When Prostate Cancer Returns – Between a Rock and a Hard Place with Health Insurance – Part 10

December 2, 2013

Last entry (Part 9) Mayo Clinic fumbles the preverbial ball – but what an awesome recovery!  Now we get the full picture and to be clear the process will be shared since the issue is NOT the Mayo Clinic, but obstinate Health Insurance Companies that seem to think they know more than my doctor.  Arrrgggg!!!

My last entry is here: https://chuckgallagher.wordpress.com/2013/11/27/when-prostate-cancer-returns-ouch-mayo-clinic-fumbles-the-ball-part-9/

NEWS on the MAYO FRONT!

Mayo Clinic LogoToday I get an inpatient email from the Mayo Clinic  that stated the following:

Your PSA is still 1.1–which is a good thing that it’s not moving anywhere quickly. Per Dr. Kwon I have placed orders for a prostate MRI and a return with Dr. Kwon. If you get the C11 PET approved through your insurance, please let me know and I will also order that scan for you.

To which I responded:

Diane (Dr Kwon’s nurse)…thank you for your email. It seems I am stuck between two competing factors – National Imaging Associates and the Mayo Clinic Urology. I cannot get my insurance company BC/BS to approved the C-11 that pre-certification comes through National Imaging Association. They won’t approved without a peer-to-peer discussion. Mayo Urology won’t do a peer-to-peer. PATIENT IS CAUGHT IN THE MIDDLE. Seems that sucks for the Patient (me in this case). Therefore, I respectfully request that someone with clinical knowledge do the peer-to-peer so that the C-11 can be approved. We both know that a pelvic MRI is likely (with a PSA of 1.1) to show nothing just like the CT scan and Bone scan. Happy to have the MRI done, but if that improves the approval of the C-11 scan great…otherwise seems it is a waste of time. National Imaging Association won’t consider a new application for the C-11 – they (according to your pre-certification dept) are only willing to reconsider with a peer-to-peer. I DO UNDERSTAND the time associated with this request. However, if it were you or your husband and there seems to be a stand off taking place that holds the patient (me) from getting what we both know I need, I’m sure you would agree that I have to ask. I am not asking that Dr. Kwon do the peer-to-peer, but do believe that there is someone in urology that is capable of convincing the physicial (likely retired and sitting on his ass with National Imaging Association) with NIA that a C-11 is the only thing that is likely to identify the location of my recurrent Prostate Cancer so that an effective treatment can be administered. I really appreciate your willingness to consider my request and hope that it falls on willing ears. Honestly that would be the best Holiday Gift I could receive – a yes from NIA. Thanks and hope your Thanksgiving was a blessing. Chuck

There is a simple saying – “You’ll always miss 100% of the shots you don’t take!”  In other words you can’t get a “Yes” without asking.  Me…well I am all about asking and more than once!  Sales motto – ask until you get a “Yes” of piss them off trying.  Either way you’ll get the outcome you desire or know that you’ve done your best trying!

Then later today a Mayo Clinic response – BETTER THAN EXPECTED!

Dr. Kwon will do a peer to peer review. Just call our pre-certification office to set it up at XXX-XXX-XXXX.

Oh my…certainly better than expected.  Dr. Kwon is the man when it comes to C-11 Pet Scans…so if anyone can convince National Imaging Associates of the value to me, he is the one that can do that!!!

THANK YOU!  And the process continues!

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When Prostate Cancer Returns – Ouch Mayo Clinic Fumbles the ball… Part 9

November 27, 2013

Some posts are simple and don’t require many words.

Mayo Clinic LogoMayo Clinic pre-certification department – 100% satisfaction rating.  Talking about a group that has gone above and beyond the call of duty…these folks certain have.  Hats off to you.

Mayo Clinic Urology dept… well it started at 100% and I can honestly say they are good – real good – but when it comes to patient first or process and time – patient loses if they pay with insurance.

