Best Intentions?

Since Humana’s latest denial of care, I have been on the phone at least 6 times with various representatives. I think it is more like 10 but I haven’t been keeping such hot logs of late. The first few calls were ostensibly intended to initiate an appeal to their grievances department. I had to go through customer service in order to do this which seemed a little stand-offish since they already know me over in G&A (that’s Grievances and Appeals to you). During three calls over the course of 9 days, a representative took my information down twice and each time said that someone from G&A would call me within 24 hours. Finally, on the 9th day, when I called and found that the rep who had been working with me was out sick I asked to speak to a supervisor. The supervisor took down all of my information again, reviewed the extensive logs of many of my previous calls going back about three months and then said that there were a few other people she wanted to speak with to fully research my case. She promised to call back later that day. Amazingly enough she did. I truth, I was impressed by her candor. She stated that the people I had spoken with had actually not been “building a case” to submit to G&A but were in fact re-presenting my information to the Access to Care Team, the group who had just told me to go all the way back to square one and get a referral from my primary care provider. However, she promised to help me “build a case” so that I could get a definitive answer as to whether my dentist Dr. Reisberg could go ahead with surgery.

The supervisor with whom I spoke struck me as concerned, organized, empathic, and determined. I have no doubt that she will do her best to try to help me. However, in my dealings with Humana I have encountered several people who exuded such quality, and each time I had to wade through a swamp of other folks with more limited powers and levels of motivation in order to get to them. Sometimes these seasoned helpers are able to provide a real service, a breakthrough even, but their aid is always temporary. It comes with an expiration date. The over-arching system which, just as in The Rainmaker seems structured to withhold service, will eventually overwhelm their efforts.

Such is our level of acceptance of the health insurance industry that no one seems particularly surprised by my story. Often, when I tell my tale, I get one-upped by an even worse encounter. When we pick up the phone to call our insurer, we brace for struggle. Just today the Institute of Medicine released a report indicating that the US healthcare system wastes $750 billion (with a B) per year. Sources of waste include inefficient delivery of care ($130 billion) and excess administrative costs ($190  billion). I have often wondered, while listening to muzak playing between call transfers, how much is all of this costing? All of these calls, all of the person-hours devoted to listening to my story over and over again, what is this costing Humana–and me? Though I have kept a record of many of the calls, I have not timed them. And though, if I wanted to, I might be able to estimate the total time spent on the phone and perhaps assign a dollar value, I have no way of knowing how much more time and effort were applied between calls. And, in the end, will it have been worth it to them? Not if I keep at it, I suppose.

I apologize for the rant. More inspiring stuff coming soon.

 

Addendum, a day later: suddenly, after my last barrage of calls I am getting return calls with updates from various levels of customer service. Literally, within a half hour span I got three calls (one from the supervisor, another from a woman working with the supervisor, and a third from the person who referred me back to my primary care physician a week ago) all to update me on their efforts and to reassure me that they should have some sort of answer next week, provided that Dr. Reisberg, whom they have been reaching out to, gets back in touch with them, The empathic supervisor even said that in the (seemingly likely) event that Humana denies this latest request, she would be there to help me to craft my appeal to Grievances. Apparently the part of the company that helps people is often at odds with the part of the company that makes decisions. Sort of like opposing sides of the legal system. While I am very grateful for her assistance, I can’t help but feel like a “perp” getting the good cop-bad cop business: “Don’t let that mean old bully scare you. I’m here to help.” All the while time it ticking by.

It is also quite possible that the reason I am now getting so much attention from Humana is because of you, good readers. When I first spoke with the supervisor, I gave her the link to Counting My Teeth, which is now up to about 3500 hits! Maybe, once again, you are helping to turn the tide. Thanks for your support! Please keep checking in.

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The Sound of Inevitability

So you are thinking that there are two possible reasons that I might have re-opened this blog for business. The first is that my teeth are finally fixed and I am throwing a virtual celebration. The other is that the process is once again in the crapper and I am reaching out to all of you good people to help. There is a third reason: that the situation is so funny, in the way that all good comedy is rooted in tragedy, so perfectly Kafkaesque, that not writing about it seems like a crime. As Captain John Miller put it (or I guess as the writer of Saving Private Ryan put it): “Things have taken a turn for the surreal.” And then the fourth reason is there is nothing like public venting to provide a false sense of vindication, which a fellow needs every once in a while. So the answer is: a combination of the last three reasons, mostly the second, a handful of the third, and a somewhat apologetic dash of the fourth.

