Maria Gil is no stranger to the medical community. In 1999 she started ER Card, a free program that enables people to electronically keep their personal medical records that now has more than 6,000 users. The aim of the program funded through grants and supplemental user services is to ensure that during an emergency a physician has a full picture of a patient’s medical history.

Gil’s goal is to see that people get the proper treatment even when they may not be able to speak for themselves.

But it’s taken nearly three months to obtain the tests – an MRI and PET Scan – that physicians say they need to properly diagnose and treat a family member. It’s taken that long for UnitedHealthcare to approve payment of the tests, which she believed was covered under United’s AARP MedicareComplete/Secure Horizons plan.

Now Gil is on a campaign to warn people about the plan. She has written letters to Rhode Island newspapers, AARP, the state insurance commissioner, Medicare, the state Division of Elderly Affairs, the Center for Medicare Advocacy and the state ombudsman.

“I’ve got to get the message out, a lot of people are being abused by this program,” she said in an interview last Tuesday. Gil has put United on notice that she is out to expose what their plan, which because of the AARP endorsement is assumed to be an AARP plan, is doing.

A spokesman for United, Matthew Burns said, “we take these allegations very seriously.” He said he could not speak about the specifics of Gil’s experience without a waiver of confidentiality signed by the person involved [Gil’s experience relates to a family member, who she acted on behalf of].

Nonetheless, he said Gil’s statement that the company is looking to avoid paying for prescribed tests is “not true.”

In a statement issued Monday, Burns said:

“Our goal is always to ensure our members have access to the health care services and procedures that will help them live healthier lives. Physician requests for certain services are subject to prior authorization to ensure the prescribed treatment is consistent with latest medical and treatment guidelines, to ensure our members are receiving high quality care and to ensure the healthcare system remains sustainable for all people.”

Asked how United handles service requests, Burns said they are reviewed by medical experts using standards established in concert with professional medical specialty and Medicare guidelines:

“If the treating physician and/or member do not agree with a determination, they have several opportunities to appeal, including peer-to-peer review with a physician in the appropriate specialty and to Maximus Federal Services, Medicare's independent reviewer,” said Burns. “If they also disagree with the independent ruling, they can request a hearing with an Administrative Law Judge.”

Based on an interview with a consultant, who asked to remain anonymous because they deal with United regularly, Gil’s story is not unique and her assessment is not exaggerated.

Gil has carefully documented efforts to get approval for the two tests, keeping a record of calls, copies of correspondence and appeals as she was pushed from one department to the next, and then back again. In what she calls typical of the treatment she received, after the MRI was denied, she requested a “fast appeal,” which United makes available. After not getting a reply in 72 hours, she appealed again. Still there was nothing. She called and was told her appeal was invalid because she hadn’t used the proper form. She requested another form and waited a week before calling again.

She asked what was happening and was told she didn’t need the form “because we already have one on file.”

“This program is designed to wear people down and give up,” Gil said. Her conclusion is that United “always says ‘no’ and you don’t appeal it and they save money.”

“Who the hell are they to say ‘no,’ if you have a doctor who knows the patient and is responsible for their care saying it is needed?” she asks.

In her letter, which is published in today’s paper, Gil writes “UHC’s national marketing message is simple: $0 monthly premium for both Medical and Part D coverage. This message is deceiving. You pay dearly in terms of your health and well-being, along with higher co-payments for physician/specialist office visits, prescription drugs, medical services and hospitalizations.”

As the Medicare Advantage Annual Election Period starts on Oct. 15 and extends to Dec. 7, those on Medicare and others 65 years old and older are receiving letters under the AARP logo reminding them that Medicare Part B only covers about 80 percent of medical expenses and “you may be responsible to pay the other 20 percent out of your own pocket.”

“Fortunately,” the letter goes on to say, “you have a simple solution to mounting costs. You can purchase Medicare supplement insurance to help with some of the medical expenses Medicare doesn’t pay.”

Linda Knutton, resource specialist at the Pilgrim Senior Center, has seen the United letter and has dealt with the often confusing issues of Medicare plans for years. Aware that there will be changes for Blue Chip and United (AARP) Medicare Advantage members next year, she has scheduled information workshops on Oct. 5 at 9:30 a.m., Oct. 7 at 1 p.m. and Oct. 11 at 6 p.m. at the center.

Knutton is sympathetic to efforts to control costs and can understand why, for example an insurer, would request an x-ray or CAT scan before approving a more expensive MRI. But she also hears Gil arguments that insurers do what they can to avoid paying claims.

Taking an historic perspective, she said that, as costs went up, the original Medicare, in an effort to keep premiums low [it is now $115 a month] they built in co-pays and deductibles.

“There are a lot of holes in it,” she said, “and private companies saw an opportunity to fill the holes.”

They came up with Medicare supplements [Plan 65C and Plan 65A] with additional premiums ranging from $130 to more than $200 a month.

Then there is a third tier of managed health care plans offered by United/AARP and Blue Cross, some of which carry no additional premium. It is one of these plans that Gil’s family member is enrolled in.

Knutton advises people to consider their full range of options and Medicare supplements for those who can afford it. There are programs for people on low fixed incomes and limited resources including Rhode Island Medical Assistance and the Social Security low-income subsidy. She also recommends people take advantage of the Senior Health Insurance Program [SHIP] that is run out of the center where volunteer counselors can help outline the options.

“Good insurance is going to cost you no matter what you do,” she said.

“People need to educate themselves well,” she added.

Larry Grimaldi, spokesman for the Division of Elderly Affairs, who was also provided a copy of Gil’s letter, said she had taken “all the correct steps.”

He said, “this is precisely the type of situation” that should be addressed during open enrollment. He pointed out that, not only do individual health care needs change from year to year, but so do the programs.

“The mistake a lot of people make is to base it on one thing,” he said, “Cost. That’s why the review is needed every year.”

It’s a course of action Gil also advocates.

“Ask a family member, friend or representative from one of the many senior-serving agencies in your community, to help you calculate your monthly out-of-pocket expenses for this inferior product. You may be surprised to learn that you can easily afford a superior product that covers the care you need,” she writes.

Rhode Island AARP was forwarded a copy of Gil’s letter. They did not respond to repeated calls.