. What nearly cost Rick his sight was not one careless adjuster or one unlucky claim. The system did what it was built to do. It was designed so that a 77-year-old losing sight in one eye, and the surgeon who saved it, could end up with nothing – and no understandable way to make it right.
No understandable way is the heart of the problem. When a privately insured patient gets an unfair out-of-network bill, federal law hands their doctor a referee: the No Surprises Act, which lets a provider force a fair payment through arbitration. But that law was written for commercial insurance and never reached Medicare Advantage. On paper, Rick’s surgeon was already owed at least the standard Medicare rate; Medicare Advantage’s own rules say so. But he was paid nothing – and unlike a commercial patient’s doctor, he had no arbitration, no referee, no way to force the issue. What finally worked was a letter to Humana’s CEO and board of directors – a lever that shouldn’t have been needed.
Not an Outlier
Rick’s is just one case among a very large number. In 2023, Medicare Advantage insurers reviewed roughly 50 million prior-authorization requests and denied about 6.4% of them. Only 11.7% of those denials were ever appealed – and of the ones that were, more than 80% were partly or fully overturned. When four of five challenged denials get reversed, the obvious question is how many of the unchallenged ones were wrong too. (Source: KFF, 2025.) The federal Office of Inspector General has repeatedly found Medicare Advantage plans denying or delaying care that traditional Medicare would have covered.
What Rick’s case adds to those numbers is texture. His problem was never that his care was judged unnecessary – it was eventually authorized. His problem was that the rules were invisible and the process had no owner. No one told him a referral was required until he’d already failed to get one. The primary care doctor who was listed on his Humana Medicare Advantage card was a stranger in another state. The insurer’s own directory listed specialists who didn’t take the plan. Every answer contradicted the last, and nothing was ever put in writing. He was expected to navigate a maze whose walls appeared only after he’d walked into them. And when the maze finally produced a number, the number was $0.00 – for a surgeon the same insurer confirmed, on a recorded line, was in network.
Three Fixes That Can Help
There are many big proposals about how to fix health care in America, but I’m going to propose three narrow, unglamorous fixes that answer the simple question: Would it have helped Rick at the time of his accident?
First: If a doctor appears in the plan’s directory, the plan pays the bill. This is the most important one, because it is the exact contradiction that trapped Rick. Humana listed his surgeon as in network. A Humana agent confirmed it on a recorded call. And Humana eventually paid $0.00, calling that “correct.” A plan should be held to its own information: if you publish a provider as in-network, that publication is a promise, and you owe the claim. No more paying nothing while insisting the directory was never a guarantee.
Second: Drop the primary-care referral requirement in Medicare Advantage. Original Medicare has no such gate; a patient can go straight to the specialist they need. For Rick, the referral requirement – which no one disclosed – was the tripwire that cost him weeks he didn’t have, all so a primary care doctor who had never treated him before could sign a form. For urgent specialty care, the gate protects no one but the insurer’s budget.
Third: Give every complex case one accountable person, and put rules, decisions, and next steps in writing. The deepest failure in Rick’s case wasn’t any single rule. It was that no one owned the outcome. Each call reached a new stranger with a new answer and no memory of the last. Members facing urgent or complicated care need a single named case manager who sees it through, and they need the plan’s requirements and decisions in writing, so the rules can’t shift from one call to the next. Faster pickup and friendlier reps would be nice, but the fix that matters is accountability: a human whose job is to get you through, and a paper trail that can’t be denied later.
What these three have in common is that the adversary is opacity. The rules are hidden, the information is unreliable, and no one is accountable for the result. Each fix attacks one of those: hold the plan to its own directory, stop hiding requirements behind a needless gate, and give the member a person and a paper trail they can follow. Transparency and accountability rather than grand redesign.
None of this abolishes Medicare Advantage, and none of it needs to. For millions of healthy enrollees it works, and it’s cheap. The problem is what happens to the ones who get sick and fall into the gaps – and right now the system answers them with contradiction, opacity, and a $0.00 payment it calls correct.
Rick finally got his surgery, and his surgeon eventually got paid, but only because one stubborn neighbor refused to give up. The reforms above mean the next Rick won’t need one.
Frank Leahy is an independent advisor & investor who had a 45 year career leading engineering teams in Silicon Valley including stints at Intel, Apple, Salesforce and several startups.
