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08 August 2006

Need some bunny brainstorming.... [More:] I've complained before about my mother's travails with the medical establishment. The short version -- she's got a really rare and serious condition that her doctors don't know how to treat (though they've been trying ineffectively for 8 months). Last month they finally referred her to a specialty clinic in Denver, but she couldn't get an appointment until October.

Okay. So, today she found out that her insurance company -- Blue Cross/Blue Shield won't approve the referral because the clinic is out of state.

This clinic treats people from all over the country, so it doesn't seem all that unusual to me for the doctors to send her there.

BC/BS told her that there was no appeals process, that there simply was no way in hell they were going to let her go to a clinic outside of Texas.

This seems like bullshit to me. Does anyone know of any way to appeal the decision, or to get an exception granted for the referral?

Only thing I can think of is going all Michael Moore on them, like he did with the guy who couldn't get an organ transplant approved. He paraded the guy in front of the insurance CEO's office with a sign saying "I'm going to die" or something like that, then held a mock funeral.

But I don't think my mom would go for that.
Insurance companies basically say "No" until you bother them enough to say "Yes."

There will of course be times when it really is "no," but a lot of companies work on the assumption that it's their customers' job to work for the reimbursement.

I would start a full-scale escalating attack. Just keep calling, keep getting the doctors to call, whatever you can think of. Letters to the editors of papers could work too. Figure your job is to make their lives hell until they say yes.

(My aunt is head of HR for a big company, and I love being able to sic her on these things. She's got that Southern steel-magnolia thing going for her, where her being super polite is the equivalent of most people swearing their heads off, but it's highly effective.)
posted by occhiblu 08 August | 12:18
Also, as you keep calling and asking to speak to supervisors, keep documenting who you talked to (Get names!!!) and when.
posted by occhiblu 08 August | 12:19
I've been trying to encourage you to use your journalistic capacity to get some pull here - you know, call them to say you're researching an investigative piece on insurance referral complications, get them to fact-check the story with you, ask about the policy, whether any exceptions have ever been made to the policy, what the existing appeals process (if any) is, what they recommend patients do who can't get the treatment, etc.

I know you could do a good job on this, and at least get some clear information if not put a little heat on them. But I also know that doing this is utterly and completely unethical (unless you're Michael Moore and it's what you do). So I'm kinda stumped.

Is there some sort of grassroots advocacy group that helps people with insurance stonewalls? I don't know - but there should be.
posted by Miko 08 August | 12:20
The articles I'm turning up on Google tend to deal with mental health issues (probably because they're denied coverage more often), but this might be helpful anyway.
posted by occhiblu 08 August | 12:24
And The Kaiser Family Foundation Consumer Protections page might also be helpful.
posted by occhiblu 08 August | 12:29
Also, I'm so sorry you're going through this. My father has been in and out of the hospital for various things over the last year, and I know how frustrating all this can be. I don't know what I would have done without my aunt's help; it's so completely unethical how apathetic and obstructionist the insurers in this country are.
posted by occhiblu 08 August | 12:31
Thanks, y'all.

To clarify a bit, they're not denying treatment -- they're telling her to go to a clinic in San Antonio or Houston instead of the one she was referred to in Denver. But the one in Denver has had more success, apparently, in treating the really rare condition she has.

I guess my take is, this is actually a life or death situation. It's not knee surgery -- this is a case where the quality of care and the practical experience of those treating her will actually affect whether she survives or not. So it seems to me that there must be some sort of review process whereby the insurance company can recognize that. She shouldn't have a lower chance of survival because she lives in Texas and not Colorado, but that's basically what they're giving her. If it were a minor thing, it wouldn't be a big deal.

At this point, I'm thinking what my folks need is a lawyer....
posted by mudpuppie 08 August | 12:42
Couldn't hurt, if they can swing it.
posted by Miko 08 August | 12:44
It sounds like you may need the doctor's office to harass them a bit, then, or at least draft a letter that you can keep sending out to whatever departments you harass.
posted by occhiblu 08 August | 12:47
Also, have y'all tried calling the clinic in CO? Maybe their billing deparment has some ideas? It seems like it would be in their best financial interest to have your mother as a patient, and to have her insurance company's payments.
posted by occhiblu 08 August | 12:48
Yeah, actually the clinic in Denver has been really helpful. They're such a specialized group (and the disease is so scary), they actually have a person who is employed as a patient liaison. I suggested my mom ask if they have other BC/BS out-of-state patients. She's waiting to hear back from them.
posted by mudpuppie 08 August | 12:57
Sorry to hear about your mom, mudpuppie. In terms of insurance, if it's something they should be covering, according to their own policies and/or the law, you might try contacting the Insurance Commissioner for Texas (or the equivalent, providing there is such a position). Just threatening to do so when I was in Ohio and had insurance woes (along with a letter from my doctor) got my insurance company moving. I'm not sure what the legalities are for your particular policy, though...

If I may, I would also suggest continuing to look for a doctor that can and will treat your mom in the meantime there in Texas. I've often had to see several doctors before I could find one that would really help me. Maybe go to the Emergency Room of a very good hospital that's on your mom's Blue Cross/Blue Shield plan and see if either they would admit her for further testing/treatment and/or refer her to one of their departments for follow-up. It's how I got into New York Presbyterian/Columbia Hospital for my gallbladder... through the ER (though it took two trips before they got the surgical consult and admitted me). They did the surgery the very next day, where as with the private doctor I saw, it was going to take almost two weeks just to get the ultrasound, and now I have follow-up apppointments with NY Pres./Columbia staff and professors. Worth a shot?

All the best to you and your mom. Don't give up, and don't keep waiting. Keep pushing and knocking on doors until someone helps you. Maybe find the hospital with the best pulmonary and cardiac departments and try there. Whatever research you can do on your own, of course, can be helpful, too. (I found a good medical school library helpful when I had fibroid surgery.)

(on preview: maybe try the Texas clinics, too, while you're waiting? Couldn't hurt? Maybe a referral from them, if they can't find the solution, would do the trick with insurance? Hope everything works out.)
posted by Pips 08 August | 13:06
Do you know anyone who lives in Colorado? Would your mother be able to "move" there and gain elegibility that way? No idea if this is remotely workable, though.
posted by dg 09 August | 01:55
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