Today was not a good day for me. The entire day was spent in finding a specialist who is a female physician on the patient’s plan. What senior with a critical illness has the stamina and patience required in researching credentials, making the appointment and obtaining insurance company approval for a physician referral? That’s why I decided this might make a good diary series, if there is sufficient interest.
The “patient”, an elderly woman, has “excellent insurance”, she did not want to deal with the challenge of communicating with someone who listed English as a second language, did not graduate from a US medical school, or had a questionable reputation. My relative is over 70, suffers from constant pain, and is unable to engage in lengthy conversations, type A personality. Sounds easy, doesn’t it, or so I thought initially.
Why not just accept the referral from her primary care physician? I spent an hour on the internet. The specialist her primary care physician recommended did not meet her criteria. Did not graduate from a US medical school, and questionable reputation were the primary dis-qualifiers.
The first complication, my friend did not know who to call for a referral. After 30 minutes of her searching her wallet, we determined she has a privately administered Medicare with supplemental insurance program, HealthNet. I did not initially perceive this as a problem. Great news I thought, only one provider to deal with. Off to the net to find specialists approved by HealthNet.
I narrowed the search to two within a 10 mile radius. There was only one woman on the list. Great reviews for the two MDs, male and female, both rated high on patient satisfaction, no state board complaints, and another hour before I was ready to call for the appointment.
I called the female first. Her office stated that they were reviewing their participation in HealthNet Medicare programs. I was told to call back in two months to determine if they would accept any new patients. Two months is an eternity when you are over 70 and desperate for diagnosis and treatment. The second choice, a male, was even less promising. I was told he was no longer accepting any new HealthNet Medicare patients. Back to square one, time to call HealthNet.
I was connected promptly to a HealthNet representative. After the required Q&A, the representative confirmed the patient does have excellent coverage, including a $3400 max out of pocket for copays ($10 each visit) within any 12 month period. It was necessary to explain all of the above before moving on to getting a list of alternative participating, specialist physicians.
The representative provided a list, including those within a 25 mile radius. There were only six within a major metropolitan area. In addition, I was informed it would be necessary to call back for a “registration” approval after confirming an appointment.
Hummpt, does this mean the physician would have received a denial had this step been missed? Would the patient be billed and held liable for failure to obtain HealthNet prior authorization? I did not ask.
A highly rated specialist in the area, my second choice, is not a HealthNet provider. Why does this specialist (located in the Phoenix Biltmore area) refuse to accept HealthNet, regardless of the plan? I’ll explore this question, and the Mayo Clinic, an attractive health care alternative for those in the Phoenix area in another diary.
Back to the story, more internet research on the HealthNet provided list of six. The only acceptable physician can see my friend on June 1st, unless it is life or death, which we can not know without a diagnosis. I should add going in circles to my diary title.
The specialist requires a referral from the primary physician. The patient has only a two week supply of medication prescribed by the primary physician. I call the primary; navigate the voice mail options, leave a message that a faxed referral is required. Then I recall the primary to make another appointment, explaining that the prescription for medication expires months before the specialist appointment.
Next, recall HealthNet, give them the details on the specialist appointment and obtain a “prior authorization number”.
My friend, wheelchair required for any trip beyond the couch and the bathroom in her home, must go back to her primary physician to obtain an extension on prescribed medications until June 1st. The reason her physician referred her to a specialist, the answer is shocking? The primary physician wants a specialist to make a determination. Maybe not so shocking, this was truly a trip into the circular logic of health care in America.
Where did this journey begin, you ask? It began in November 2010 with a trip to hospital emergency, followed in two weeks by the first visit to a primary physician.
Is this experience typical of how we want our private health care system to perform as patient advocates for seniors? Have insurance companies found the golden egg by collecting premiums while limiting access to care for the elderly?
Unless you pay cash for health care, don’t need health care, have the time and patience to navigate the maze, or face the monsters of the labyrinth, you become another victim of a delayed, or undetermined diagnosis, and death by neglect?
Please share your stories, or reference your diaries so that we can build a body of evidence that supports Medicare for ALL. Please let me know if you are interested in more stories from the crypt. I’ll respond to all comments.
Over to you…