Wednesday, September 26, 2007

September 25, 2007 - Insurance Denied, Assurance Supplied

This morning I receive a phone call from Cindy, my new case manager from CIGNA Care Allies (last week, they moved my case from their general oncology division to their stem-cell transplant division, which necessitated a new case manager). She gets right to the point, informing me that a physician on their staff, reviewing my case, has denied Hackensack University Medical Center’s request for pre-approval of funding for donor-compatibility testing of my two brothers.

This denial, she’s quick to explain, is just for the donor testing. The reason their doctor gave is that I’ve not yet been approved for a transplant, so the testing of Jim and Dave is premature. Cindy will send me paperwork I can use to appeal this decision, if I wish. This is the type of call she hates to make, she adds (I can sympathize with her on that, on a personal level, but it doesn’t bring me a whole lot of comfort).

This decision doesn’t make a whole lot of sense to me, I explain. Isn’t the information about sibling donors essential to deciding whether or not a stem-cell transplant is the way to go? There’s also the element of time. Because sibling donor testing – and a subsequent search of the national donor registry, should that prove futile – can take a while, I thought the point was to get as much of this preliminary work out of the way as possible, in case future circumstances should make a transplant suddenly urgent. The insurance company evidently doesn’t operate that way. If it’s not urgent, it doesn’t matter how important it is.

Dr. Donato told me Hackensack offers a “Family and Friends Program,” a subsidized program that reduces the cost of donor-compatibility testing for patients whose insurance doesn’t cover this. I believe she said the subsidized cost was $150 per potential donor, which I would need to pay out of pocket. I didn’t pay close attention to her at the time, because I was assuming Highmark Blue Cross/Blue Shield would step up to the plate, but now I see why she mentioned it. Evidently, this sort of denial happens often enough that the hospital has developed its own work-around arrangement.

This is the first time, since I got sick, that any insurance claim of mine has been denied. I suppose I should count myself lucky that I’ve gone this long without getting the ol’ thumbs-down. Thanks to the Family and Friends Program, it’s not that large an amount of money; I’ll probably just pay for it myself, then submit an appeal and hope for the best. (I’d probably only have to pay for Dave’s testing, anyway, since Jim is evidently already in the national registry.)

Cindy’s call leaves me with a strange, empty feeling: more betrayal than anger. I don’t feel it as being directed towards her (she’s just the messenger), but rather towards the nameless doctor on the insurance company’s payroll who wields the rubber stamp. Who is this guy, anyway, and what makes him think he knows more than Dr. Donato, a nationally-regarded stem-cell transplant specialist?

I put all this out of my mind, reminding myself that I haven’t even heard from HUMC’s Tumor Board yet (I’m supposed to call Brenda tomorrow, to find out their recommendation).

This evening, I attend a meeting of Monmouth Presbytery – the regional governing body of the Presbyterian Church (U.S.A.) of which I’m a member. In the past year or so, the presbytery has been meeting less frequently, about four times a year. Some of my fellow presbyters I haven’t seen in quite some time. I swiftly lose count of the number of people who come up to me, shake my hand, and ask, “How are you?” – with emphasis on the “are.”

It’s not just a casual “How ya doin?” There’s a genuine desire to hear some details. I know most of my minister colleagues in the presbytery, but a good many of these people who come up to me with words of support are elders (elected lay leaders) from other churches – some of whose faces I recognize, but whose names don’t come readily to mind. I’m been on their church’s prayer list, they explain, and they’ve been concerned about me.

It’s a very different experience, this evening, than I had with my insurance company this morning – although, of course, the circumstances are quite different. In both cases, there are people I don’t know who have been considering my medical situation. Some of those people responded by wielding the dreaded rubber stamp. Others joined hands in prayer.

Note to self: Never forget to be thankful for the church of Jesus Christ, which has a way of coming through when you need it.


Suzanne G. said...

Dear Pastor,

Here's the deal. Just because you want to do God's will does not mean that other people do. Sometimes you have to fight and scream a little (remember Jesus turning over tables?)

Since you are fighting cancer, you may want to pass this task of raising heck to a very determined woman or a blazingly effective man in either your family or congregation.

I think the dread and abandonment you feel is a "slippery slope" argument inside your head. You're wondering "if they deny this, what will they deny later when I can't pay?" My mom is fighting cancer at the moment and I fear a denial of care for her, she's had lots of huge claims in the past 10 years.

-Prayer is the best and most total cure I've ever seen
-Sometimes you need to fight
-You will get through this
-When you counsel future people, you will have so much compassion you'll almost burst
-You'll realize with each passing day what Love really is

Be well

Carl said...

Thanks, "herdingcats," for your supportive words. It's just what I needed to hear today.

I don't know about the fighting and screaming part, but I have learned that I need to somehow keep track of all that paper that arrives in my mailbox, and be energetic about responding to problems and discrepancies as they come up. It's always a good thing to be assertive, in this sort of situation.

What really cheeses me is that the insurance moguls expect sick people to do this. I'm feeling fine right now, fortunately, but what if this stuff were happening while I was in the middle of chemotherapy or something? I think they actually expect a certain number of appeals to either not get initiated or die on the vine, because the patients aren't feeling up to all the secretarial and accountant work necessary to breach the bureaucratic battlements.

In a day or two, I'm planning to write a piece on an amazing essay written by Barbara Ehrenreich about this whole, sorry situation. Sometimes it takes a prophet, standing far enough away from the situation to get some objective distance, to point out how INSANE our health-care funding system is, for rewarding people for denying care.

Unknown said...


Count it all joy. I'm sort of an internet gadfly of the moment, debating the "Marriage Mandate" with some very strong-willed pastors and women writers.

I just went through an intestinal cancer episode and have to go back to the clinic every month for screening.

I just put it out of my mind and keep going. We all end up in the same place in the end. The body isn't meant to last forever. I just try and be authentic, but as Christian as I can be. Life is very short, and the life to come lasts forever.

A rabbi once told me, it doesn't matter what is going on with you, God is with you. Just remember that we all have a moral obligation to be as happy as we can be, no matter what is going on in our lives. That idea has helped me through a lot of very difficult situations.

All the Best.

Carl said...

So true, Captain. Thanks for sharing.

I'm not sure I know what the "Marriage Mandate" is, by the way, but I'm glad you're enjoying discussing it.


Sandy said...

God bless you in your cancer fight. Our family is going through a battle with cancer right now, too.

Fighting For Mike