Clearing the Air: No. 3

The transplant chronicles of a journalist, bibliophile, epistemophiliac and homo sapien.

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Lest it appear that my last post was nothing short of a whole-cloth evisceration of all private health insurance companies everywhere, I do have more information to share that may balance the scales a little. Obviously, I did get another evaluation and did get approved for a transplant, or else I would not be sitting here looking out over UPMC at this moment. But more on all that later.

But first, let me say a word about customer service. In dealing with my company’s insurance carrier, UMR, I was almost solely in communication with one person — the transplant case manager. As we all know, the robotically trained peons who answer the phone at any insurance company’s 800 number are, by and large, utterly useless. Case managers, then, are supposed to be more skillfully trained in being able to answer complicated questions, and my particular case was about as complicated as it gets. Even so, the failures were many.

corporate_lobby

Here is what I tried to explain for weeks and months during the previously referenced appeals process: I didn’t know that my insurance company even had a limit on the number of medical evaluations a potential transplant recipient could receive until I had already reached the mark. There is nothing special about a transplant evaluation. All it is, is a weeklong series of tests and meetings with doctors and consultants to ascertain whether a patient can be accepted into the program. As such, I was under the impression that these appointments would, for insurance purposes, be treated like all other appointments. But no. Transplant evaluations are categorized differently because they can get quite costly, usually totaling $50,000 or more. Thus, from an insurance company’s perspective, if a patient is unhealthy enough to “fail” two evaluations, she is unlikely to be approved on the third try, so companies usually set the cap at two. So, while I wasn’t aware of the limit — technically, again from the insurance’s perspective, it was my fault for failing to find the pertinent language, plainly spelled out in black and white, on page 80-something of the voluminous policy — perhaps I could have been afforded a little slack in being solely concerned about getting access to health care rather than having an atomic-level knowledge of every nuanced detail in the document.

Although my insurance case manager knew that I was trying to get approved for a transplant, no one bothered to mention before I set up the second evaluation at Duke that the University of Pittsburgh Medical Center could become an in-network facility in a matter of weeks (see previous post) or that it was even being considered. Surely, this process doesn’t take place overnight. At the time, I was more confident than not that Duke would accept my case, so it’s not like I went there kicking and screaming, but had I known that UPMC was a possibility in the near future or if someone had told me about other in-network options like Cleveland Clinic or John Hopkins — both of which treat high-risk cases like myself — perhaps I would have waited. 1 As I have said, only after I used up the second evaluation did I learn that UPMC had become an in-network facility, which is what I tried to explain multiple times to my case manager who should have had my best interests at heart. I saw little evidence of it.

With the above information, I requested a narrow exemption given the particulars of my case, the severity of my condition and the requisite expediency. During the earlier, verbal part of my appeal, the case manager claimed she would take my case to her superior, but after that failed — who knows whether she actually did or not — I was told to write a letter and send it to some shady post office box address in Wisconsin. That was the second appeal. After that was rejected, I was told to send yet another one, and following the third fruitless endeavor, which included the aforementioned letter from myself and my doctor in New York, I was told I could then petition my secondary insurance for evaluation coverage. During all of their delays, belated return phone calls and long waiting periods between appeal responses, I lost at least five to six months, jerked along all the while, that could have been spent on a waiting list.

… It’s water off my back as long as I maintain the physical and mental ability to excoriate the idiocy and cold intractability of the system, plainly spelled out in black and white, as I am doing now.

The fire drives me on. I’m fairly young and have a strong constitution, and so, although all of this was certainly irritating and makes me think we should rip the insurance industry asunder and start anew, it’s water off my back as long as I maintain the physical and mental ability to excoriate the idiocy and cold intractability of the system, plainly spelled out in black and white, as I am doing now. But imagine the typical transplant patient: weak, infirm, emotionally drained. How much more difficult would it have been for them to go through this labyrinthine process only to get turned away with a few blithe keystrokes? How much more defeating to have gotten that far and have to start over?

Back to the story. Having thus exhausted all options to get coverage for a transplant evaluation with my company’s insurance carrier, I, along with a helpful case manager from my secondary carrier, who had more sympathy in her voice on the first phone call than I got with the other company in six months, began the process by which I am here today. Essentially, the medical director at the second insurance company discussed my case with the transplant director at UPMC and got the necessary approval for me to be seen, assuring the insurance director that the hospital in Pittsburgh had “different techniques” that could be deployed to mitigate my particular set of complications, of which, I will take up next time.

[Artwork credit: “Corporate Lobby” by DeviantArt user ianllanas.]

  1. Given what I know about conservativism on all levels, even at supposedly “progressive” centers like Duke, I had a hunch deep down that I would have to get out of the South and go north to get treated for my lung and immune system problems. There are no political overtones in that statement; it’s just the blunt truth.

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