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I turned seventy-one last week, a milestone birthday. For many of us, anything over 65 is truly a milestone and we tend to celebrate among strangers in medical office waiting rooms. Last week I had a CT scan on Monday, two Ultrasounds on Tuesday, and an MRI on Thursday. This week features two doctors’ visits and lab work. It costs a lot of time and money to prove I’m still here.
My primary doctor asked me about the differences between Original Medicare paired with a Medicare Supplement vs. a Medicare Advantage plan. He had a pretty good idea, but he wanted to confirm the reasons why I am on Original Medicare. Actually, he really understood how this choice had worked so well for me and was trying to learn whether my decision had been well-planned or just a happy accident. Really? There are no accidents. We talked for a few minutes. Medicare is about 20 years away for him. He hopes to have the choices I had when I turned 65. I made no promises.
My Original Medicare and Medicare Supplement Cards have
gotten quite the workout this year. Over
and above the usual stuff, I had a little eye issue in late June. It started on a Thursday evening. I felt like I was in my late teens and my then
shoulder length hair was flopping in front of my eyes. I could see these dark waves in front of my
face. The problem was that there was
nothing there! It was not much better
the next day. Dots. Lines.
My right eye was seeing lots of stuff that wasn’t there. My secretary looked for these symptoms online. Ruling out pregnancy, she was positive that
it was definitely a serious eye condition.
·
I called the optometrist that did my last eye
exam. He was too busy to talk.
·
I called a friend, an ophthalmologist at the
Cleveland Clinic. He was not available.
·
I called University Hospital. I was told that the emergency room at main
campus has an ophthalmologist on-call. I
drove to UH, but instead of going to the E/R, I went directly to the ophthalmology
department. They viewed me with a little
healthy skepticism but listened to my description of my symptoms. They took my insurance information and started
to exam my eyes.
Let’s stop here for a moment. You may have noticed that I attempted to see doctors from the two competing medical centers. I didn’t waste any time verifying network participation. I didn’t have a referral. I haven’t asked nor received anyone’s or any insurance company’s permission to pursue care. I have access to any doctor any facility anywhere in the country that accepts Medicare. The payment issue has already been addressed and resolved. Back to my eye care.
·
The first tests got everyone’s attention. There were more tests. I was brought into an exam room and introduced
to Dr. K, an experienced ophthalmologist and another doctor on his team. After another exam he explained that I had
four tears in my retina. One was
horseshoe shaped and of real concern. He
outlined a treatment plan that included an immediate laser retinopexy
followed by surgery as soon as possible.
He was trying for the following Tuesday.
·
I had two questions: What is the success rate of these procedures
and is this all covered by Medicare? He
quickly answered that there was no problem with MY Medicare coverage. He pegged the success rate at well over 90%,
but if I was in the less than 10% failure rate, I could have a permanent
problem. I would not have believed him
if he had said that there was a 100% chance of success.
· The tests and procedures of that Friday, the surgery on the following Tuesday, and the subsequent follow-up visits and testing have all been covered. Would a Medicare Advantage plan have covered all of this? Probably, but I would have been limited to a network doctor, their availability, the possibility of pre-authorization, and I would have had co-payments every step of the way.
Original Medicare coupled with a Medicare Supplement provide greater access to care. Would a Medicare Advantage plan have approved all of last week’s tests? It depends on the company. As agents we all knew of companies that had the reputation of throwing up roadblocks. The pre-certification process can take months. Stall. Deny. Submit for “review”. The insertion of Artificial Intelligence when common sense might be the better choice. I am bringing this up today because it is front and center in my mind after the experiences some of my friends and I have had recently and because our government wants to insert A I into Original Medicare claims’ management.
The Center for Medicare Advocacy sounded the alarm this past September. The program will be tested in Ohio and five other states.
“The model, designed in theory to cut down on “fraud” and “unnecessary” services, would introduce AI-powered Prior Authorization requirements for about a dozen procedures into Traditional Medicare. What the model would likely do – as has been the case with Prior Authorization in Medicare Advantage – is complicate, delay and even outright deny necessary care.”
This is the link to a recent article posted by the Centers for Medicare and Medicaid (CMS). WISeR (Wasteful and Inappropriate Service Reduction) Model. Will I still have the same access this time next year? I hope so, but there are no guarantees. What happens if the same people who discourage parents from vaccinating their children suddenly take a jaundiced view of CT scans? Medical imaging costs a lot of money. It doesn’t take a lot of effort to convince yourself to not spend the money, once you are predisposed to cutting care.
Our nation’s leaders are wrestling with the cost of healthcare. Some, OK a few, really are concerned about the health and wellbeing of their constituents. Most see this as a line item and the challenge to balance the competing desires of the people pounding on their office doors. And we are in the middle. If you, like me, spend a lot of time with strangers in medical office waiting rooms, your concerns are personal and time-sensitive.
I’m seventy-one and counting. I hope to have the opportunity to show how good a counter I can be.
Dave
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Picture – I Couldn’t Find A Stunt Double – David L Cunix
