{"id":15349,"date":"2026-09-01T08:40:00","date_gmt":"2026-09-01T08:40:00","guid":{"rendered":"https:\/\/medical-article.com\/?p=15349"},"modified":"2026-09-01T08:40:00","modified_gmt":"2026-09-01T08:40:00","slug":"were-sorry-thats-the-policy-how-a-medicare-advantage-runaround-nearly-cost-a-senior-his-sight","status":"publish","type":"post","link":"https:\/\/medical-article.com\/?p=15349","title":{"rendered":"\u201cWe\u2019re Sorry, That\u2019s the Policy\u201d: How a Medicare Advantage Runaround Nearly Cost a Senior His Sight"},"content":{"rendered":"
\n<\/div>\n

By FRANK LEAHY<\/p>\n

On a gray February morning, I sat in my office in Inverness, in rural northern California, with the phone pressed to my ear, jotting down notes and Humana reference numbers. Across the table, my new friend Rick, 77, waited anxiously, struggling to follow the conversation. Nearly deaf and now partially blind, Rick had lived with a detached retina for weeks. Time was running out to save his vision.<\/p>\n

I was determined to get Rick the surgery he needed. But as hours turned into days and days into weeks, I found myself ensnared in the kind of bureaucratic maze familiar to millions of Americans with Medicare Advantage plans.<\/p>\n

This is the story of a vulnerable senior and his advocate, caught between doctors, clinics, and insurers at the hard edge of Medicare Advantage \u2013 America\u2019s privatized Medicare system. It is a story of denials, delays, and a rulebook no one would explain \u2013 and of the human cost when a system is built to save money, not sight. It is also a story about how and why it took seven months, and a letter to a Fortune 500 CEO, to get one surgeon paid.<\/p>\n

\u201cI Just Want to See Again\u201d<\/strong><\/p>\n

Rick\u2019s world had been shrinking for years. Hard of hearing and living on less than $1,200 a month in Social Security and SSI, he split his time between Colorado and a friend\u2019s spare room in rural California. With no family nearby, no internet, and only a battered flip phone, he relied on friends for help.<\/p>\n

In mid-November 2024, Rick fell out of bed, striking his head and injuring the left side of his face. He shrugged off the pain, but over the following weeks his vision blurred, then faded. \u201cI thought it would get better,\u201d he said. \u201cBut it just kept getting worse.\u201d<\/p>\n

I met Rick in late December 2024. He told me about his fall, the injury, and that he could no longer see out of his left eye. It was clear how serious his situation was, and how much support he needed, so having recently retired I had the time to help him. But it was nearly too late. After weeks of back-and-forth with Humana, I finally got him in front of an ophthalmologist, who diagnosed a retinal detachment \u2013 a medical emergency where prompt treatment is essential to prevent permanent blindness.<\/p>\n

Getting that treatment would prove far harder than I could have imagined.<\/p>\n

The Medicare Advantage Trap<\/strong><\/p>\n

Rick was enrolled in a Humana Gold Plus HMO, a Medicare Advantage plan based in Colorado. Why Humana? Pure happenstance. He had been shopping at a Walmart in Colorado when a man \u201cwho seemed nice\u201d signed him up. Like a lot of older people, Rick didn\u2019t know the difference between Medicare Advantage and Original Medicare with a Medigap supplement \u2013 or why that difference would come to matter so much.<\/p>\n

Like more than half of all Medicare beneficiaries, Rick had been drawn to a private plan by the promise of extra benefits and lower costs. The catch is that Medicare Advantage plans are built on narrow provider networks and strict rules about where and how you get care. For snowbirds, part-time residents, or anyone who lives in more than one state, those rules can become a trap.<\/p>\n

My first call to Humana set the tone:<\/p>\n

\u201cI searched for a doctor on your website. I found one and called them. They say they don\u2019t take Humana, even though your website says they do,\u201d I told a representative, reading from my notes. \u201cCan you find one for me?\u201d<\/p>\n

\u201cYou can, but I need Rick on the line.\u201d<\/p>\n

\u201cHe\u2019s right here.\u201d<\/p>\n

\u201cOkay, but I also need additional documentation\u2026\u201d<\/p>\n

The runaround had begun.<\/p>\n

The Rules No One Explained<\/strong><\/p>\n

To get surgery, Rick needed a referral to a retina specialist. No one at Humana told us that at the start. We learned it the way we learned every rule in this process \u2013 by hitting a wall, calling back, and being told, after the fact, that we had failed to do something no one had mentioned.<\/p>\n