I’m not sure exactly where and how to start. A fair bit has happened in the last 14 months, though most of it maddeningly similar to the original nonsense. For those of you who are new this story, or who in the interlude since the preceding post have forgotten the details, which I am sure is near everybody, this blog is largely about my dealings with Humana Health Insurance following a bicycle accident. I took a nasty spill on the Lasalle Street Bridge in downtown Chicago, and metal grating of the roadway made quite a mess of my mouth. To make a long story short (if you want the long story, start here and work your way up), Humana first refused to cover my extensive dental work, then agreed to cover it, and now over a year later, is refusing to cover it once again. Nearly two years have gone by and I am still missing teeth. Are you surprised? Whether or not I ought to be, I must admit that I am. Perhaps because it took so much work, and the invaluable cooperation of so many of you readers to–coerce is such a strong word–prod(?) Humana into reasonableness such that they would actually abide by the terms of their contract with me, I believed that our victory must hold. I guess I had the same unreasonable certainty in my hard-fought dental coverage that Chuck Noland from Cast Away has in his life raft. Apologies for my second Tom Hanks reference. I endured innumerable phone calls, letters, a grievance process, constructed this blog, enlisted the services of The Fixer at the Sun Times before finally getting Humana to agree that, yes, it makes sense to provide medical coverage to the victim of an accident. But getting back to that short story…I think I will start fresh with a new paragraph.

When last we left, Humana had agreed, in writing, to authorize the work of Dr. Reisberg a restorative dentist at the University of Illinois in Chicago. This is the man who was to (hopefully is to) help me get back my smile. However, Humana’s written approval came with a caveat: a 6 month term, after which I would have to reapply for coverage. I found it kind of funny that Humana should put a term of 6 months on putting my face back together after they had essentially denied service for nearly a year, but Dr. Reisberg did not seem discouraged. Extending service beyond the initial coverage window was usually a simple matter. A letter from the provider, in this case him, would suffice. So we got started. After X rays, impressions, and photos, Dr. Reisberg decided that my remaining teeth would need to be straightened before he could drop any implants into my jaw and fill in the gap in my lower teeth. Unfortunately, this would require another specialist, an orthodontist, to take part. I will spare you the details, but you’d better believe there was more fighting through bureaucracy and unnecessary delay involved in getting Humana to agree to this. But eventually Humana did agree, and I got braces and a temporary crown on my broken canine. By this time the 6 month term of service was drawing to a close. I was under the impression that Dr. Reisberg would be writing a letter to extend coverage. A couple of months go by, and I will be the first to admit that it was a bit naive of me to let them go by, and Dr. Reisberg, who has been waiting for the orthodontics to conclude before he could start work again, asks me to contact Humana to see about getting his authorization renewed. This I did. And after speaking with a myriad of people, who seemed to have no idea what I was talking about–apparently getting coverage via a grievance creates a lot of confusion on their end–they agreed, in writing, to extend coverage for my dental work for another six months. But only for the orthodontist. Now in all of my conversations and letters I had asked specifically that Dr. Reisberg be included in the authorization. The majority of work left to be completed would be done by him. When I spoke again with the person on the “Care Access Team” who was responsible for extending the coverage, she told me not to worry about it. Dr Reisberg and my orthodontist work in the same facility and share the same tax ID number. Any claims submitted by Dr. Reisberg would be honored as well. Wise Dr. Reisberg, who has worked with HMOs before, did not believe this. He demanded that before he resumed work Humana must specifically state that authorization for coverage extended to him.

So now I’m sure you can see where this is heading. Dr. Reisberg provided Humana with a formal care plan and they have balked. Essentially, Humana has said: “What?! You want dental implants?! Well, we didn’t know you wanted implants. We never agreed to cover that. If you want implants you are going to have to go back to your primary provider and get a referral.” The way I see it, approving prosthedontic work and then claiming surprise when implants are ordered is sort of like hiring Mike Ditka to give a motivational speech and then objecting to his use of football analogies. Either extreme naiveté or willful ignorance is at play. This is especially true given that the first prosthedontist I met with also proposed dental implants. For those of you who haven’t been following the story from the beginning, or who have and are now confused (which describes me most of the time) it might not be apparent why this is so funny. At this point I feel that I must recap so that the comedy comes through. I will do so in graphical form with the aid of a flow chart. A caveat: I have never used a computer to make a flow chart.

Chronology of obstacles

So that’s it for now. After nearly two years of wrestling with Humana, I am back to square one. Well, not quite at square one. There is clause in my insurance policy which says that if medical treatment following an accident is not completed within two years, Humana does not have to pay. My wife suggested that this is perhaps why Humana has taken their current tack. The last orthodontist I visited with at UIC said something else that I found interesting. He said that it might have been better if I never had health insurance to begin with. Sadly, the same thing had occurred to me more than once.

For the second time, I am filing a grievance with Humana to insist that they allow Dr. Reisberg to go ahead with his care plan. I will probably also re-enlist the help of The Fixer. Other than that, I am open to suggestions. But whatever I do, it will have to be soon. Unless the majority of the rather expensive restorative dentistry is completed by November 23, 2012, I may never be able to re-coup from Humana. The tooth implant process can take up to 6 months. But more than anything, this ridiculous situation has been going on for far too long and I just want it to be over.