Let me explain.  National Imaging Association denies the C-11 Pet Scan which would be the most likely test to determine the source of my recurrent prostate cancer.  What they require is a Peer-to-Peer consultation with the folks at the Mayo Clinic.

Why?  Likely because this particular Pet scan is so highly specialized that the NIA folks need to be “convinced” (my word) that its useful in my case.  To be fair, Dr. Kwon, through the Mayo pre-certification dept sent extensive material to help them understand.  Do I think the folks at NIA read it – na…not a chance.

But the problem is – Dr. Kwon and the Mayo Urology folks don’t (won’t) do peer-to-peer consultations with insurance companies.  I was told if they did that is all they would do and therefore get no scans done.

Wait a minute…time out.  You’re telling me that you (the Mayo Clinic) can’t hire someone with clinical urology experience to handle the interaction with insurance companies so that patients (like me) don’t get caught in the health insurance circle of death?

Sorry, but it is unacceptable that no one with enough specialized knowledge from Mayo Urology can take the time needed to do the peer-to-peer knowing that this test is “the” test needed to help me get appropriate direction needed for an effective treatment.

One call, but the Mayo Clinic won’t make that… at least that’s what I have been told for two days.  So much for the patient coming first.  Remember I (your patient) didn’t create this screwed up system of health care or payment system.  I just need cooperation so I can move forward to eliminate this disease once and for all.

You sure you won’t make the peer-to-peer call?  Please!


When Prostate Cancer Returns – The Great Health Insurance Run-around! – Part 8

November 27, 2013

I am becoming more firmly convinced that the health care system is so screwed up that recovery is challenging at best.  Wonder if we should call in palliative care for our health care system?

Blue Cross Blue Shield LogoMany of you have been following my journey dealing with recurring Prostate Cancer.  Treatable?  Yes!  Easy?  No!!!

THE GREAT INSURANCE RUN-AROUND!

Yesterday was a red-letter day when it comes to getting the run-around from all sources.  Even the great Mayo Clinic contributed (but we’ll get to that later).  Since this is in two parts – the first part was posted yesterday and can be seen here:  https://chuckgallagher.wordpress.com/2013/11/26/health-insurance-companies-and-the-ethics-of-health-care-you-aint-gonna-believe-this/

In my case since I was denied the test that I need to identify the source of my recurrent prostate cancer, I elected to call Blue Cross – Blue Shield of SC.  Ooops…calling – well that’s not possible.  Rather you have to communicate through their BC/BS website (something I can do, but not sure it’s easy for all customers/patients).  The connection with BC/BS was to appeal their denial.

BC/BS says – Sorry, but National Imaging Association is who issued the pre-approval denial and they would have to be the ones to reconsider.  Fair enough…

So I call National Imaging Association and was told that I was denied because the Mayo Clinic in its submission for approval indicated “Prostate Cancer” but did not provide a “tissue diagnosis”?  Bureaucratic bulls**t.  What tissue is there to diagnose?  My PSA is rising and that has only one practical source – recurrent prostate cancer.

CHINK IN THE MAYO CLINIC ARMOUR

Mayo Clinic LogoFollowing the logical process…I follow up with the Mayo Clinic pre-certification folks and am told that they have done all they can do and that a peer-to-peer might be in order.  Seems reasonable to me.  So I am told to talk to Dr. Kwon’s admin to seek his help.

Moments later I talk to Dr. Kwon’s admin and, well I must have called either on a bad day or too late in the day.

“Why are you calling me?”

“The folks at the Mayo pre-authorization or certification dept told me to call as a peer-to-peer might be in order,” was my response.  They just told me this minutes ago.

“They shouldn’t be doing this.  Dr. Kwon is not going to do a peer-to-peer with an insurance company.  Do you mind if I put you on hold while I resolve this with the pre-authorization dept.  They should have never had you call me.”

On hold…and I’m thinking “well that didn’t go well” – as the patient what message was sent that my doctor who is the champion of this particular procedure would not do a peer-to-peer.  I really do get it…that is time and time is money, but reality is if that is what is required surely there is a solution other than complaining about receiving a re-referral from another department within the Mayo organization.

