THEY THOUGHT THEY COULD GET AWAY WITH IT

In the August 7, 2018 issue of the L.A. Times there appeared the following article by David Lazarus: 

Sorry about your Stage 3 cancer. Here's a bill for $21,000 in charges you thought were covered.

When Michele Brough was diagnosed with Stage 3 breast cancer in April, her oncologist wasted no time in reaching out to her insurer, Anthem Blue Cross and Blue Shield, to obtain pre-approval for a drug that would strengthen her immune system to better withstand chemotherapy.

The good news came shortly afterward. “We are pleased to authorize benefits for the service(s),” Anthem informed Brough, 56, by letter.

The chemo began in mid-May, with each session including an injection of the pre-approved drug Neulasta Onpro to stimulate production of white blood cells and help ward off infection.

It wasn’t until after the second round of treatment that Brough’s oncologist informed her Anthem wasn’t covering the injections, sticking her with the staggering cost of $7,000 for each shot.As if that weren’t devastating enough, Anthem’s reasoning was downright absurd.

Yes, the drug had been pre-approved, but only if Brough bought it herself through the online pharmacy Express Scripts, and only if she gave herself the shots.“It just made no sense,” Darrell Brough, Michele’s husband, told me. “They covered everything else, all the drugs, all the doctor’s visits. But not this?”

There was nothing in Anthem’s approval letter that said anything about buying it exclusively from Express Scripts or handling your own shots.

And even if Indianapolis resident Brough had bought the drug, her husband said the oncologist refused for legal and safety reasons to administer a drug she had acquired herself.

“They wouldn’t administer it because it wasn’t from their own pharmacy,” he said.

I’ve come across some strange insurance denials, often involving treatments that corporate bean counters say are experimental whereas actual medical professionals say otherwise. But Anthem took this up a level.

The company’s behavior seemed inconsiderate to the point of cruelty — at best an act of gross incompetence, at worst sheer meanness.

I mean, who does that, approving part of a cancer patient’s treatment but not the whole thing? And then sticking the patient mid-treatment with thousands of dollars in unexpected costs for some totally bogus reason?

To be sure, insurance companies are entitled to make money for managing people’s healthcare risk. But that doesn’t justify acts and decisions that demonstrate a near-total lack of empathy.

Michele Brough’s Stage 3 cancer is considered an advanced form of the disease, although the American Cancer Society places the five-year survival rate at 72% with appropriate treatment.

Her husband, who handled all the bills and the dealings with the insurer, said no reasonable person would anticipate a patient receiving chemotherapy treatments from doctors and nurses would be personally responsible for administering her own immune-system booster shots.

Moreover, once the chemo has begun, you’re committed. Even though Brough and his wife were $14,000 in the hole after the second session, they weren’t going to stop even when the oncologist made Michele sign a waiver before the third round promising that she’d be responsible for the cost.

Anthem denied that claim as well, placing the Broughs $21,000 in debt.

For the fourth and final round of chemo, the oncologist decided to skip the booster drug, hoping Michele’s immune system was by now strong enough to take the punishment.

I’m not second-guessing a doctor, but it seems to me that any time you forgo an established treatment solely for financial reasons, you’re placing yourself in danger. Happily, Brough said his wife has responded well to the chemo treatments.

But they weren’t in the clear. Brough said he was told by the oncologist that if Anthem wouldn’t cover the $14,000 for the first two shots, he and his wife would be held responsible and the case could be referred to debt collectors.

“It’s crazy,” he told me. “Any way you look at it, it makes no sense.”

Brough, 56, a project engineer for a computer consulting firm, appealed the charges to Anthem. Weeks later, he wasn’t getting anywhere. So he came to me.

Within days of my getting involved, Anthem acknowledged it had screwed up.

“When we were recently made aware of a concern pertaining to an oncology drug used by one of our consumers, our team began working to understand what happened and found the claims were processed incorrectly,” said Leslie Porras, a company spokeswoman.

I asked why it took a call from a reporter to figure that out. Why didn’t Anthem discover the mistake as soon as Brough lodged his appeal?

“Since the member first contacted us, we have been working with all parties involved to coordinate and resolve this matter,” Porras replied.

All appearances to the contrary notwithstanding.

Shortly afterward, Brough told me he’d heard from Anthem. “They are covering the three injections in full,” he said.

That’s great. It goes without saying, however, that no one should have to rely on the press to resolve an insurance matter — especially when the insurance company is at fault.

The Broughs did everything right. They sought pre-approval for coverage. They promptly appealed questionable charges. Yet they still got what they felt was the runaround.

The only other thing I’d advise in a situation like this is to bring in a professional patient advocate, a person who specializes in navigating the twists and turns of the healthcare system, including billing issues.

Many group insurance plans will cover the cost of a patient advocate — ask your employer. Otherwise, the advocate might charge on an hourly basis or receive up to a third of whatever savings can be secured.

You can search for a local advocate on the website of the National Assn. of Healthcare Advocacy Consultants or via the Alliance of Claims Assistance Professionals.

Another piece of advice: Don’t give up.

As the Broughs saw, insurers make mistakes.

They’re just not particularly good at admitting it.

There's something rotten in the state of our health delivery system, and this article typifies it. First of all, for an insurance company to cover a drug only if the patient purchases it from a specified source, and then administers it herself, is cock-eyed.  What -- did they suppose that any hospital would allow a patient to purchase the drug from a  source other than the hospital? No hospital I've ever heard of would allow such a thing.  Even if the medicine was perfectly safe, the hospital needs to issue the medicine itself for the obvious legal and safety reasons, and, incidentally, so it can make its own absurd profit on the transaction. And would they allow anyone but a licensed professional to administer it? Come on! Anthem Insurance might as well have said, "we'll cover it only if it comes in a plaid wrapper." It's a non-starter, absurd. And even if the above were not so, to inform the patient of all this after the fact, would be ludicrous if someone's life weren't at stake.

I'll tell you what I think: After the pre-approval was granted, somebody at Anthem took a second look at the procedure and thought: "$7,000 per shot is a lot of money! Let's deny it and cook up a reason why -- any reason." And this is  why repeated appeals to them failed: They were, after all, Anthem Insurance, one of the biggest in the nation; who was  going to cross-examine them? 

Which bring me to the most rotten thing of all: It took an appeal to the press to set things right -- after all, the L.A. Times is a very big paper, with a very big circulation.  Did Anthem want all that bad publicity? 

Louis Brandeis once said, "Sunlight is said to be the best of disinfectants; electric light the most efficient policeman." To me, this means that if something is wrong, we have to scream to high heaven, and MAKE IT PUBLIC! That's what this blog is trying to do.

Which brings me to a request: If you or someone you know wouldn't mind making known their struggles with our broken healthcare system please let me know. You can email me at indivisible12401@gmail.com. There are more than a few state politicians out there who got Brownie Points for voting for NYHA when they were confident the Republicans would bat it down. But now that Democrats have the Senate, these "wobbly" Democrats are not so confident, and they may come to remember the source of the money -- corporate -- that got them elected.  SO PLEASE  CONTACT ME ABOUT THIS. You'll be doing us all a favor.

Dio

PS: if you'd like to make a comment -- and I hope you will -- simply click on the number of  comments area and share your thoughts in the "comment box" below.