Anonymous(M) lives in FL where he was a teacher in the community college system and now lives on a modest state pension. The state retirement system includes enrollment in Medicare Advantage program. On a Saturday evening, M fell down a flight of stairs at his health club. They took him to a near-by hospital emergency room where they stabilized his arm with a sling, but he also needed a brace and cast that would permanently immobilize the arm during the healing process. That needed to be done by an orthopedic surgeon, but none was available on a Saturday. They made an appointment for him with an orthopedic doctor for Monday. M had to wait two days without a cast.On Monday he went to the orthopedic surgeon, but he couldn’t be treated because the doctor wasn’t in M’s MA network. So M went home with his arm not properly stabilized. He made an appointment with an ortho doctor in his network, but it was for nearly one week later. Michael spent a stressful week trying to avoid any movement that might do further damage to his arm. He couldn’t go to the store, drive, take a shower or even dress himself. Finally, the in-network ortho doctor put on a brace and cast from wrist to above the elbow, but M had to pay $900 out of pocket because his insurance company wouldn’t cover cost of the brace. Worse, the brace didn’t fit right; it rubbed against his wrist, which caused bleeding and infection. Michael called the ortho doctor to make an appointment to have the brace adjusted. But the doctor said he couldn’t see him without a referral from his primary care physician. M got angry, saying “I saw you just two weeks ago, why can’t you see me?”; The answer: M’s MA plan required a referral from the PCP. M had to make an appointment with the PCP and get a referral to the Orthopedic doctor who had treated him earlier. Causing another delay of several days as the infection set in. Finally, after nearly three weeks and $900 later, M got the proper cast and brace. He’s still arguing with the MA plan over the $900. What should have been a fairly routine treatment turned into a very uncomfortable 3 weeks ordeal. M’s story demonstrates the three major defects of Medicare Advantage, networks, required referrals, and unpredictable coverage.

Leave a Comment