Medicare HMO’s: When Health Coverage is No Coverage at All by Steven Mussey MD


This month, a terrible thing happened to our practice and an even worse thing happened to a patient.

Our small practice goes to great lengths to stay out of all HMO products. In an HMO insurance, the Primary Care Doctor must get a prior authorization before almost all tests, procedures and referrals.

Late last year, our contract with a PPO insurance was expanded, without our knowledge, to include a Medicare Advantage HMO plan.

A long-time patient of ours signed up for this plan and needed cataract surgery.

Her Medicare Advantage plan told the eye specialist that cataract surgery would not be permitted without prior permission and prior authorization from her primary care doctor.

Of course, this makes sense. As an Internist, I operate on eyes all the time and am an expert in eye surgery. Yes, I am being sarcastic.

Just as there are stages in dealing with death, there are stages in discovering you are in an HMO:

  1. Denial: “It’s a mistake! We can’t be in this plan”
  2. Anger: “How could they do this to us?!”
  3. Bargaining: “Okay. Just this once, but we are getting out of this plan!”
  4. Depression: “You mean it takes six months before we are out of this plan?”
  5. Acceptance: “Okay. Let’s get this referral done.”

We called the plan and thought we had gotten the prior authorization. Two days later, we found, contrary to what we had been told on the phone, the referral was invalid. Instead all referrals are contracted out to a separate company with a web site and zero phone or human support.

After hours of getting our practice signed onto this third party site, we entered the referral information. Amazingly, the cataract surgery was still denied, giving a cryptic 9-digit code for the reason. There was no option for an appeal. There was no human contact possible. For several more hours, we tried and failed.

Sorrowfully, we notified the Medicare Advantage HMO patient we could not get the approval and she would simply have to go blind from an easily treatable condition.

Days later, our screaming complaints were answered from an authority at the company who took steps to remove our practice from this plan within 30 days. The representative acknowledged the company was receiving tons of complaints.

The patient, meanwhile, has still not gotten a referral and all we can do is ask she complain directly to the company, Medicare and appropriate government agencies.   After many hours of work, we have simply done all we can.

The entire HMO concept is terribly flawed. When you use the HMO process on elderly Medicare patients with multiple complex problems and a limited ability to navigate arcane insurance coverage rules, you create an elaborate method of denying appropriate care.

It would be more humane to simply place everyone over 65 on an ice floe and wave good-bye.

How is it possibly legal to funnel taxpayer dollars into such a scam?


Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  3 comments for “Medicare HMO’s: When Health Coverage is No Coverage at All by Steven Mussey MD

  1. Dr. Harvey Hechel
    May 28, 2016 at 4:42 pm

    All Medicare “Advantage” plans should be considered “Disadvantage ” plans! Since the Insurance power structure would never allow this, the neutral term, Medicare Alternative plans to Traditional Medicare should be required on a National basis.

  2. Elliot Wortze
    May 25, 2016 at 10:19 am

    Of course this problem exists with all commercial as well as Medicare HMOs. Government and business make the rules, call the shots, and we comply. If we ever were, we are certainly no longer captain of the ship. Except maybe still in the event of malpractice litigation!

  3. Thomas Guastavino
    May 23, 2016 at 6:51 am

    Item number 437 on a very long list of boneheaded health reform mistakes was the idea that all physicians are alike and have the same knowledge and experience. How else do you explain why someone would ask an internist whether cataract surgery is appropriate ? Do they think asking the opthamologist whether an internists treatment of diabetes is appropriate?
    Gatekeepers, ya gotta luv’um.

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