The Plot Thickens
I went to Westchester with Ana and Jim today on the off chance that Dr. Rosencranz (the pediatric hepatologist) would show up at the infusion center to speak with us. I really wasn’t sure what he’d have to say that could persuade me to put the brakes on our plans to switch Ana to the care of Dr. Kato and his liver team at Columbia.
Right before we left, I got a call from the transplant finance coordinator at Westchester. She was the person I spoke with originally who encouraged me to switch to MVP (another insurance company) because emergency Medicaid would likely not pay for the transplant if CDPHP didn’t approve it. There’s a long back story of misinformation and confusion on both our parts (mine and the coordinator”s), but I just want to summarize a few key points she made on this call:
1) The reason emergency Medicaid won’t cover the transplant is that CDPHP approved it as being medically necessary and will cover it – even though that means we’d need to transfer Ana to a different hospital. Medicaid only kicks in when insurance won’t pay, but that’s not the case here. So, if CDPHP had denied the transplant outright, THAT’s when Medicaid would kick in. We still may be entitled to some benefits from Medicaid (e.g., covering certain medications) so the hospital is trying to expedite this process for us.
2) The transplant team has repeatedly tried to appeal this denial at CDPHP to no avail (I didn’t realize they also contacted CDPHP to appeal – I thought the appeals had only come from me).
3) In Tara’s experience, insurance companies NEVER deny appeals for procedures like liver transplants in children. This is very rare and she seemed at a loss as to what to do next (another reason she’d agreed with me that we should transfer Ana to Columbia).
So, I went off to Westchester with this bit of info in my brain, fully expecting to say farewell to Dr. Rosencranz if he did, indeed, show up at the infusion center (the infusion center is not part of the hospital, it’s in a building down the street). This would’ve meant he showed up on his own time – after hours and outside his office.
Well, Jim and I were in for a big surprise. About 20 minutes after we got to the infusion center, Dr. Rosencranz and Dr. Wu (the transplant surgeon) showed up to meet us there! Dr. Wu had come straight from surgery and he’d been up through the night preparing an organ for transplant. He did not look tired. He looked relaxed. Both doctors earnestly spoke with us about trying to get us to stay at Westchester. Dr. Wu was utterly sincere – he wanted to take care of Ana and that includes post-transplant.
I communicated what Tara told me about the repeated denials and that basically I had no confidence that CDPHP would reverse their decision due to the “center of exellence” bullshit they keep throwing at us. At this point Dr. Hochberg had joined us and she said that insurance companies ALWAYS say this and they ALWAYS get an exception. So I said, “well, Tara told me that this denial is something she’s never experienced before with a child as sick as Ana.”
So all the doctors looked at each other and Dr. Rosencranz said – I am on this now, believe me. Dr. Wu then said he’d already tried to call the Medical Director at CDPHP personally today, right after he finished his surgery, but the guy wasn’t there! Dr. Rosencranz said (very confidently) that he would have this cleared up within the next day or two.
So I said, “Okay, this is on you. But Ana will likely meet with Dr. Kato on Monday and begin the transplant screening process and I do not plan on canceling that appointment unless I hear that you have convinced this medical director to change his mind.”
In case you want to know the guy at CDPHP who is putting us through this, his name is…well…we’ll call him Mr. X. According to his bio, Mr. X is a career healthcare administrator/management drone. This basically means he’s held executive positions at various hospitals, healthcare centers and insurance companies, including a lonnnng history at Kaiser Permanente. Based on his bio (which boasts an M.B.A. in Healthcare Management), he’s never actually seen a patient even though he’s board certified in Family Practice. This naturally makes him completely qualified to make the final decision about what surgeon will save Ana’s life.