Margaret M. Manchester Writes

Hello Again!

As I mentioned in a previous post, I had a minimally invasive procedure on my spine performed on January 3. After having exhausted all the conservative measures, my sciatic pain had become incapacitating at times. My neurosurgeon is renowned in this field. If you are interested in learning about this procedure, endoscopic foraminotomy, check out https://youtu.be/JrGC97y7Ao0?si=ut7FoE7VlCQKcFPa.

I am pleased to report that I am making progress every day. I am no longer taking pain killers and am moving more, albeit cautiously. Getting to this point, however, was a long and frustrating process.

If your physician has retired or if you need a specialist, you already know that it is incredibly difficult 1) finding a doctor and 2) getting an appointment. I guess I was living in a bubble when people talked about the health care crisis. Here in New England, we have great doctors and great medical facilities. I felt as if we had dodged the bullet. Not anymore.

I did not expect any problems when I was finally able to meet with my neurosurgeon. After all, BC/BS Federal had previously approved and paid for my spinal injections, MRI’s and X-Rays, and multiple rounds of PT. One of the women from my golf league had the same procedure with the same surgeon two weeks earlier. Turns out, she also has the same insurance plan as we do. The hospital generated an estimate, which was the same as my friend’s out-of-pocket expenses. So, I was completely blindsided when I received the notification that my claim had been denied because the procedure was considered “experimental” and “investigational.”

The neurosurgeon had a peer-to-peer call early in the following week. BC/BS denied the claim a second time. I called them as soon as I received the notice. The customer service rep was very kind. I asked her why my procedure had been denied when my friend had the exact same thing less than 3 weeks earlier, and whose claim was approved the first time around. Without violating confidentiality, she was able to confirm that my doctor’s office had used the same code when they submitted both claims. She also dug a little bit and found that according to the medical review board that had rejected my claim, “the provider had failed to demonstrate the medical necessity for this procedure.” I asked her what more the insurance company needed: I could not stand, nor could I walk because of sometimes debilitating pain. She had no answer.

My neurosurgeon called me shortly after my phone call with BC/BS. He had submitted more evidence that this procedure was no longer investigational or experimental. He had already done 4000 of these procedures. I told him about what the BC/BS rep had told me regarding the medical necessity for my operation. Shortly thereafter I received a call from BC/BS informing me that they had received the request for an expedited review of our appeal.. When I mentioned that I could not stand or walk, he said he would note it in my file. Long story short, I received the approval for my procedure on December 16, two days before my scheduled surgery. But, the nightmare continued.

We arrived at the Ambulatory Patient Center at RI Hospital promptly at 7am on the morning of December 18. I went through the usual pre-check, donned my gown and cap, and had my IV inserted. Then we waited. Ultimately, my surgeon informed me they had to cancel my procedure because none of the packs of surgical instruments had been properly sterilized. Apparently, it been an ongoing problem with the multi-million dollar machines and more than 30 surgeries had to be canceled. After all the months of testing, office visits, and the increase in my back and leg pain, you can imagine how frustrating this news was. I mean WTF?

Because of the upcoming Christmas holidays, my surgery could not be rescheduled until January 3. The hospital generated a new estimate. This time, the cost was almost $1200 more for the same procedure; and because it was a new calendar year, I would also have to pay a $350 deductible. To add insult to injury, the hospital also wanted to charge me a $30 copay for an office visit. Remember, this second estimate was generated about ten days after the first. I called BC/BS and double checked that my out-of-pocket costs were 15% of the cost of the surgery. The two estimates generated by the hospital had been incorrectly based on 35% coinsurance.

I called the billing department at RI Hospital to contest the bill, describing everything that had happened, stressing that the procedure had been delayed through no fault of my own and arguing I should not have to pay either the higher cost or the deductible. I asked them to refund the prepayment I made since the costs had been incorrectly calculated. Later that day, I received a revised bill that was several thousand dollars less than the original estimate. I am still waiting for the refund for my original payment.

I have a lot of thoughts about this entire experience. Forgive me if they are a little disorganized. How many people accept the estimates generated by the hospital in good faith and pay them without contest? What happens to people who do not have the wherewithal or the confidence to challenge the way they have been treated? Luis Mangioni, according to news reports, was enraged because an insurance company had delayed and denied cancer treatment for his mother who died as a result. How many others have experienced this, feeling powerless and without any kind of recourse? Some of my friends have to wait many months to see a specialist or a new doctor. Health insurance companies continue to delay or deny benefits for medical treatment, superseding doctors’ professional judgement. My friends who are in the health care system tell me it is broken. I believe them.

I am very fortunate. I can afford and have health insurance. There are options available to deal with my chronic pain. I had a great neurosurgeon. It was a slog, but I am recovering and am optimistic about the future. But I worry for my fellow Americans, especially those who do not have the same privileges. Members of the incoming administration have indicated they are going to impose severe cuts in government services and spending, threatening to eliminate entire federal departments and agencies. I do not know the details, but I fear this will worsen the ongoing health care crisis.

So, I can understand Mangioni’s rage, but I do not condone his actions. Something has to be done about health care in this country; but honestly, I don’t know what the answer is.

Thanks for tuning in. Hope to see you next time.

Margaret