THE GAME

I’m becoming more and more confident that the insurance company game is played this way:  DENY! – wait and see if the patient or doctor’s office gives up = INSURANCE COMPANY WINS!

Well, I don’t give up that easily either with the insurance company or the Mayo Clinic.

Looks like its back to the phones for me!

YOUR COMMENTS ARE WELCOME!


Health Insurance Companies and the Ethics of Health Care…You Ain’t Gonna Believe This!

November 26, 2013

Some may know – especially those who have been following my most recent blogs related to a return of Prostate Cancer that I’ve been dealing with – but today was a Red Letter day when it comes to Health Insurance, Health Insurance Companies and how they ethically (oops unethically) deal with their customers.  I am not sure how we got here, but where we are when it comes to our health and how that is paid for is so broken it’s quite unbelievable.

WHAT’S THE SCOOP?

healthcareToday was a follow up visit with my local doctor.  Nothing special and almost a waste of time, but the appointment was scheduled and kept.  Routine visit – weight, blood pressure, temperature, and nothing unusual.  Today I was to receive the results of my bone scan and CT scan, but since I got a CD with the data ready to send to the Mayo Clinic (which of course I read – not that I’m a doctor, but I can read, and a report that says nothing was found was exactly what I was expecting), which I sent, I knew the outcome before the visit.

Doctor enters the room with a pleasant smile asking me how I am.  Now that was a loaded question since I am full of frustration over the way Health Insurance companies deal with their customers (namely me).  Of course since I am the one that wants treatment, I personalize their actions.  Yes, I know better, but to me it is personal since it is my health.  So…I proceed to vent to the doctor.

“Doc, I don’t know how you deal with these insurance companies day in and day out!  They are a pain in the ass.”

“You don’t know the half of it,” he responded, “and it’s only getting worse!”

For a few minutes he openly allowed me to vent, then looked at me, removing his glasses and said, “Let me vent a bit.”

AMAZING STORY!

Of course with no identifying information shared, my doctor shared with me the most amazing story I’ve heard (and I suspect that this is nothing in comparison to many many more stories like this out there).

“So I have a patient with advanced lung cancer.  He’s been a smoker most of his life, so as you can imagine his lungs are pretty damaged.  Likewise, he has cancerous lymph nodes in his chest.  So I suggested a form of radiation treatment that is more localized to his tumor so that I can spare what little lung he has left.  If I use traditional radiation the tissue damage will create substantial problems for this man who needs to salvage as much of his lung as possible.

I submitted my request to his health insurance company.  Their reply:  DENIED.  They wanted me to use the conventional treatment!

I told the person on the phone, because by now I was personally involved, that if it were their lung or even their father in a similar situation, they would want the better treatment.  The treatment that would salvage what lung he has left.

They then suggested that I resubmit the request showing the two treatments: (1) more effective treatment and (2) conventional tissue destroying treatment.  We did that.

Got the response today:  DENIED!

I was incensed and called again for a peer to peer discussion.  Not more than 30 minutes ago I was told that the conventional treatment was all that was needed, even though I know that the damage from that will substantially diminish his quality of life and could create more medical costs down the road.

Chuck, they just don’t care!”

HOW DID WE GET HERE?

How did we get to the point that a person checking off a checklist is the determining factor into the kind of health care we receive in the United States of American?  Are we really OK with care provided at the lowest common denominator?  We we can receive quality treatment but the insurance company will only pay for adequate treatment, is that OK?

SHARE YOUR STORY

You don’t have to name names, but feel free to share your story.  Maybe if enough of us get our stories told…SOMEONE WILL LISTEN.

FEEL FREE TO SHARE YOUR STORY OR YOUR COMMENTS.


