By FRANK LEAHY
On a grey February morning, I sat in my workplace in Inverness, in rural northern California, with the cellphone pressed to my ear, jotting down notes and Humana reference numbers. Throughout the desk, my new buddy Rick, 77, waited anxiously, struggling to comply with the dialog. Practically deaf and now partially blind, Rick had lived with a indifferent retina for weeks. Time was working out to save lots of his imaginative and prescient.
I used to be decided to get Rick the surgical procedure he wanted. However as hours changed into days and days into weeks, I discovered myself ensnared within the sort of bureaucratic maze acquainted to thousands and thousands of Individuals with Medicare Benefit plans.
That is the story of a susceptible senior and his advocate, caught between medical doctors, clinics, and insurers on the arduous fringe of Medicare Benefit – America’s privatized Medicare system. It’s a story of denials, delays, and a rulebook nobody would clarify – and of the human value when a system is constructed to economize, not sight. It is usually a narrative about how and why it took seven months, and a letter to a Fortune 500 CEO, to get one surgeon paid.
“I Simply Wish to See Once more”
Rick’s world had been shrinking for years. Laborious of listening to and dwelling on lower than $1,200 a month in Social Safety and SSI, he break up his time between Colorado and a buddy’s spare room in rural California. With no household close by, no web, and solely a battered flip cellphone, he relied on buddies for assist.
In mid-November 2024, Rick fell away from bed, placing his head and injuring the left aspect of his face. He shrugged off the ache, however over the next weeks his imaginative and prescient blurred, then pale. “I believed it will get higher,” he mentioned. “Nevertheless it simply stored getting worse.”
I met Rick in late December 2024. He informed me about his fall, the harm, and that he may not see out of his left eye. It was clear how severe his scenario was, and the way a lot help he wanted, so having just lately retired I had the time to assist him. Nevertheless it was practically too late. After weeks of back-and-forth with Humana, I lastly obtained him in entrance of an ophthalmologist, who identified a retinal detachment – a medical emergency the place immediate remedy is important to stop everlasting blindness.
Getting that remedy would show far more durable than I may have imagined.
The Medicare Benefit Entice
Rick was enrolled in a Humana Gold Plus HMO, a Medicare Benefit plan based mostly in Colorado. Why Humana? Pure happenstance. He had been buying at a Walmart in Colorado when a person “who appeared good” signed him up. Like quite a lot of older folks, Rick didn’t know the distinction between Medicare Benefit and Authentic Medicare with a Medigap complement – or why that distinction would come to matter a lot.
Like greater than half of all Medicare beneficiaries, Rick had been drawn to a personal plan by the promise of additional advantages and decrease prices. The catch is that Medicare Benefit plans are constructed on slim supplier networks and strict guidelines about the place and the way you get care. For snowbirds, part-time residents, or anybody who lives in a couple of state, these guidelines can develop into a lure.
My first name to Humana set the tone:
“I looked for a physician in your web site. I discovered one and referred to as them. They are saying they don’t take Humana, though your web site says they do,” I informed a consultant, studying from my notes. “Can you discover one for me?”
“You may, however I want Rick on the road.”
“He’s proper right here.”
“Okay, however I additionally want further documentation…”
The runaround had begun.
The Guidelines No One Defined
To get surgical procedure, Rick wanted a referral to a retina specialist. Nobody at Humana informed us that firstly. We realized it the best way we realized each rule on this course of – by hitting a wall, calling again, and being informed, after the very fact, that we had didn’t do one thing nobody had talked about.
The referral needed to come from a major care doctor (PCP), and Rick, in any sensible sense, didn’t have one. There was a Colorado PCP listed on his Humana card – somebody he’d by no means met, in a state he couldn’t journey to with a indifferent retina – however once we referred to as the workplace they mentioned Rick would wish an in-person appointment to get a referral. Functionally, he had no PCP in any respect.
Getting one was its personal ordeal. Major care is scarce in all places now, and getting scarcer, and a brand new affected person who’s aged, low-income, and on an out-of-state HMO is precisely the sort of affected person practices are least focused on taking up. Some weren’t accepting new sufferers. Some didn’t take the plan. Some couldn’t schedule him for weeks. In the meantime the requirement nobody had defined was standing between Rick and the specialist he urgently wanted.
And after I did attain somebody at Humana, the solutions contradicted one another. Some reps mentioned a referral was required; others mentioned it wasn’t. Some mentioned we may change Rick’s major care physician to a neighborhood one; others mentioned solely throughout open enrollment, or solely with extra paperwork, or solely with Rick on the decision. And even with each of us on the road, the change stalled. There was no map of the method, no single one that owned it, no method to know prematurely what the subsequent hidden requirement could be. The foundations existed. They had been simply invisible till you had damaged one. And nothing was ever supplied in writing.
Humana’s personal listing solely deepened the confusion. It listed a number of in-network retina specialists, however after I referred to as, most didn’t really take the plan, or demanded a referral from the native physician Rick didn’t have. “We will’t approve the surgical procedure with out pre-authorization, however it’s essential see an in-network specialist first.” “There are not any in-network specialists obtainable.” “I’m sorry, that’s the coverage.” All of the whereas, Rick’s imaginative and prescient slipped additional away.
An Emergency Room, an Emergency Referral – and Nonetheless No Surgical procedure
Determined, I took Rick to the emergency division at a serious San Francisco educational medical heart. Medical doctors there confirmed a continual left retinal detachment, with a poor prognosis for restoration due to the delay. They issued an pressing referral to the hospital’s ophthalmology clinic, hoping to fast-track surgical procedure.
