Managed Health Care

We've always had private health insurance. This is a good thing. I worked in the billing department for five years for a private practice 15 years ago. It's a good thing. I know how insurances and doctors work in order to provide services and treat a patient.

I also know that managed health care is not the way to go! The doctor's are barely paid and the patients are barely taken care of! The one thing we've always done is make sure that we choose the PPO!

Except, that my husband has been out of work since October. You cannot pay a COBRA payment if you don't have an income. (Most people cannot pay a COBRA payment even if they DO have an income!) So, that means we go without insurance. Except…and I don't say this to share our personal finances, but to inform the public of what really happens..anyway….

We make so little money that we actually qualify for medicaid. Not only for our children, but for us, too. That said, it seemed silly not to seek medical help in an area of mine that needs attention. And so starts the merry-go-round.

You see, not many doctors take full medicaid, but there are some pretty good doctors out there who do. I was afraid of medicaid, but at least I was able to continue seeing my physicians for the most part. I learned that you can't break a tooth, because medicaid won't cover it, but the rest was fairly easy. And so, I went in for a check up.

I'll be honest and state that I had no idea what that would end up as. I went from a mammogram, to another mammogram, to a biopsy that all turned out ok in the end. Except that I wasn't seeking medical treatment for that, it was just supposed to be routine.

And what I was seeking treatment for turned out to be a referral to another specialist, more tests and surgery to correct the problems. No problem.; I was told medicaid considered it important and approved it within days and I would have surgery within the week. It was all set to go when I got the call that I had to have the biopsy, so my surgery was postponed for 10 days while we awaited the results. 

And in that ONE week, I was transferred from full medicaid to HPN HMO; otherwise known as Health Plan of Nevada Managed Care for medicaid.

So, my surgery is set to go after many uncomfortable tests. I get a phone call on Friday from HPN telling me that I've been transferred over to them and I need to pick a primary care physician. Of course, none of my primary care doctors are on their list, so I need to pick a total stranger. Ok.

But wait…I tell her I'm supposed to have surgery next week; what happens now? She responds that since my surgeons are not on their provider list, I have to find a new primary care doctor and make an appointment to see him. Then, I have to get a referral from him to see whatever specialist is on their list (there's one choice…no choice), and then I have to wait for him to get approval and only then can I have my surgery. But, I ask, if medicaid approved it and they are the HMO for medicaid, why do I have to start all over? You just do.

So, refusing to accept that answer, I contact medicaid. See, I'm thinking it doesn't make FINANCIAL sense for them to make me start all over again. I"m thinking that is a waste of the tax payers money; that'd be me, too, right?

The nice lady states that I have been officially transferred over to HPN HMO now and there is nothing that she can do about it. She feels my pain and states that if she could, she would do something. She goes on to state that I was transferred so quickly because I'd had medicaid previously.

Um, nope, I've never had medicaid.

Yes, you  have. And she tells me when I had it.

I explain to her that I didn't have medicaid during that time period, but that my niece had it, but I had custody of her during that time period.

She states that I'm mistaken, because the computer states that I had medicaid so now I have to be under managed health care. (Obviously, the computer is smarter than I am and has a memory and knows what happened better than I do, so there is no argument to be had.)

I call my surgeon and leave a message for them to call me and start the process of looking for a doctor. The only one I can find I don't really care for, but it seems I have no choice. (Which is why I like PPO's) In the meantime, the surgeon's office calls me back and states that they've talked to medicaid and medicaid told them that the surgery is approved, they don't need to make anymore phone calls and I can move forward. She talks to her office manager, it's all set and they send me the paperwork to do my pre-op.

Yesterday afternoon, I get a phone call from the surgeon's office. HPN has contacted them and is refusing to pay for the surgery because they did not get authorization from them first. They tell the doctor to cancel the surgery and call the patient (me) and inform me to go to a doctor on their provider list. They are also calling my other surgeon to cancel.

Ok, I realize I should give up by now, but now it's personal. AND it's the principle of the matter. AND I'm mad. AND, I'm thinking if you want to get things done, once in a while you have to fight for it!

