Descent Into Health Care Madness, Revisited

Open season for switching government healthcare programs begins Oct. 15, not a moment too soon for this contributor, who again finds himself plummeting into the health care abyss.

When we last visited this correspondent’s Kafkaesque interactions with the health care system, he had learned his insurance plan had been cancelled mere hours before open season ended (cross-reference Politifact’s “Lie of the Year”), his provider claimed he’d missed the deadline to acquire Marketplace coverage (nope), and he faced fines for something the government wouldn’t let him do (sign up for his selected plan).

Fast forward to 2021, and this correspondent’s joyous enrollment in an Aetna Medicare HMO plan. Freed from $20,000+ annual Obamacare premiums plus $13,000+ deductibles. Providers in-network. “Free” generic prescriptions. All was right with the medical world.

Until it wasn’t.

Until prompt replacement surgery was needed when a waning pacemaker battery caused the device to speed up as an alert – basically inducing perpetual, tiring a-fib. And commencing insurance whack-a-mole.

The recommended surgeon? Not in-network, advised the primary care physician’s (PCP’s) office, required to request an authorization. In-network, asserted the surgeon’s office, which had heard from his cardiologist and scheduled an appointment two weeks hence, as the pacemaker pounded uncomfortably away.

Not in-network, Aetna customer service averred, prompting calls to alternative in-network surgeons – none nearby, most with no openings for months.

In-network, sputtered a frustrated insurance specialist in the recommended surgeon’s office, calling to ask about the appointment’s cancellation.

Not in-network, confirmed another Aetna rep – until sensing near-apoplectic exasperation, she checked a mysterious second list. Oops. Yes, in-network. The surgery ultimately occurred nearly a month after the pacemaker’s first discomforting warning signals.

Things settled down for a few weeks until a disquieting health situation suggested itself from tests and a confirmatory gastro scan was ordered – for two-and-a-half unsettling months later. 

Then a shocking call the following month: a referral could not be completed for a long-scheduled annual urology screening, as the PCP was dropping the Aetna plan mid-year – with no prior notice!

Can they “strand” longtime patients like that in the middle of a plan year?? You betcha: happens all the time.

With referrals needed within weeks for the screening and string of other appointments, it was full scramble mode for a satisfactory in-network replacement, settling on HCA JFK Primary Care Physicians, and their intriguing approach of residents under the supervision of respected teaching physicians. (Cue foreboding foreshadowing music.)

Following thereupon: literally 90-minute waits on HCA JFK’s phone trees to work on referrals. Sorry, requires an introductory visit. And since your correspondent was on an extended sojourn to out-of-town family, that necessitated a time-wasting round-trip flight home. Referrals ordered, in plenty of time to be processed.

Until on the drive home, suspicions led to calls to providers. None had referrals. Call to Aetna customer service. No referrals requested. Call (another long wait) to the HCA JFK practice. Yes, the referrals had been dispatched. Call to Aetna. No new referrals requested, only previous gastro referrals, so at least you’re good there. Call (more waits) to HCA JFK. Referrals must be cleared by Aetna, can’t speed up that process, no, you can’t talk to the referrals specialist, leave us alone.

Frantic call to the surgeon. Come in anyway, we think you’re covered under the prior authorization. Then a day before the urology screening, a call: no referral, appointment cancelled. Frantic call to Aetna. Let us call HCA JFK and see what’s going on. Representative returns after talking to referrals person to whom this scribe had been denied access: apparently referrals were sent to specialists, never to Aetna.

Three days later, headed to the long-awaited gastro scan, another call: no authorization, appointment canceled. Say what? Aetna confirmed referrals for four visits. This procedure requires an authorization, not a referral. Frantic call to Aetna: referrals should cover it. Call to main gastro office: yes, authorization is needed, someone here dropped the ball, transfer to person handling scheduling and authorizations.

Leave voicemail message, no response. The next week another voicemail, no response. A busy month goes by. Another voicemail. Now a response: we can reschedule – earliest Dec. 30, eight months after the initial scan was ordered for a concerning health condition. And we don’t do authorizations – talk to your PCP.

Meanwhile, payment denied for a prescription and a test – because they were ordered by residents and not the PCP-of-record overseeing them. Appeal pending.

Returning to the 2015 piece’s conclusion and the point of this recitation: This is what happens when the government inserts itself between willing contracting parties. Frustrating bureaucracy with conflicting and often wrong answers, and roadblocks to and delay and denial of care. Fed-up doctors and workers quitting. All leading to horrific customer service. 

At this point, this contributor is done with HCA JFK and Aetna. During open season, he’ll seek another plan enabling a return to his old PCP and liberation from referral hell, regardless of cost. And reschedule all appointments for after Jan. 1.

Will that release him from this abyss? Ha. We’re talking Medicare. New bureaucratic nightmares unquestionably await.

The moral: Abandon all hope, ye who enter government health care. And that’s now all of us.

Bob Maistros is a messaging and communications strategist, crisis specialist and former political speechwriter. He can be reached at bob@rpmexecutive.com.