<\/span><\/p>\n

The referral had to come from a primary care physician (PCP), and Rick, in any practical sense, didn\u2019t have one. There was a Colorado PCP listed on his Humana card \u2013 someone he\u2019d never met, in a state he couldn\u2019t travel to with a detached retina \u2013 but when we called the office they said Rick would need an in-person appointment to get a referral. Functionally, he had no PCP at all.<\/p>\n

Getting one was its own ordeal. Primary care is scarce everywhere now, and getting scarcer, and a new patient who is elderly, low-income, and on an out-of-state HMO is exactly the kind of patient practices are least interested in taking on. Some weren\u2019t accepting new patients. Some didn\u2019t take the plan. Some couldn\u2019t schedule him for weeks. Meanwhile the requirement no one had explained was standing between Rick and the specialist he urgently needed.<\/p>\n

And when I did reach someone at Humana, the answers contradicted each other. Some reps said a referral was required; others said it wasn\u2019t. Some said we could switch Rick\u2019s primary care doctor to a local one; others said only during open enrollment, or only with more paperwork, or only with Rick on the call. And even with both of us on the line, the change stalled. There was no map of the process, no single person who owned it, no way to know in advance what the next hidden requirement would be. The rules existed. They were just invisible until you had broken one. And nothing was ever provided in writing.<\/p>\n

Humana\u2019s own directory only deepened the confusion. It listed several in-network retina specialists, but when I called, most didn\u2019t actually take the plan, or demanded a referral from the local doctor Rick didn\u2019t have. \u201cWe can\u2019t approve the surgery without pre-authorization, but you need to see an in-network specialist first.\u201d \u201cThere are no in-network specialists available.\u201d \u201cI\u2019m sorry, that\u2019s the policy.\u201d All the while, Rick\u2019s vision slipped further away.<\/p>\n

An Emergency Room, an Emergency Referral \u2013 and Still No Surgery<\/strong><\/p>\n

Desperate, I took Rick to the emergency department at a major San Francisco academic medical center. Doctors there confirmed a chronic left retinal detachment, with a poor prognosis for recovery because of the delay. They issued an urgent referral to the hospital\u2019s ophthalmology clinic, hoping to fast-track surgery.<\/p>\n

Even then, the insurance barriers held. The hospital would not schedule Rick without a payment guarantee from Humana. Humana would not guarantee payment without a referral from his out-of-state primary care doctor and pre-authorization \u2013 steps that could take weeks.<\/p>\n

\u201cThe system is not set up for people who move between states, have no fixed address, or have cognitive or hearing impairments,\u201d I told my wife one night. \u201cIt\u2019s a constant loop of referrals, authorizations, and confirmations, with no one accountable. I have spent 45 years as a software engineering leader in Silicon Valley and am finding it almost impossible to navigate. Now I see how people end up without the care they need, or living under a freeway overpass.\u201d<\/p>\n

The Clock Runs Out<\/strong><\/p>\n

Retinal detachment is a race against time. The longer the retina stays detached, the lower the odds of restoring sight. For Rick, the delays were devastating.<\/p>\n

After weeks of calls, faxes, and appeals, I finally found a local primary care doctor willing to see Rick and write the referral. A retina specialist then agreed to operate. Even then, the insurance hurdles didn\u2019t end.<\/p>\n

Humana\u2019s Explanation of Benefits statements told the story in cold, bureaucratic language. For the initial consult, imaging, and surgery \u2013 thousands of dollars in care \u2013 Humana paid nothing. The denial cited a charge that \u201cexceeds fee schedule\/maximum allowable or contracted\/legislated fee arrangement.\u201d In plain English, the provider \u2013 who was listed as in-network on Humana\u2019s website \u2013 was treated as out of network, so the allowed amount was $0.00.<\/p>\n

As a dual-eligible for Medicare and Medicaid, Rick was protected from being billed directly. But his surgeon went unpaid, and the follow-up procedure to remove the silicone oil used to reattach the retina hung in limbo.<\/p>\n

\u201cIt Should Have Been Removed Within Three Months\u201d<\/strong><\/p>\n

In July, roughly five and a half months after the first surgery, the retina specialist wrote to Humana: he had repaired Rick\u2019s retina with silicone oil in an emergency operation, and it was important to remove that oil in a separate procedure so Rick could reach his best possible vision.<\/p>\n

