The Insurance Intelligencer 3/23/11
Appeal #71: Brandon's story
We accept insurance "networks" as a given. They are not a given; they were invented forty years ago by insurance companies.
Most of the appeals that I fight nowadays are not for denials -- I am fighting out-of-network APPROVALS. Did you know that it is possible to appeal an approval? Or that, if you are going out-of-network for something expensive, you had better appeal it. Why? Because PPOs are a deception. They compute their "70%" or "80%" based not on billed charges, but on a secret number which they themselves come up with. An out-of-network approval is no better than a denial.
All PPOs are essentially the same as HMOs. You can go wherever you want, and go broke doing it.
Networks are the mechanism by which insurance companies control what treatments they will pay for, how much they will pay for them, and who we may go to for these treatments. What effect forty years of "networks" has on the quality of medical care?
I just won appeal #71, for a 34-year-old man named Brandon. He has a two-year-old son, and a baby on the way. Brandon had the same cancer that I did -- late-stage, metastasized appendix cancer. He needed to get to Dr. Sugarbaker in Washington, D.C.
Dr. Sugarbaker saw Brandon on Friday, it was decided that he couldn't wait, and the surgery was scheduled for the following Wednesday -- five days later.
Why the hurry? Because of what Brandon's in-network surgeon had been doing to him for four years ...
The worst bad medical story
I ask each of my helpees to write a three-page story of what happened to them since they first went to the doctor with symptoms. Names, dates. What they asked, what the doctor said, what the doctor did, how it turned out. I call this the Bad Medical Story.
During the process of discussing Brandon's story with him over the phone, I realized in one moment that this was the most shocking story of all of my seventy-one appeals. Nobody knew how bad this story was, until I interviewed Brandon about his story on Saturday morning.
I was asking questions, and Brandon was looking at his medical records. He said, "Oh, I found a pathology report." I asked him to read it to me. The report stated clearly -- in six different ways -- that Brandon had a low-grade appendiceal malignancy, with a serious risk of metastasis.
Brandon was first told that he had cancer in January 2011. I assumed that the report would be from 2011.
"The report is dated 5/2/07," he replied. The report concluded: "This report was delivered to Dr. Anderson* on 5/2/07." Brandon didn't make the connection until I said, "Brandon ... your doctor knew that you had cancer in 2007." The silence was so great ... I could hear my own heart beating.
Brandon's four-year saga passed before me: Appendectomy in April 2007. Visit to Dr. Anderson a few weeks later to hear the results of the pathology report. Dr. Anderson saying, "The report is inconclusive. Don't worry about it."
Brandon returns to Dr. Anderson many times over the next four years -- complaining of pain in the lower abdomen, bloating, nausea. Dr. Anderson tells him that he has acid reflux, prescribes Prilosec, and says, "Come back and see me in a year." Six months later, Brandon comes back in with worse pain. Dr. Anderson says, "You have gall bladder trouble, but you don't have enough pain to justify removing it. Come back and see me in six months."
And so on, until January of 2011, when Dr. Anderson finally agrees to remove Brandon's gall bladder. He comes to the hospital room after the surgery, and says, "You have tumors. You have cancer. But don't worry, it can be taken care of. I asked some people, and we have to get you to Dr. Sugarbaker. He is the only one who gets good results with these advanced cases."
The insurance company proceeded to deny the referral to Dr. Sugarbaker ... because he is out of network.
Making them pay
The Bad Medical Story was the star of this appeal. I called that section, "Cancer diagnosis concealed for four years."
I also proved that the in-network surgeon who they would compel him to see had no qualifications, experience, or training in the complex surgery which was at issue. Further, this in-network surgeon was not offering the same surgery or heated intraperitoneal chemotherapy as Dr. Sugarbaker. I dug up a newspaper article from 2006, announcing that Dr. In-network had just performed this exciting new treatment on three patients. Guess what I found, when I went looking for them? Obituaries. All three patients had died within six months of their surgeries with Dr. In-Network.
I wrote the appeal over the weekend. Late Sunday night, I faxed and emailed it to all of the top executives of the insurance company. By Tuesday at 11:00 a.m., the insurer had signed a single-case agreement with Dr. Sugarbaker's office.
Brandon had his surgery on Thursday. Dr. Sugarbaker was able to remove all of the cancer, and he is doing very well.
All networks must go
Some of the finest physicians with the very best outcomes have dropped their contracts with insurance companies. The first one to go is always Blue Cross Blue Shield. Why? Because Blue Cross Blue Shield's reimbursement is the most insultingly low, and they have the most paperwork. What good is your network, if the one surgeon who can remove your child's brain tumor is not in it?
I have heard of doctors being fined or reprimanded by the insurance company for referring patients out-of-network. What kind of a system is it that tolerates and protects bad medical care, and denies extraordinary medical care?
It is a system that ignores evidence-based medicine -- while pretending to practice it. A system that has no investment in good outcomes for patients. In what universe is it OK to wait four years to treat a cancer, then to deny the one treatment, then to deny the one treatment that could save his life?
Brandon's story is happening right now, in your town. Today, primary care physicians will be referrring more patients to Dr. Anderson -- because he is the in-network surgeon on their list.
I was referred to an unqualified and inexperienced surgeon six years ago here in Seattle -- because he was contracted with the insurance company. He stopped performing these complex abdominal surgeries in 2008, because he "wasn't happy with his mortality rate." He started doing them again six months later, because there was nobody else in the network to do it. How easily I could have been one of his casualties.
These networks are all about abuse and deception. The only ones who benefit from "networks" are insurance companies. If I had my way, I would forget the 1,000-page healthcare bills, and abolish all networks tomorrow.
Peaceful but passionate Insurance Warrior-ing,
Laurie Todd
health insurance help