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Table of Contents

• ↓ Everything you always wanted to know about the Health Care system. But were afraid to ask.
• ↓ When “Paying Correctly” Means Paying Nothing: How to Make Medicare Advantage Accountable
• ↓ The Pandemic Risk of “What I’ve Never Seen Before”
• ↓ “We’re Sorry, That’s the Policy”: How a Medicare Advantage Runaround Nearly Cost a Senior His Sight
• ↓ Big Bucks, No Whammies: Patient Access Was Never the Finish Line
• ↓ Hospital Price Transparency Legislation Will Burden Poor and Rural Patients
• ↓ Top Alternatives to thehealthcareblog.com

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"This is the second of two pieces. The first told the story of “Rick,” a 77-year-old Humana Medicare Advantage member who nearly lost his sight in a months-long runaround over a retinal detachment. This one asks what his case reveals, and what would help fix it."

"The runaround was exhausting – the hold times, the repetition, the new voice on every call. But the most disturbing moment wasn’t any of that, and it wasn’t a denial. It was a justification. The claims that paid his surgeon $0.00, a Humana representative explained, were “paying correctly based on the contract loaded.”"

"Hold onto that sentence, because it reframes everything. What nearly cost Rick his sight was not one careless adjuster or one unlucky claim. The system did what it was built to do. It was designed so that a 77-year-old losing sight in one eye, and the surgeon who saved it, could end up with nothing – and no understandable way to make it right."

"No understandable way is the heart of the problem. When a privately insured patient gets an unfair out-of-network bill, federal law hands their doctor a referee: the No Surprises Act, which lets a provider force a fair payment through arbitration. But that law was written for commercial insurance and never reached Medicare Advantage. On paper, Rick’s surgeon was already owed at least the standard Medicare rate; Medicare Advantage’s own rules say so. But he was paid nothing – and unlike a commercial patient’s doctor, he had no arbitration, no referee, no way to force the issue. What finally worked was a letter to Humana’s CEO and board of directors – a lever that shouldn’t have been needed."

Key Topics & Focus Areas for thehealthcareblog.com:

Everything you always wanted to know about the Health Care system. But were afraid to ask.

When “Paying Correctly” Means Paying Nothing: How to Make Medicare Advantage Accountable

The Pandemic Risk of “What I’ve Never Seen Before”

“We’re Sorry, That’s the Policy”: How a Medicare Advantage Runaround Nearly Cost a Senior His Sight

Big Bucks, No Whammies: Patient Access Was Never the Finish Line

Hospital Price Transparency Legislation Will Burden Poor and Rural Patients