My daughter, 21, otherwise healthy, has recently been diagnosed, via symptoms and blood test, with celiac disease, a serious but not life-threatening condition. To confirm the diagnosis, the gastroenterologist recommended an upper endoscopy. However, before she could have that done, she had to fly to San Francisco to begin a months' training for her new job. We found a specialist in that area who could do the test and asked our daughter's physician to request that the procedure be done there. The reply which follows (all names redacted) is a perfect example, in a non-emergency, of everything that is wrong with the way we deliver and pay for health care.
Dear Ms. O----,
We are writing to share the results of our medical necessity review of a request for coverage of a visit with a nonparticipating specialist (Dr. L----) for you.
Our Physician Review Unit reviewed clinical information received from an appeal letter from member's mother (N----) dated 8/6/09, and the standard request form dated 8/7/09. We received the following information regarding this request: You request coverage for a proposed upper endoscopy for evaluation of presumptive celiac disease. We could not approve coverage of this service because you do not meet the medical necessity criteria required for coverage of a visit with a nonparticipating gastroenterologist. Coverage is denied because the situation is not emergent or urgent, as defined in the Subscriber Certificate, the same service is available in-network, and you are medically able to travel back to the network service area. In lieu of this service, your policy does offer a visit with an in-network gastroenterologist, whom Dr. G---- may designate. Coverage of this service is dependent upon the benefit maximum and your Subscriber Certificate. The criterion used to guide this decision was in your Subscriber Certificate.
[Paragraphs on appeals process omitted]
Sincerely,
J---- S----, MD
Physician Reviewer
...
Blue Cross Blue Shield of Massachusetts
One Enterprise Drive, Quincy, MA 02171-1754
This is a form letter, of course, and I can nitpick some of it: My wife ("member's mother") did not send an appeal letter; she called their office. But there are bigger issues here:
"[T]he situation is not emergent or urgent" is false. The diagnosis is based on the blood test, which is known to have a significant false positive rate. The recommended follow-up procedure is needed to confirm the diagnosis. Without confirmation, my daughter will have to begin a gluten-free diet and stay on it forever. Once you go on such a diet, it becomes impossible to do the follow-up procedure unless you go off the diet and let the symptoms resume. She may indeed be "medically [their italics in the original] able to travel..." but by the time she can arrange that (let alone pay for it) she will have to postpone starting the diet, and continue dealing with the symptoms.
What really boils me, of course, is that Dr. S---- is sitting in his office in Quincy, 15 miles from our home in the western suburbs of Boston, and 3000 miles or so from my daughter in the Bay Area. How can he even pretend to know anything at all about her condition? How can he know whether he is violating the first rule of his medical oath: "First, do no harm"? He admits in the letter that our policy would cover the procedure if we stayed "in-network," then throws the full weight of the "Subscriber Certificate" in the way of dealing with the fact (no guesswork here) that the network stops about 2900 miles short of where my daughter is.
In addition, how much overhead was involved in my wife calling Dr. G---- (my daughter's primary care physician), then calling Blue Cross Blue Shield of Massachusetts and going through voice mail purgatory for an hour before finally talking to someone, then that office passing some information on to Dr. S----, who twiddled his thumbs for a while before churning out this form rejection? Could all of that just have paid the extra cost of Dr. L---- in the first place?
I guess I should be thankful that, at worst, my daughter will have to give up pasta, which has been the staple of her diet for only, oh, twenty years. But I keep wondering, what coverage did she really have during her four years in college? How much did my son have before her? Had this arisen while she was there, would Dr. S---- have smugly said that there was no medical reason she couldn't just drop everything and come home for services? What was I paying premiums for, anyway? It's not as if I had a choice--I work for a small company that only offers one health plan.