Monday, July 11, 2011

July 11, 2011 – A No-Brainer

On Friday I had a routine follow-up appointment with Dr. Lerner. It had already been rescheduled once, because of difficulties in getting my routine CT scan approved by my insurance company’s pre-screening agency, Care Allies, acting as an agent for the Presbyterian Church’s Board of Pensions. Well, the delay in approval turned into an outright denial. When I asked if I should postpone my appointment yet again, Dr. Lerner sent word through his office staff that he still wanted to meet with me, even without the scan results that were to have been the focus of our conversation.

When he came into the examining-room, Dr. Lerner explained that he had just called Care Allies on my behalf, and had spoken with the doctor who had denied his request for the scan. It appears that doctor was baffled by the fact that I would be having scans of my neck, chest, abdomen and groin after a thyroidectomy.

Dr. Lerner explained to his counterpart that the scans are not for my thyroid cancer, but for my lymphoma, which is an ongoing, chronic situation that needs to be carefully monitored.

“Oh,” the insurance company doctor harrumphed, “that wasn’t made clear to me.”

“Well, it was right there on the script I wrote, authorizing the scan, which was sent to you. What could be clearer than that? As far as I’m concerned, approval for this sort of scan ought to be a no-brainer.”

“Well, there are many factors that have to be considered in making this sort of decision...”

“The reason I say it’s a no-brainer is because if you don’t approve it, people could assume that you have no brains.”

I doubt the Care Allies doctor was amused. But he did issue the approval, and I expect to go for the CT scan in a week or so. That will be a couple of months late.

Good old Dr. Lerner. He tells it like it is.

I told him I felt bad that he had to spend so much time on the phone chasing down and disproving this frivolous denial of coverage.

He responded, with a sigh, that it’s just part of his job these days. He strongly suspects that insurance companies routinely disapprove a certain percentage of these requests, for whatever reason they can justify. They do this, knowing full well they’ll eventually grant approval, in most cases, on appeal. Along the way, he continued, some less persistent people may grow weary and give up. That’s what the insurance companies want. It’s not good for those patients’ health, but it saves them money.

I suppose, also, that these doctors on the insurance companies’ payroll have to fill a certain quota of denials, to justify their jobs. My case will probably be counted, somewhere on this doctor’s personnel evaluation, as one of a number of appeals he generated – which, in the eyes of the insurance company’s bookkeepers, shows he’s looking out for the company’s interests.

My insurance company is the Board of Pensions of the Presbyterian Church (U.S.A.) – a non-profit that’s nominally under the oversight of the denomination, but acts quasi-independently, for the benefit of plan members like me. The Board hires Highmark Blue Cross/Blue Shield to manage its medical-benefits program, and Care Allies – a contractor specializing in cost-control – comes in there somehow as the pre-screener of certain costly medical procedures. How involved Highmark is in recommending Care Allies to the Board, I couldn’t say.

I think well of the Board of Pensions. Based on the individuals I know who have served on the Board, I believe their highest priority truly is the welfare of plan members. Yet, when decision-making is outsourced to contractors like Highmark (ostensibly a non-profit, but with a big-business corporate culture) or Care Allies (a for-profit consulting firm), something of that charitable concern is undoubtedly lost.

What happened to me is no different than what happens to countless other people around the country every day. Add this incident to so many others like it, and the amount of wasted time, wasted effort, wasted expertise, wasted money is simply staggering.

Any healthcare system that involves a multitude of private insurance companies - and their contractors - competing for profits will continue to generate scenarios like this. I’m lucky to have a concerned, experienced doctor who’s willing to go to bat on my behalf against corporate greed. Not every patient does.

Universal, single-payer healthcare can’t come soon enough.

8 comments:

Joan Calvin said...

I sure wish someone would explain to me why I get an amazing number of contacts from Care Allies wanting to provide health info to me to help me understand my issues (including ovarian cancer). My guess is none of their nurses know anything more than I do.

I had a stress test and Highmark denied part of the coverage. They said it required pre-certification. I called the doctor's office and the nurse said Care Allies told her it didn't require pre-certification. Still waiting for that one.

OTOH, I am grateful to have health care coverage. And as I look at the Medicare supplement provided by the Board of Pensions, it is better and cheaper than many other plans.

But, yes, I too, wait for single payer. When I hear the argument that you don't want the govt deciding your health care, my response is why should my insurance company.

Rant over.

Anonymous said...

PRAYERS SAID.

GRANNY FROM FLORIDA

openid said...

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Whidbey Woman said...

I laughed at your post. There are so many problems with our health care system... what can you do? Thank heavens for the doctors that advocate on our behalf.

mutuelle swiss life said...

very interesting

Toyin O. said...

We certainly don't have the best of Health care system; thank God for the insurance we find in Christ. Will keep u in prayer.

Anonymous said...

IT'S HAS BEEN AWHILE SINCE YOU POSTED ANYTHING NEW. I JUST WANTED YOU TO KNOW I'M STILL PRAYING FOR YOU AND THE OTHER TWO MEN EVERY NIGHT.

GRANNY FROM FLORIDA

Anonymous said...

THIS IS THE DAY THE LORD MADE. SMILE AND BE GLAD IN IT.
WHILE WATCHING MY 11 O'CLOCK SERVICE ON TV THIS MORNING, I THOUGHT ABOUT YOU AND THE TWO MEN ON YOUR BLOG COMMENTS A WHILE BACK THAT I PRAY FOR EACH NIGHT AND EVEN LIFT YOU KIDS UP DURING THE DAY WHEN YOU ALL CROSS MY MIND. SOMETIME I WONDER WHY GOD IS HAVING ME SAY A LITTLE PRAYER FOR YOU. I DON'T QUESTION. HE MUST HAVE A PLAN. JUST KEEP DOING WHAT YOUR DOING AND I'LL SAY MY ONE LINERS FOR YOU. WHAT I THOUGHT WAS NEAT THIS MORNING , THE MINISTER WAS SAYING THAT WHEN SOMETHING BAD HAPPENS TO US, WE SAY WHY ME. THEN WE PRAY AND PRAY. SOMETIMES HE SAY YES AND SOMETIMES HE SAY NO TO HEALING. BUT THE BEAUTIFUL THING TO THE NO answers is WE GET ANSWERED PRAYER BECAUSE WE GET TO GO TO HEAVEN. I THOUGHT THAT WAS SO NEATLY SAID.

GRANNY FROM TAMPA.