Up until this point in my life, I have been fortunate enough to steer clear of this side of private health care reimbursement. Though I work in medicine, I have remained relatively healthy and have been spared the needless frustrations inherent in fighting for care with big insurers. Certainly my struggle with Humana is representative of difficulties a great many people face. When delaying tactics take precedence over addressing health concerns, we are working with a broken system. Perhaps in some small way this blog can help generate discussion on changing the way that health insurers do business. I guess that’s a fifth reason for starting this blog.

So please: share this blog with your friends on Facebook; post a link on Twitter; follow the blog; leave comments and suggestions. The more people this blog reaches, the more likely Humana is to listen. The clock is ticking. Thanks!

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You Did It!!!

I just heard that Humana has agreed to cover my dental work! The woman from the grievance squad who gave me the news referenced the blog, so clearly it had an effect on their decision. How cool is that?! The Fixer was not yet on the job–see previous post. Oddly enough she had a dentist appointment. So it was all you! Thanks again to everyone who has visited this site and increased its influence. I appreciate you more than I can say.

So far Humana has just said that they will cover the work without specifying limitations: implants vs. bridgework vs. ?? Nor have they said what fraction of the work will be reimbursed so the story is not yet over. But this is a great start.

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The Fixer

Thanks to everyone who read and responded to my story. I am overwhelmed by your support. Thanks especially to those who have offered suggestions as to how to proceed. My friend, Gin Kilgore, thought that The Chainlink, a Chicago bicycling community website, might be another good forum to post my story and I have gotten a great response from there as well.

On your advice, I submitted my story to several print media outlets and heard back from one: The Fixer, aka Stephanie Zimmerman at the Chicago Sun Times. She has a regular column where she goes to bat for individuals who have been taken advantage of or have run into roadblocks with big business. Ricky Rosado thought she might be helpful so kudos to you, man! Stephanie will start making calls wielding the leverage of the mighty free press. So cool! I will update you as I learn more.

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What Happened

Not long ago, I had a pretty decent smile. Then on November 23, 2010 I had a bike accident. My wheel slipped through two metal grates on the Lasalle Street Bridge in downtown Chicago. The bike stopped moving in a split second but my face kept flying forward and met the bridge hard. It must have looked a little something like this. It hurt. It hurt a lot. I managed to stumble off of the roadway. There was blood everywhere. Someone called an ambulance and I took a ride to Northwestern Hospital. Moving my tongue through my mouth, it was clear that things weren’t right. In fact, the contents of my mouth had moved around quite a bit. X rays were taken. I had some deep facial lacerations(graphic), three teeth and some jaw knocked out (graphic), and six more teeth jarred loose. Dental residents splinted my loose teeth with wire, my face was sewn up–rather excellently, I might add–and I was sent home. Quite a day.

Where Things Get Confusing

Time passed. I visited the dentists at Northwestern who splinted my teeth, but things weren’t healing up the way they had hoped and after giving the splinted teeth a couple of months to set it was time to start thinking about how to repair the damage. The folks at Northwestern referred me to one of their oral surgeons. He sounded pretty good, but after checking with my primary care provider, I discovered that he wasn’t in my network. Now I figured that this meant that he wasn’t in my Humana HMO network. I had signed up with Humana through my work. However, it turns out that she was referring to my IPA network. When I selected my primary care physicians, I had unwittingly opted into a sort of sub-network called Resurrection Preferred that contracts with Humana to provide all of my care. So in order to see an oral surgeon, I had to start with one of their providers. As it turns out, Resurrection Preferred has only two oral surgeons to select from. So after some back and forth with my primary care doctor, I made an appoint to meet with him. This was the end of January. The oral surgeon entered the exam room with his scrubs on and wearing one of those head-mounted lights like a spelunker. He looked at my mouth, the X rays I had brought with me, then asked, in so many words, what I was doing there. What I needed, he said, was a good restorative dentist to “quarterback” my care. Because of the extensive and complicated nature of my injury, I would likely have “one good shot” at achieving a good result. He recommended a particular dentist who could coordinate all aspects of my care including root canals, bone grafting, and tooth implantation.

So okay. There are no restorative dentists in my IPA network, let alone this particular one. After weeks of lobbying Resurrection Preferred and getting testimony from their oral surgeon, I finally got permission to visit the suggested dentist, thank goodness. I meet with him. He seems fantastic. He comes up with a plan to help put my mouth back together and submits it to the IPA. Negotiations ensue. The IPA offers to pay for a small fraction of his estimate. More back and forth. Then negotiations stop. Humana, the big insurer, steps in. I have heard from Resurrection Preferred that taking over dental claims was Humana’s idea. I have heard just the opposite from representatives at Humana–that Resurrection punted to them after my claim became too costly. Whatever the case, my request for care was suddenly in Humana’s realm and they decided to take a wholly different tact. They denied the dentist’s treatment plan because he was “out of network.”