Even then, the insurance coverage boundaries held. The hospital wouldn’t schedule Rick with out a cost assure from Humana. Humana wouldn’t assure cost with out a referral from his out-of-state major care physician and pre-authorization – steps that would take weeks.
“The system shouldn’t be arrange for individuals who transfer between states, don’t have any fastened deal with, or have cognitive or listening to impairments,” I informed my spouse one night time. “It’s a relentless loop of referrals, authorizations, and confirmations, with nobody accountable. I’ve spent 45 years as a software program engineering chief in Silicon Valley and am discovering it virtually inconceivable to navigate. Now I see how folks find yourself with out the care they want, or dwelling below a freeway overpass.”
The Clock Runs Out
Retinal detachment is a race towards time. The longer the retina stays indifferent, the decrease the percentages of restoring sight. For Rick, the delays had been devastating.
After weeks of calls, faxes, and appeals, I lastly discovered a neighborhood major care physician prepared to see Rick and write the referral. A retina specialist then agreed to function. Even then, the insurance coverage hurdles didn’t finish.
Humana’s Rationalization of Advantages statements informed the story in chilly, bureaucratic language. For the preliminary seek the advice of, imaging, and surgical procedure – 1000’s of {dollars} in care – Humana paid nothing. The denial cited a cost that “exceeds price schedule/most allowable or contracted/legislated price association.” In plain English, the supplier – who was listed as in-network on Humana’s web site – was handled as out of community, so the allowed quantity was $0.00.
As a dual-eligible for Medicare and Medicaid, Rick was protected against being billed instantly. However his surgeon went unpaid, and the follow-up process to take away the silicone oil used to reattach the retina hung in limbo.
“It Ought to Have Been Eliminated Inside Three Months”
In July, roughly 5 and a half months after the primary surgical procedure, the retina specialist wrote to Humana: he had repaired Rick’s retina with silicone oil in an emergency operation, and it was vital to take away that oil in a separate process so Rick may attain his absolute best imaginative and prescient.
Silicone oil is usually eliminated inside about three months. Leaving it longer raises the danger of glaucoma, cataracts, and additional imaginative and prescient loss. However Humana stored denying cost and authorization, citing the identical community and contract boundaries. The appeals dragged on for ever and ever.
How It Lastly Ended
Right here is the half that also stuns me. Rick’s surgical procedure was lastly approved. His referral was lastly accepted. However nonetheless, for months, the surgeon who saved what was left of his sight was paid precisely nothing.
The rationale had nothing to do with whether or not the care was crucial. It was buried in Humana’s personal data. After I lastly reached Humana’s govt decision workforce – and solely after I wrote on to Humana’s CEO and board of administrators – the specialist assigned to the case informed me the claims had been paying $0.00 due to how the surgeon was “loaded” in Humana’s system. His most revealing sentence: the claims had been, he mentioned, “paying appropriately based mostly on the contract loaded.”
Sit with that. By Humana’s personal logic, paying the surgeon nothing wasn’t a mistake. It was the system returning the proper reply.
And right here is the contradiction that proves how arbitrary that reply was. Across the similar time, when the surgeon’s workplace referred to as Humana instantly to rearrange Rick’s second operation, a Humana agent confirmed on the cellphone that Rick was in community with each the surgeon and the hospital, and that the oil-removal process required no prior authorization in any respect. In community and paid zero, on the similar time, by the identical firm.
There was no exterior referee to attraction to. The No Surprises Act – the federal legislation that lets an out-of-network physician power a good cost by arbitration – doesn’t cowl Medicare Benefit, and so the one backstop constructed for precisely this example was unavailable. Escalation was the one lever left, and escalation meant going over the heads of everybody within the peculiar course of, all the best way to the boardroom.
So that’s what it took. Not the supplier listing. Not the appeals line. Not the handfuls of hours I logged – by my very own conservative rely, greater than ten calls to Humana totaling practically 4 hours, plus two dozen extra to clinics and hospitals. What lastly moved the declare was a letter to the CEO and board of a Fortune 500 firm, which routed the case to an executive-inquiry workforce, which spent weeks working with contracting earlier than somebody lastly wrote the sentence I had been ready months to learn: “We’ve got up to date the supplier’s data so claims ought to course of with funds in accordance with their contract.” The claims had been despatched again for reprocessing, and in early September 2025 – roughly seven months after the emergency surgical procedure – the surgeon was paid.
Solely then may the follow-up proceed. The silicone oil that ought to have come out inside about three months had stayed in for roughly seven. It waited not on medical approval – Humana had confirmed the removing wanted none – however purely on cash. The surgeon, fairly, wouldn’t schedule extra unpaid work till the primary invoice was settled. As soon as it was, the oil was eliminated in September 2025 – virtually ten months after he fell away from bed.
Rick can see slightly now. His imaginative and prescient is completely diminished by the delay, however he’s not at rapid danger. He was fortunate – fortunate largely in that he occurred to have a neighbor with the time, the stubbornness, and finally the proper folks to jot down to. Most individuals have none of that.
That’s the half that ought to fear everybody. As a result of Rick’s case shouldn’t be a narrative about one dangerous insurer or one damaged declare. It’s a story a couple of system designed for delays and denials, and about what that reveals for the thousands and thousands of people who find themselves one fall away from getting the identical runaround remedy from their Medicare Benefit plan.
Frank Leahy is an impartial advisor & investor who had a forty five yr profession main engineering groups in Silicon Valley together with stints at Intel, Apple, Salesforce and a number of other startups. Partially 2 of this text he’ll recommend how some easy reforms may repair Rick’s expertise
