Navigating the medical maze

My mother-in-law got the care she needed, but getting there was like an Abbott and Costello routine — without the laughs

November 30, 2011|By Angela Dale

It's "open season" for health care coverage, and the hunt to find just the right plan is coming down to the wire; for Medicare, the last day to make a selection is Dec. 7.

Earlier this year, thanks to Medicare and medicine, my 82-year-old mother-in-law received eye surgery that promises her clearer vision than she's had in more than three-quarters of a century. Still, despite due diligence during last year's open enrollment, and a first-hand trip through the system this year, the coverage choices and their consequences remain frustratingly opaque.

My husband's mother moved into our home a year ago from overseas, enabling her to avail herself — finally, fully — of her Medicare benefits. Surgery to replace her cornea, which had been scarred in a childhood illness, could offer her improved vision, safer mobility and better quality of life with her grandchildren, and now we were in a position to act. We met with a top ophthalmic surgeon and crosschecked him against the Medicare Advantage HMO-style plans available in our area. Although Medicare would pay for the surgery directly, the copay would have represented nearly two months of my mother-in-law's retirement pension. Under the HMO we found, her cost would be $120.

In January, my mother-in-law switched over to the HMO's primary care clinic, the first step in the surgery process. The next step, a hair-pulling quest for referral — though ultimately successful — felt like an Abbott and Costello routine without the laughs, with one office after another insisting it was someone else's job. Then, long after surgery, I received a call from a claims processor from the HMO, poised to deny payment despite that hard-won referral. It turned out our doctor was not actually "in network" (whether anymore or ever, I don't know), despite my having confirmed, via the HMO's website, printed directory, and telephone customer service, that he was.

Fortunately, it also turned out (after clarification from me) that this particular surgery fell outside the HMO doctors' expertise. Therefore, the HMO agreed to honor the referral and pay the bill — that is, their portion of it, which, for the doctors, including surgeon, anesthesiologist and pathologist, was 5 percent. Medicare paid 18 percent. Seventy-seven percent of the bill was simply adjusted away. (With such a pig-in-a-poke referral and billing process, it's perhaps not surprising — though perpetually shocking, to me at least — that so many of the nation's personal bankruptcies result from medical expenses, even among those who have health insurance.)

This fall, suture removal required a new referral. The HMO denied it in a certified letter, stating that we had to use their in-house doctors. But if our specialist was the only guy who could put those stitches in, then he was the only guy who was going to take them out. We tried to get a cost estimate to budget for the 20 percent Medicare copay, but the doctor's office couldn't give us any numbers. I pressed again for a referral, clarifying, again, the specialized nature of the condition and treatment, and we got it.

In the end, we didn't really need it, since the surgeon decided her eye needed four more months of healing (by which time we will need — and I will get — a new referral). I do shudder a little, wondering if the HMO doctors, had we been financially compelled to use them, would have made the same call to delay suture removal.

With this surgery, my mother-in-law has received a late-in-life gift. But our bumpy ride through the health care bureaucracy — which I suspect is typical — has left us wondering what medical care gantlets we'll need to navigate going forward, and what missteps we might catch only in hindsight. In the scheme of things, we scaled mole hills rather than mountains and received excellent coverage for excellent care. But how can one be a truly informed consumer and advocate in such an inscrutable, and therefore oppositional, system?

This year's open enrollment season is winding down, and we've decided to stick with our current Medicare Advantage HMO — at least until the stitches come out. We can only hope, in the meantime, that we don't get caught in the procedural cross-hairs.

Angela Dale is a writer and editor in Ellicott City. Her email is ahdale@yahoo.com.

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