So, I call the HMO and stay on hold for a while. After 20 minutes, I get another urgent call from another matter regarding another family member so I have to hang up. UGH. But, I choose to see it as God looking out for me, because when I call back again, I don't have to wait too long, AND I get someone who actually has some common sense! She states that we've all been misinformed and no, they won't make me start all over and all we need is for my doctor to call such and such number and tell them when my surgery is and that medicaid has approved it and they should approve it no problem. I explain to her that I am supposed to be pre-opping in the morning, so she says call your doctor right now and they'll have it taken care of by the morning.

This morning, I decided I'd better call the HMO and make sure things are moving along. After holding for another 20 minutes, I finally get someone on the phone. She informs me that the doctor has contacted them for approval. I remind them that I need to pre-op today and ask when it will be approved. She states it should be approved by my surgery date. I remind her that I need to pre-op TODAY, so it needs to be approved. She states that my doctor did not ask for STAT approval. I inform her that they did not ask us to request STAT as per my conversation with them yesterday. She then states that they only JUST got the request last night. I explain to her that had we been told correctly FIVE DAYS AGO when we asked we would have submitted sooner. She says to call my doctor and have them call back and request it to be STAT.

I call the doctor and ask them to please call the HMO and request approval STAT so that I can get my pre-op today. She states that the HMO did not tell them this yesterday. I know; I believe you.

3 1/2 hours later, I call back to check the status. This time, I'm on hold for 40 minutes! I finally get through, and the lady on the phone says that it is in STAT status, but that I should have done this earlier. I kindly inform her that if her co-workers knew their jobs, we would have. In addition, she states that they are now asking for more doctor's notes and that the doctor needs to let them know that I need to pre-op today so that it can be approved today. I ask when this was decided. Two hours ago. I ask if the doctor was informed. She states that they should have called. I laugh. Then, I remember my manners and ask her EXACTLY what the doctor needs to do. I get the fax number, the rest of the information, etc and call my doctor.

Two hours later, I call the HMO back to check the status. Remember, I am waiting on them. After a lengthy hold and a not so great conversation, it boils down to this. The authorization department is now stating that
it is NOT in STAT status and the doctor has not contacted them, nor given them any of the doctor's notes. (I know they have.) I ask how could it be in STAT status two hours ago and not now? She says it's not. She also says that I can't talk to her supervisor and I can't talk to the authorization department because she'll get fired. And I can't call back and talk to her and she isn't allowed to give her extension. I explain to her that I know that the doctor has contacted them and given them the information and what is it going to take? She says, "30 days after the doctor sends in his notes." I also explain to her that unfortunately for me, her co-workers can't seem to really know exactly what their job entails or the even the proper procedure for getting things done. I also explain to her that every time I call, I get a different story from a different person and that there seems to be a serious lack of communication at their office. She is nice, but has to hang up now. Ok fine.

So, I call the doctor's office again. And speak to the poor soul who has to deal with them; and me. And she says that she sent everything over when I called the first time. She says that after that, the STAT girl at HPN called her and asked her to fax everything over to her, too. So she did. But, she called the insurance company again, and verified that yes, they do have everything that they need and we need to call back in an hour. And if I have to, I can pre-op tomorrow.

I'm now waiting. Husband wants to know what the problem is and why the lack of communication. The thing is, this really makes me think about managed health care, etc. It's no different than two different specialist stating that my nephew needs special leg braces, but the insurance company doesn't feel it's necessary, so he can't have them.

It's no different than my needing a breast surgeon to perform a biopsy and being told that they can't find any that will accept my insurance.

It's no different than medication being denied because the state won't approve it.

It's no different than when we first applied for medicaid for our children. We had to talk to four different people that day. And EVERY time we went into a different room, we had to start all over again. Why? Because their computers are not connected and the data had to be inputted each time. Seems redundant and ridiculous when they are ALL IN THE SAME OFFICE!

Maybe this is the state's way of saving money. Most people would probably just give up by now. They say that managed health care is good because they'll make sure you get the health care you need. Doesn't seem to be happening in my case. Or my nephew's. The problem is, they want to take the cheapest, easiest way out. And the doctor's aren't standing for it. And the patient's have no choice.

If you want to have real health care, you have to make real money. In this economy, work is a hard thing to come by. But that's another blog for another day.