Some background. My wife contracted a rare form of cancer—only ten patients diagnosed a year—and underwent two operations. The removal of her uterus and a lobe of her lung. Fortunately she went to Sloan Kettering and the oncologist there had had just treated three patents with the same cancer and so she was in good hands. Post-op she visited the hospital once a month and remained in close to touch whit the oncologist.
OK: Here we go.
On a Wednesday morning three years after the operations , my wife felt a sharp pain on her side in the area where the incision was made during the surgery to remove a lobe of her lung. She had had pain there for about a year or so following the operation but not so sharp and not so prolonged. The night of the following day, after working outside in the woods for most of the day, when my wife took a deep breath the pain was incredible. I mean; it almost knocked her out. Since we have some powerful pain killers left from the post-op period three years ago, she took one along with a valium to calm her down. The pain disappeared and she had a painless and restful sleep.
Then on Thursday morning. She woke up and the pain had built from a level-1 to a level-5. My wife immediately called her gynecological oncologist at Sloan Kettering who tells her that she should go to an emergency room of a local hospital immediately—as we live a two hour drive from the city. This might be a blood clot. My wife needed an immediate X-ray and possibly a CAT scan.
Now the story really gets interesting. My wife and the children are insured under her former husband’s policy. He was an MD on the staff of a hospital recently absorbed into an even larger hospital system. As a result my wife and the kids are now insured by a different HMO than the one they used prior to the hospital incorporation. Everything had to be changed to; doctors, hospitals etc. that are in this new HMOs “system.” Does this make sense, of course not? And this was an HMO that serves MDs. Does this make sense, of course not?
So, I go on the web to the find a hospital in this HMO’s “System.” We found one in Sharon Conn. about a 20 minute ride from where we live. We’ve used that hospital before. It’s a good hospital and, in fact, the mother of one of my step-son’s old girlfriends used to work there. Having learned from the past, I told my wife to call the hospital and make sure that they are, indeed, in the system. She learned that the hospital was in the system for everything except radiology. You figure that out. I’m still trying.
As what she needed was an X-ray, my wife calls up the HMO to make sure she was going to a hospital at which the bills will be covered. My wife was now in charge and I am in the background.
My wife got an HMO employee. The woman looked up Sharon Hospital and said that it was in the system. My wife repeated what she was told by the hospital. As the phone was on speaker, I heard everything. The woman told my wife that she can’t understand something like that and that my wife should just go to the hospital.
In the background I shout:
“OK, she just gave your authorization. Get her name and phone number and lets go. ”
My wife asked for the woman’s name and suddenly the woman equivocated. She then told my wife that she would connect her to another department and the phone clicked dead. Obviously the woman didn’t want this coming back to her so she cut the line off. Incredible.
My wife is now very pissed. I told her.
“Don’t you see what’s happening. Their staff are not aware of the nuances of the system and so they tell you to go, you go and then you discover after treatment, that it’s not covered. By then it’s too late and you get a bill for $5,000.”
This had already happened to us. So, I tell my wife that, depending on the size of the HMO, this little twink can save them millions each year.
“The guy who thought it up probably got a promotion.”
My wife is now very hot. She called again and told the woman that if she was disconnected again, that this woman was going to be in a lot of trouble and so, gets the woman’s name. The woman told her that Sharon was covered and my wife told her what she was told by hospital staff. So the woman checks and tells my wife that she will be completely covered if the problem was life threatening.
I’m in the background laughing and I shout:
“I see, if she dies you pay. If she lives we pay. How the hell are we supposed to know if it was life threatening, you moron. What Einstein came up with that one! She’s in pain, her oncologist told her to go to an emergency room, the clock is ticking. We don’t know what the hell is wrong and that was why she’s going to the hospital.”
Now remember, my wife’s got the woman’s name and so my wife told her, “If anything happens to me I’m going to sue you. Not the HMO but you. Now give me a hospital that I can get to in less than an hour.”
I’m still laughing and in the background shouted:
“She doesn’t have to hear you talk to her like that. She’s not paid to hear you insult her because she doesn’t know her job. She has a right to connect you to her supervisor. That’ll take another 20 minutes and if you die in that time the HMO will be off the hook because they don’t pay for funeral expenses even if the funeral parlor was in their system.”
The woman finally wised up and connected my wife to another department that gives authorization. Now, the woman my wife speaks to in this department was not at a computer and had to shout to someone else across the room who was at a computer. It had now become farce. My wife was really giving it to her.
“I’ve been on this phone for one half hour. I don’t want to go to a hospital and then find I’ve got a $5,000 bill. So give me a hospital at which I will have full coverage. I have pain. I’ve been told by an oncologist that I may have a blood clout that could kill me. Now give me a hospital that I can get to before I drop dead on this phone. Give me your name so if something happens I can sue you and don’t you dare hang up!”
My wife got the name and you have never seen a woman take such care to make sure that she found a hospital at which my wife will receive full coverage. She gives us one in Danbury Conn. My wife was about to blow up.
“Danbury is over an hour away. I don’t know the streets and will probably get lost and therefore I may not be in an emergency room for an hour and a half to two hours. Get me one closer. And do it fast.”
She came up with Vassar Brothers in Poughkeepsie. I’ve been to Vassar College doing research I don’t know how many times and I told my wife I can get her there in 45 minutes. The woman on the phone–remember she was shouting to someone across the room—took another ten minutes to make sure that everything will be covered in this hospital. My wife then took down her ID number and extension and warned her that she had better be right because if she’s wrong she’s going to be in a lot of trouble.
I shouted in the background, “Sure, if you sue her the HMO will fired her and then tell our lawyer that they never heard of the woman. She better be right.”
These phone calls have taken a full hour. My wife turns to me, “What if there was something really wrong so that I needed to be treated immediately.”
“One of two things. You’d be taken to the wrong hospital which means they wouldn’t have to pay or, two, you would drop dead waiting to find out which hospital to go to which means they still wouldn’t have to pay. It’s a win-win situation for the HMO. They’re not stupid.”
Anyway, long story short. Forty minutes later my wife’s in an emergency room, they took X-rays, blood and finally a CAT scan. It’s not a blood clot but simply a post op occurrence in which the muscle layer below the rib cage, but surrounding the lung, had tightened which, when the lung enlarges due to deep breathing, was irritated and this caused the pain.
When we get home I gave my wife another pain killer, she turned on the TV and went to the bed. The next day she was back working outside.
The American Health Insurance system. Nothing like it. Just remember to take down names and Id numbers. It will save you thousands.