Out of the blue I got a text from a friend who is a nurse and has worked with me at two separate employers, both managed care organizations.
After a few texts back and forth to catch up the conversation rolled around to work.
What can I say except, “It’s a perfect set up?
It’s a perfect set up except there were too many things that made me say hmm…
In the end I could only reply that it wasn’t a good use of my time and talent.
This morning I talked to another friend who brought back memories of why I left -memories of why I couldn’t just be content with my work at home, lots of vacation time, & a great 401K match job.
She shared a situation she was working on about a 77 year old gentleman who was away from home, had a heart attack, and ended up in a small town hospital. He was transferred to a metropolitan facility a couple of hours away and ended up having coronary bypass surgery. Then he gets a bill for close to $10,000 because apparently although the surgeon was in network, the facility he was transferred to was not. So he filed a grievance with the managed care organization and never received a response. He asked my friend to look into it.
Sure enough my friend could see his letter of grievance in the system. When she finally was able to speak to someone in appeals to ask why the man never received a response the initial person was not sure either. After the appeals associate checked with her manager she reported back that the reason he didn’t receive a response was because he was not specific enough in his request about what he wanted the organization to do. So the grievance was filed away and basically never addressed.
There is a 60 day window of opportunity to file a grievance. This time had elapsed.
The gentleman had already paid the bill using a credit card… And his 75 year old wife has went back to work to pay the credit card bill. I’m sure she is able, and it might be good for her to go back to work. The point is that they had health insurance and it’s not supposed to be this way.
So what is wrong with this picture? Lots of things, but let me just say that upon further investigation this renown surgeon was in network, but not one of the hospitals he operates in is in network. Hmm…
Appeals told my friend that the patient could probably have found a different surgeon to operate or gone to a different facility and the surgeon could have operated there.
Okay. In his hospital bed he’s supposed to be shopping for a surgeon and a facility that are both in network to have his heart surgery at?
Well no, the appeals associate suggested, maybe his wife should have been doing that.
Okay. So wife who has been married who knows how many years to this man that she loves is supposed to be on the phone making arrangements for where her husband is going to be transferred to and who’s going to operate?
How in the world does this make sense? Hmm…
Let me just tell you that is doesn’t work like that. The patient isn’t calling the shots from their hospital bed. The doctors are the ones making the decisions.
This happens to be a couple who is lucky enough to be 77 years old and have all their faculties and the ability to do these things had they thought of it, or realized they would need to. Not everyone is that blessed. It’s not remotely realistic to put this on the patient.
How about both the admitting facility who knew they were out of network or the managed care organization who knew full well the facility was out of network speak up at the time and notify the patient or the family of the situation? Don’t they have some accountability?
How reasonable is it that you have a 60 day window following bypass surgery to get your appeal in?
I would think that in those 60 days he and his family were more concerned with the immediate task of getting him on his feet again and recovered.
Another thing that troubles me about this story is areas where there are not very many in network providers to choose from. Then if you do have an in network provider, like in this case, they go to a facility that is not in network. How can this be? Hmm…
My friend’s story reminds me of a similar situation I encountered with a gentleman who had a heart attack, had coronary bypass surgery, was told he couldn’t go home because he lived alone (even though he most likely would have been capable and told the doctor so).
When he arrived home from rehab he had a $10,000 bill sitting on the table waiting for him because apparently his rehab wasn’t paid for because it “wasn’t medically necessary.”
If it wasn’t medically necessary then why wasn’t he allowed to be discharged home? He wasn’t the one who suggested rehab. He wanted to go back to his own home. This was another case of doctors making decisions for a patient without it being made clear to the patient how it will impact him financially. Hmm…
Another credit card bill. Another senior who paid into the system, paid extra for increased coverage, and another senior who’s bills were denied for reasons beyond his control.
I realize that nothing is free in this world and that if you have the misfortune to need cardiac surgery you might have a bill to pay.
However, these are both examples of retirees who think they have done everything right. They’ve worked their lives, paid into Medicare, bought additional coverage beyond basic Medicare only to find out that there are these little loopholes of why they still have a bill.
I have a problem with the notion that when you are in a hospital bed trying to get better that it is your responsibility to be doctor and facility shopping. It shouldn’t be your family’s responsibility either. Neither you, nor your family, is in an emotional place to be doing that.
The lesson to be learned here is that I need to be thoughtful about what positions I’m applying for. I am looking for a position that won’t have as many things that make me go hmm… or at least will offer me an easier pathway to resolving these issues when they arise.
Feature photo by Lotte Meijer