My good friend and colleague PoliteTenaciousMom (PTM here on in) has a young son with a couple of serious moles/birthmarks. PTM also has a family with a serious history of skin cancer. I guess they're from good, Northern European stock...where they never see the sun. And here somehow they've migrated to California...just a genetic disaster waiting to happen!
Anyway, the doctors agreed that PTM's boy should get these babies taken care of before the age of 10, and he's going in tomorrow for surgery to have them removed. Real surgery with full-on anaesthesia.
Like me PTM is a sole proprietor, mistress of her life and her health insurance, which is through HealthNet PPO. And that PPO is supposed to pay 80% of in-network surgery costs, but only 50% on out-of-network surgery costs. As you can imagine that delta is pretty steep.
The Hospital scheduled her surgery after telling her they got the all-clear from HealthNet, "no additional authorization required."
But as PTM put it, her Spidey-senses started tingling, and she made a phone call of her own...and all was definitely not right with the world in HealthNet land. Find out what she went through to get it squared away in time for her son's surgery to go on tomorrow as planned.
Now why did PTM mistrust the nice hospital representative who told her everything was fine? Because, as she put it, "It's never that easy."
Oh, cynic!
Good thing, though. Because when she called HealthNet they told her, "Um, no, that surgeon's not on our list." And the day of back-to-back phone calls began. Phone calls where different people from the very same company were telling her different things.
Now, I guess the problem (or more kindly, the "issue") is that surgeons can be signed up to a network on their own, or they can be signed up by virtue of sub-contracting through various groups. And all of this tracking is done, apparently, not by name, but by Name and Tax I.D. No. What that means is that they can't look up Dr. H's name and say "yes" or "no." They need a Tax I.D. No.
Before she was done PTM had found three different Tax I.D. Nos. of the various groups with which Dr. H. practiced. And not one was working out to be on the list.
So today, 24 hours before surgery, PTM is calling the hospital again. They still think it's all fine; she's all covered...let's go baby! But as she patiently explains to them...if he's not covered at that 80%, she can't do it with this surgeon. And she can't do it tomorrow. Now she gets the hospital to call HealthNet directly.
And finally they figure it out. Of course the guy should be on the list. In fact, he is on the list for working at UCLA...but not Stanford. In fact, he even was on the list at Stanford until 2001 when apparently some paperwork didn't get properly filed, and he disappeared into the ether.
And there are probably three years worth of patients of this doctor at Stanford who got hit with bills they didn't plan on, but who didn't have the polite tenacity of PTM.
So, it all worked out. Tomorrow PTM's son is getting his surgery.
But if she hadn't asked i the first place, Spidey-senses all a-tingle, she would have been hit with a mosntrous bill.
And if she hadn't pushed and pushed and pushed, albeit ever so politely, when told she wasn't covered, they might never have figured out what was, in the end, a paperwork filing error.
So, more evidence that you must be ever-vigilant. How tiring, huh?
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