Silicone oil is generally removed within about three months. Leaving it longer raises the risk of glaucoma, cataracts, and further vision loss. But Humana kept denying payment and authorization, citing the same network and contract barriers. The appeals dragged on with no end in sight.<\/p>\n

How It Finally Ended<\/strong><\/p>\n

Here is the part that still stuns me. Rick\u2019s surgery was finally authorized. His referral was finally accepted. But still, for months, the surgeon who saved what was left of his sight was paid exactly nothing.<\/p>\n

The reason had nothing to do with whether the care was necessary. It was buried in Humana\u2019s own records. When I finally reached Humana\u2019s executive resolution team \u2013 and only after I wrote directly to Humana\u2019s CEO and board of directors \u2013 the specialist assigned to the case told me the claims were paying $0.00 because of how the surgeon was \u201cloaded\u201d in Humana\u2019s system. His most revealing sentence: the claims were, he said, \u201cpaying correctly based on the contract loaded.\u201d<\/p>\n

Sit with that. By Humana\u2019s own logic, paying the surgeon nothing wasn\u2019t a mistake. It was the system returning the correct answer.<\/p>\n

And here is the contradiction that proves how arbitrary that answer was. Around the same time, when the surgeon\u2019s office called Humana directly to arrange Rick\u2019s second operation, a Humana agent confirmed on the phone that Rick was in network with both the surgeon and the hospital, and that the oil-removal procedure required no prior authorization at all. In network and paid zero, at the same time, by the same company.<\/p>\n

There was no outside referee to appeal to. The No Surprises Act \u2013 the federal law that lets an out-of-network doctor force a fair payment through arbitration \u2013 does not cover Medicare Advantage, and so the one backstop built for exactly this situation was unavailable. Escalation was the only lever left, and escalation meant going over the heads of everyone in the ordinary process, all the way to the boardroom.<\/p>\n

So that is what it took. Not the provider directory. Not the appeals line. Not the dozens of hours I logged \u2013 by my own conservative count, more than ten calls to Humana totaling nearly four hours, plus two dozen more to clinics and hospitals. What finally moved the claim was a letter to the CEO and board of a Fortune 500 company, which routed the case to an executive-inquiry team, which spent weeks working with contracting before someone finally wrote the sentence I had been waiting months to read: \u201cWe have updated the provider\u2019s information so claims should process with payments according to their contract.\u201d The claims were sent back for reprocessing, and in early September 2025 \u2013 roughly seven months after the emergency surgery \u2013 the surgeon was paid.<\/p>\n

Only then could the follow-up proceed. The silicone oil that should have come out within about three months had stayed in for roughly seven. It waited not on medical approval \u2013 Humana had confirmed the removal needed none \u2013 but purely on money. The surgeon, reasonably, would not schedule more unpaid work until the first bill was settled. Once it was, the oil was removed in September 2025 \u2013 almost ten months after he fell out of bed.<\/p>\n

Rick can see a little now. His vision is permanently diminished by the delay, but he is no longer at immediate risk. He was lucky \u2013 lucky mostly in that he happened to have a neighbor with the time, the stubbornness, and eventually the right people to write to. Most people have none of that.<\/p>\n

That is the part that should worry everyone. Because Rick\u2019s case is not a story about one bad insurer or one broken claim. It is a story about a system designed for delays and denials, and about what that reveals for the millions of people who are one fall away from getting the same runaround treatment from their Medicare Advantage plan.<\/p>\n

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.<\/em> In part 2 of this article he\u2019ll suggest how some simple reforms might fix Rick\u2019s experience<\/em><\/p>","protected":false},"excerpt":{"rendered":"

By FRANK LEAHY On a gray February morning, I sat in my office in Inverness, in rural northern California, with the phone pressed to my ear, jotting down notes and Humana reference numbers. Across the table, my new friend Rick, 77, waited anxiously, struggling to follow the conversation. Nearly deaf and now partially blind, Rick…<\/p>\n","protected":false},"author":0,"featured_media":15348,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2],"tags":[],"class_list":["post-15349","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-articles"],"_links":{"self":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/posts\/15349"}],"collection":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"replies":[{"embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=15349"}],"version-history":[{"count":0,"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/posts\/15349\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/media\/15348"}],"wp:attachment":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=15349"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=15349"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=15349"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}