Out of Network??

To review: when I left the dental team at Northwestern, I went out of my way to way to see an oral surgeon who was in Resurrection’s network. He referred me to a restorative dentist. There are no similar practitioners within the Resurrection network so after much finagling, I am able to see this person that the Resurrection provider recommends. But when Humana takes over, suddenly the network changes. So the expectations about who I am supposed to be consulting with changes. Never mind that months and months have passed and a definite plan has been arrived at. Casts of my teeth have been taken. An endodontist has been consulted who has done testing to see which teeth need root canals; I can no longer be seen by her either. Now that Humana rather than Resurrection is overseeing things, I am expected to change everything midstream. This was May 13.

So fine. I figure I am stuck. If Humana is only going to consider reimbursing someone who is in their network and they actually have providers capable of handling my case, so be it. I will meet with someone on their list. That the dentist who had been working with me up to this point decided to bail, explaining that he had already expended too much time and energy on my case, with little promise of proceeding: this also influenced my thinking. I reach out to the same Humana representative who had told me that my dentist was out of network and ask for a list of in-network providers. She faxes me a list of oral surgeons. After some research on my part, I discover that indeed a few of them do specialize in restorative work. I select one from my alma mater, UIC, who seems to have a good reputation and call to set up an initial consultation. I actually end up speaking with him over the phone, and when he hears I have Humana, he advises me to make absolutely sure that he is considered in network; there have been issues before. So I call Humana back, and again speak with the woman who faxed me the list. She confirms that this doctor is indeed in their network. However, she explains that in cases such as mine, where Humana has taken over from the IPA, typically they will only cover “facility fees.” They will not be covering “professional fees.” But, I ask her, won’t the vast majority of my expenses be professional fees: whatever the dentist charges for the root canals and implants, for instance. Silence on the other end of the line. What should I do if I want to get the professional fees covered? She said that I should speak with Resurrection Preferred, the IPA. At this point, I’m pretty sure I asked her if she was kidding. I may have cried a little bit, too.

Inside Voice

When the dentist I had been working with decided to drop me–and I entirely understand this decision; his staff had put in many hours in phone conversations and emails with Resurrection Preferred with little to show for it–I asked for all of their correspondence with the IPA. A large portion of the dealings were with one person. In her emails, she comes across as both helpful and exasperated with the bureaucracy of her organization. I decide to try to phone her directly rather than just speaking with whatever claims expert is in the office as I had been. She is out of the office and I am directed to her voice-mail. Later that afternoon I get a call back from her. Amazingly, she is on vacation on the west coast but felt that because the way things have turned out and all of the time that had passed that she should respond quickly. She agreed that the current situation is unreasonable and that my best course of action was to lodge a formal appeal of Humana’s denial of coverage. When I mentioned that I was frustrated and considering hiring a lawyer, she intimated that this probably wouldn’t go very well. She strongly suggested that I enlist the help of my human resources representative and try to keep working within the system. Perhaps a bit naively, this is what I have decided to do. In typical cryptic fashion, Humana has sent me a letter stating: “we are currently doing research and and will send a decision letter within the required timeframe” without actually stating what the required timeframe is.

The Mouth

In the meantime, my teeth structurally are just as they were immediately after the accident occurred. Plaque has formed around the wire splint and I have a lot of gingivitis as a result. Most of the remaining front teeth have “died” as a result of the trauma and may or may not be salvageable with root canals. I can’t bite down on anything. The fractured tooth still has an exposed nerve making brushing difficult. I speak with a bit of a lisp and look like an old school hockey player. Though none of this constitutes the end of the world, it is awfully inconvenient. And because the issue is right out in front of me at all times, I get a lot of questions and a lot of comments. I smile less, and I wonder what people are thinking of me as I speak.

Moving Forward

So rather than simply waiting for Humana to make their decision, I thought I would write about what has been going on and to get some input from you out there. Have you been through anything similar? What would you suggest I do? I plan to research the relationships between “major medical” insurers like Humana and the small IPAs that they contract with. How do they typically reach decisions about who covers what? I am also  interested in issues of physical appearance. Have you suffered an injury that left you disfigured, if even in a small way? How did it affect you? What did you learn from it? Finally, I will be exploring my love of urban cycling and my continued obsession despite the sting. For those of you wondering why I do not have a lawsuit pending against the city given that roadway conditions led to my accident, read here and here. I was not in a bike lane meaning that, according to a ludicrous legal precedent, I was a permitted but not intended user of the road.

I would appreciate any and all feedback and will be writing more soon. Thanks!

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