On the surface, Medicare Advantage plans can look appealing $0 premiums, added perks, and one-stop-shop coverage. But behind the advertising is a growing problem that many patients don’t learn about until it’s too late: delayed care, denied services, and limited access to providers.
At Integrity Wound Care, we regularly meet patients who are struggling with chronic wounds that just won’t heal. Many of them have tried everything, but because they’re enrolled in a Medicare Advantage plan, they can’t access the advanced care they truly need like regenerative wound therapy. These treatments are not covered or are blocked by prior authorization requirements, leaving patients in a difficult, and sometimes desperate, position. Here’s what every senior and every caregiver should know.
Real Consequences for Real Patients
Medicare Advantage (MA) plans are run by private insurance companies. To control costs, they often:
- Require prior authorization for essential services
- Limit you to narrow provider networks
- Delay approval for advanced therapies
- Change benefits or coverage rules year to year
These restrictions can be dangerous especially for people who rely on timely, ongoing care like wound management.
Case in Point: Delays That Risk Lives
A 2022 report from the Office of Inspector General (OIG) found that 13% of prior authorization denials from Medicare Advantage plans would have been covered under Traditional Medicare. (OIG Report)
That’s not just paperwork it’s real people being denied medically necessary care. And for patients with non-healing wounds, waiting even a few weeks can mean infections, emergency room visits, or amputations.
Limited Provider Access Hurts Patients
Unlike Traditional Medicare, which allows you to see any provider who accepts Medicare, most MA plans operate within tight networks. If your wound care provider or specialist isn’t in-network:
- You may be forced to switch doctors
- You may be denied treatment altogether
- Or you may be charged out-of-pocket for essential services
Seniors in rural and border communities like El Paso often face even greater challenges, where specialist care is already hard to come by.
Prior Authorization: A Barrier to Healing
Medicare Advantage plans often require approval before you can start treatment even for things like:
- Regenerative wound therapy
- Imaging or diagnostics
- Inpatient rehab or skilled nursing
Getting that approval can take days or even weeks. And if it’s denied? You start the appeals process, which adds even more delays.
In contrast, Traditional Medicare does not require prior authorization for most services. This means your doctor and/or Integrity Wound Care can treat your wound based on your condition, not based on what your insurance allows.
Annual Plan Changes = Uncertainty
Every year, MA plans can change:
- What providers are in-network
- What services are covered
- What medications are approved
A plan that worked for you this year could drop your provider or increase your costs next year and there’s no guarantee you’ll be able to switch back to Traditional Medicare with Medigap if your health has declined.
Why It Matters for Wound Care Patients
Wounds that don’t heal are not just an inconvenience they are a serious medical risk. Treatment must be timely, consistent, and tailored to the patient. When a Medicare Advantage plan slows that down, the patient suffers.
We’ve seen patients denied regenerative medicine that is fully covered under Traditional Medicare Part B. We’ve seen delays that lead to hospitalizations. And we’ve seen families confused and frustrated trying to make sense of a medical insurance system that feels impossible to understand.
Our Commitment to Patients
We accept Traditional Medicare because it lets us provide care without delays or red tape. But Medicare also has specific rules we must follow for wound treatment. These rules tell us how long we can treat each wound and when advanced care is allowed. For example, Medicare may limit treatment to a certain number of weeks, or require that basic treatments have been tried first. We follow these guidelines to stay in compliance so we can continue helping our patients safely and effectively.
If you’re currently on a Medicare Advantage plan and struggling to get the care you need, you may have options during open enrollment or if you qualify for a special enrollment period.
Care delayed is care denied. You deserve better.