When Prostate Cancer Returns – The Insurance Company Two-Step – Part 7

November 22, 2013

Getting a straight answer from an insurance company – well that is like asking the Government to simply explain the Tax Code or the Affordable Care Act – it’s impossible!  And impossible leads to frustration.  The saga continues…

Health InsuranceFor those who have been following – I am on one had a prostate cancer survivor – on the other, it appears that prostate cancer has reared its ugly head again and my challenge is getting the treatment that I want with the blessing of my health insurance company.  Now mind you, the treatment I want is FDA approved and offered at the Mayo Clinic in Rocherster, MN.  So the question should be – why is this so hard?

APPROVAL VS APPEAL

The process should be simple!  Doctors says “You need this.”  You get it done and the health insurance company pays.  Simple right?  Not so fast.  It appears that the health insurance companies distrust the doctors so in order for the health insurance company to pay one must get preapproval.  As I asked in my last entry – “Who made Health Insurance Companies God?”

OK…I’ll play by the rules.  So, in my case, in contact with the Mayo Clinic, the request was sent for the one thing that can isolate where my prostate cancer growth is originating and thereby help me have an effective treatment – a C-11 Pet Scan.  Thanks to the folks at the Mayo Clinic who have to put up with this never ending bull shit.

Answer back – DENIED!

What next?  Well the C-11 Pet Scan – so says National Imaging which does the pre-approval screening for Blue Cross/Blue Shield of SC – was not medically necessary.  What?

They approved a bone scan and CT scan which was destined to show nothing, but the one scan that can show where the new cancer is embedded is denied.  I don’t know about you, but that’s the damn dumbest thing I’ve ever heard.  But there has to be a solution.

NEXT STEPS

Nothing being one to give up (which is likely what the insurance company would like me to do), I went on the BC/BS website to seek information on how I could appeal their decision.  Guess what…nothing there that answers that question.  Amazing?  Na…they don’t want people to appeal.  Rather, my guess is they would rather us (the patient) just take their finding as God and quit.

Not a chance!

Web based connection to BC/BS and the question is raised about appealing the decision.

Instant email in return indicating that I would get a call within 1 to 3 business days.

Sure enough I got the call.  Pleasant lady on the other end tells me that I can’t appeal since I had not submitted a claim for service.  Duh!!!  Of course I didn’t.  I didn’t get that far.  I tell the nice lady that the preapproval process is where the failure occurred and that is what I need to appeal.

“Oh,” she responds, “well you’ll have to take that up with National Imaging, we can’t help you.”

“How might I go about doing that,” I asked.

“Oh…your doctor will have to talk with them.  They don’t deal with patients.”

Let me get this – BC/BS can’t talk with me since I tried to follow the rules and National Imaging can’t talk with me because I’m not a doctor.  I am sure that those who follow understand how this is crazy making for a consumer just wanting to get appropriate treatment.

WHERE FROM HERE?

Not being a person to give up…looks like on Monday I’ll be calling the Mayo Clinic and see if they can help by giving National Imaging more of the information they need to get the test approved.

Sad, but this should not be such a stressful process.

YOUR COMMENTS ARE WELCOME


When Prostate Cancer Returns – Who made the Health Insurance Companies God? – Part 6

November 10, 2013

I am angry!  Just how did we get here?  WHO MADE THE HEALTH INSURANCE COMPANIES GOD?

Blue Cross Blue Shield LogoThere is one test offered at one place – FDA approved – that could help drive an effective treatment for my recurrent prostate cancer and, no surprise, the insurance company said – NO!  This is not an experimental test, it’s offered at the prestigious Mayo Clinic – and yet, the insurance company believes it’s not valuable.  WHAT?  One test that has the potential of focusing treatment to cure a problem and minimize costly side effects and somehow BC/BS of South Carolina thinks it’s not WORTH IT.  Who made these people GOD?

BACKGROUND

For those who have been following this series, you by now know that I have a recurrence of prostate cancer.  Where, well, that’s the question.  Again, fortunately it was caught early as evidenced by a slowly rising PSA.  Early is great, but that doesn’t minimize the importance of selecting the best treatment to eradicate the cancer and preserve quality of life.  I don’t care to die early from prostate cancer and equally, I desire to have a normal quality of life not hampered by too aggressive a treatment.  Both desires seem to me to be reasonable!

