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 – Mayo Clinic’s Choline C-11 PET Scan – Part 4

October 20, 2013

“Your prostate cancer is back.”  As any man can imagine, those were words that I didn’t want to hear.  Thought I was over this phase of my life…apparently not.  But I have two choices, dwell on how I feel or find a solution.

Mayo Clinic LogoAs the journey continues it appears that for recurring prostate cancer there are few tests (well only one that I’ve found) that can shed light on where the cancer might be in my body.  That test is the Chloine C-11 PET scan done at the Mayo Clinic in Rochester, MN.

Here are comments from the Mayo Clinic website:

  • Helps detect recurrent prostate cancer sooner. Choline C-11 PET scan can help doctors detect recurrent prostate cancer before it may be detected by more conventional imaging tests. In men with rising prostate-specific antigen (PSA) levels, this test may help detect sites of possible recurrent prostate cancer at PSA levels as low as 2 nanograms per milliliter (ng/mL). Conventional tests may not detect a recurrence until PSA levels are between 20 and 30 ng/mL.
  • FDA-approved Choline C-11 PET scan site. Mayo Clinic in Rochester, Minn., is the first, and currently the only, medical center in North America to receive approval by the Food and Drug Administration (FDA) to prepare and administer the Choline C-11 PET scan imaging agent (Choline C-11 Injection). Mayo Clinic in Rochester, Minn., is currently the only site in the United States using the FDA-approved imaging agent.
  • Helps identify areas of recurrent prostate cancer after all forms of treatment. Previous treatment may leave scar tissue that can be confused with active cancer when viewed using conventional imaging. Choline C-11 PET scan can help doctors distinguish between scar tissue, inactive cancer cells and active, recurrent prostate cancer.

THE PROCESS

Not being a person to delay action, I went to the Mayo Clinic site and requested the test.  Of course, it was not quite as easy as that.  I was informed that I would be approved for a consult and an appointment was scheduled.

Wow…that was easy.

Then it hit me, wonder if my insurance would pay for my treatment choice.  My wife, the person in my life that thinks more analytically than I, suggested that I call my insurance provider to see if preapproval was necessary.  Now I have to be honest, I really have a hard time with insurance.  When did big insurance companies become the dictators of one’s health?  Arrrg.

THE APPOINTMENT

Not sure what I expected, but the Mayo Clinic was far nicer that my wildest imagination.  Johns Hopkins provided great service, but the place was kind of a dump – especially compared to the Mayo facilities.  But pretty wasn’t what I was there for.

I met with Dr. Eugene Kwon and quickly found a kindred spirit.  He was articulate and focused on, what I would call, the right kind of patient care.  He made the comment that all too often Doctors, with recurrent prostate cancer, were concerned with palliative care for the patient vs. cancer elimination.  In fact, he seemed to believe that we need to do better with initial treatment options.  Either way, after our interview Dr. Kwon laid out a specific course of action that would lead me to gaining what I desired – a Choline C-11 PET scan.  But there were some pre-conditions.

1.  I would need to have a CAT scan.

2.  I would need to have a bone scan.

Now, to me, that made no sense.  But, as Dr. Kwon explained, in order for the insurance company to approve the Choline C-11 PET scan, I would have to fail both a CAT and bone scan.   While I’m not sure the costs, it appears that these are prerequisites to insurance approval for the scan that would make a difference.  Such a game and one that makes no practical sense.  Doesn’t it just make more sense for reason to rule when making decisions like this?  Seems that the insurance companies set the rules and doctors have to play by them.  What a waste of time, energy and money.

As I left the Mayo Clinic I have to admit I was impressed with the efficiency of their operation.  On the spot a PSA test was ordered and within 1 hour it was completed.  I was told that I could sign in to the Mayo Clinic website and create my own account so that we could use that as a portal for results and communication.  OK…that’s different.  And by the time I flew home and logged in (the next day) I had my PSA results.  Amazing!

NOW THE TESTS

I have to admit it’s a bit funny…both the CAT scan and bone scan are painless so why the anxiety.  It’s the freaking needle!  Yes, I am such a baby when it comes to being stuck.  So here I am at the imaging center and what I fear is a simple injection so that the scans can be done.  Oh well…it appears that I may as well prepare for the fact that being stuck is going to be an active part of life moving forward whether I like it or not.

So…I tell the nurse that I request a “baby” needle.  She looks at me kinda funny and says, “Really?”

“Yes, really!  Or perhaps you want me flopping around on the floor.”  I’ve come to understand that if I want baby treatment I will exaggerate my fear of needles so that they take me seriously.  Why not?  Seems that any babying I can get is better than just being treated as a piece of meat.  And then as they prepare my arm I hear, “Good veins!”  My I hate to hear those words as I know being stuck is the next thing that follows.

“Now drink this.”  Before the CAT scan I had to drink what seemed to be a quart (but more likely a pint) of some nasty liquid flavored with vanilla.  Now that’s a way to turn someone off of vanilla.  But drink it I did and within an hour or so, I was in for the CAT scan.  The scan – well that was easy – just lay down and the machine does the rest.

“The scan is done, Mr. Gallagher.  You’re free to leave.  Come back at one for your bone scan.”  And with those words I gladly left the imagining center for some nourishment.

MIND GAMES

The tests weren’t what was bothering me.  Rather, it was the thought that here I am at 56 and facing again those dread two words, prostate cancer.  Somehow I felt, having defeated prostate cancer once (or at least I thought I had), that I would have a long life ahead.  Now there were doubts.  Not that dying is a great fear (well I guess for us all it is at one level), but more than that it is not finishing what I came into this life to accomplish.  For the current moment, it seems that I dwell more of the value of the moment rather than taking them for granted.  Actually I wonder at times if I have done OK.  God knows that I’ve made mistakes, but I’d like to think that when I am gone – the world will be a better place.  Then I think about my life to date and wonder if it truly is.

Mostly I think of my two sons and hope that I’ve been a good enough father.  Being reared without a father, I have had little to go on as an example.  I love my sons.  Perhaps it’s time to show that more than I do.  Either way, it is becoming painfully clear that life doesn’t last forever and we all have a mortality…so what ever I can do I need to do it now.

FINAL TEST FOR TODAY

“Mr. Gallagher, step back here for your scan.”

Soft music was playing and in no time I found that I was awakening myself with a resilient snore.  Seems I had drifted off during the bone scan.

“We done here.  Hope you had a nice rest.”  And with those words this part of the journey was complete.

https://chuckgallagher.wordpress.com/2013/10/18/when-prostate-cancer-returns-one-mans-chronicle-psa-rising-part-1/

https://chuckgallagher.wordpress.com/2013/10/19/when-prostate-cancer-returns-one-mans-chronicle-where-from-here-part-2/

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