Enter the insurance company – in this case Blue Cross/Blue Shield of South Carolina.  At one level I am confident that they are doing their job as they see it.  But are they acting ethically?  Again, from their perspective my guess is they would say – Yes.  But is their perspective of profitability the perspective that yields the best results?  Perhaps that “rabbit trail” of an ethics discussion should be best saved for later.  For now, who made them God when it comes to my health?

THE JOURNEY GETS COMPLICATED

CT scan completed!  Bone scan completed!  Both – as expected – showed nothing.  To be clear both tests were a waste of time and BC/BS money, but they were “required” in order to get the one thing I need – a Choline C-11 Pet Scan from the Mayo clinic done.  As a point of reference, the CT or Bone scan won’t detect prostate cancer until it’s fairly well progressed.  Mine is recurrent cancer and as evidenced by my PSA of 1.1 it is not well progressed – YEA – so those scans are worthless (but a prerequisite to the C-11 scan).

Scans done, so now I work with the Mayo Clinic to gain insurance company “pre-approval”.  Yuck.  First who says what should happen to my body – the insurance company of my doctor?  Apparently, it’s a mind numbing insurance company that is more concerned with their financial outlay than my health.   However, I have no choice but to play the game.  The folks at the Mayo Clinic are great, but when I tell them my insurance company is BC/BS of SC, they respond with a dull, “Oh”.  They then proceed to tell me that “Southern” insurance companies are tough to deal with, but they will do their best.

Days later, I get a call from Rochester, MN – home of the Mayo Clinic – the gentleman on the other line shares as kindly as he can, that “National Imaging” the folks BC/BS of South Carolina use to pre-approve imaging services has DENIED my scan – saying that PET scans don’t work.

PET scans don’t work.  Well, perhaps that’s true for the average ordinary PET scan.  But this is a highly specialized PET scan that is incredible at detecting recurrent prostate cancer in the very early stages.  BINGO – just what I need.  But some numb nuts at National Imagining likely has never heard of a Choline C-11 PET scan and just give me, what I’m sure tens of thousands have heard – a big resounding NO!

IT’S MY LIFE AND HEALTH and WHO CONTROLS IT?

The Insurance Company – plain and simple!  It’s wrong and evidence of a system broken!

An example – remove the emotion I feel from this discussion – let’s look at a different situation.

I went to the BC/BS store front in Greenville, SC to inquire about insurance effective January 1, 2014 since my current coverage will expire.  (Nothing like facing a medical challenge knowing that in less than two months you won’t have coverage).  So I ask for the Platinum plan.  “We don’t offer that,” I was told by the BC/BS agent.  “Ok, then quote me the Gold plan,” I responded.

The Gold Plan price was calculated with a brief explanation.  Then I asked the following question:  “Let’s say I had a brain tumor and the best treatment was at MD Anderson in Houston, TX.  How much would my insurance pay toward my treatment?”

“Nothing!  They are not in our network.”

At this point my mind is racing for my next question.  “So let me get this, the only thing my insurance would cover is treatment by Dr. Bumfuck here in SC (no offense to SC physicians, but MD Anderson vs SC – I’d take Anderson!) otherwise 100% is out of pocket?”

“Yes, that’s right.  And, we just added the Greenville Hospital System.  Slowly we’re adding more to the network.” (at the time of our meeting only one hospital system was in the network, thereby meaning that if my local doctor was affiliated with the one not in the network, I would be forced to change doctors or pay out of pocket)

“Wow,” I responded, “so under this new plan I’m stuck with who you select for my medical care or I have nothing?”

“That’s right!”

THE BEGINNING IS THE END

Who made the Insurance Companies God?

YOUR COMMENTS ARE WELCOME

https://chuckgallagher.wordpress.com/2013/10/19/when-prostate-cancer-returns-researching-treatments-for-a-rising-psa-part-3/

https://chuckgallagher.wordpress.com/2013/10/20/when-prostate-cancer-returns-mayo-clinics-choline-c-11-pet-scan-part-4/

https://chuckgallagher.wordpress.com/2013/10/30/when-prostate-cancer-returns-the-mayo-clinic-process-continues/


When Prostate Cancer Returns – The Mayo Clinic Process Continues – Part 5

October 30, 2013

Not only is it disconcerting to find out that you have recurring prostate cancer, but then to have to deal with restrictive insurance companies and find out that it will only get worse, just adds icing to the cake of worry and stress.  The bright spot – dealing with the Mayo Clinic.

Health Care 2So here’s the deal.  You find you have a rising PSA when, without a prostate, your PSA should be zero.  Problem!

You then find that there is a wonderful test that potentially could identify where the growing prostate cancer is located so that appropriate treatment could take place.  Get the test!  Right?  Not so fast…

In the Mayo Clinic consult I find that in order for insurance to cover the test, they require other tests – CAT scan and Bone Scan – be done so that (my words – less expensive diagnostic tests) one can find out if there is a “cheaper” way to determine where the problem is.  At a simple level that makes some since, but reality and bureaucracy don’t often mix.

Starting cheap and controlling costs is the insurance company’s way of creating profit.  But at what cost?  My health?

Reality is – the only test that has a chance of detecting where my recurring prostate cancer is originating is the Cholene C-11 Pet Scan.  With a low level PSA (1.1) the chance a CAT Scan or Bone Scan will show anything is slim to none.  Ah, hell…None!  So…the ONLY option is the C-11 Pet Scan.  Now doesn’t it make sense that someone with some fundamental intelligence would look at the facts and circumstances and just order the C-11 Pet Scan from the get go?

The insurance approach has done nothing but waste money.  Start cheap and then (potentially) approve the one test that would work.  Arrrrg!

INSURANCE SOAP BOX TIME

But it gets worse – and yes now I am on my soap box.

So…knowing my insurance will change at the end of December 2013, I go to Blue Cross Blue Shield of SC to inquire about the “gold” plan for South Carolina residents for 2014.  What a eye opener.  First, they calculate the monthly cost which is high, but in this day and age that is expected.  So far no surprises.

Then I ask – what is covered and for how much?  That’s when it starts to get interesting.  I am told the deductibles and out of pocket expenses.  When it’s all said and done I’d be out of pocket $4,200 plus the monthly cost.  OK…not bad.  But wait there’s more.

So I ask, where are these insurance benefits available?  “You mean who can provide them,” asked the Blue Cross representative.  “Yes.”  Now dumb me, I figure that if you have the “Gold Plan” you should be able to get benefits anywhere.  WRONG!

I’m told that coverage is only available through providers in the network.  STOP!  Really?  Then the BC/BS representative said we’ve just added the Greenville, SC Hospital System.  I used to just be St. Francis.

I was blown away.  You mean to tell me that if I don’t choose a provider in your network, I have to pay for services out of pocket?  The response from BS/BS – YES!

Pardon the way I put this, but WTF?

I proceeded to ask, “So if I had a brain tumor and the #1 brain surgeon was at MD Anderson and they are not in the SC BC/BS network, I would either have to choose Dr. Nimrod or pay out of pocket for the best care?”  “Yes, that’s correct!”

OMG…if that’s what we have to look forward to with the Affordable Care Act then God help us.

BACK TO A MORE COMFORTABLE REALITY

Thank God for people that know how to navigate this mess.  Back to simplicity.  I email through the Mayo Clinic system to find out next steps and was provided the phone number for those (blessed) folks who get pre-approval for people like me who need the help and are pissed with insurance companies (who made them the decision makes for my health?).  I simply called the Mayo Clinic – got a lovely lady on the phone who was interested in helping me.  She listened to my story, found the CPT code, got my insurance information and is proceeding today to be my advocate with my current insurance provider.

The C-11 Pet scan is scheduled and the journey continues to health…