Insurance, even in the medical field, was always something I ignored.  Patients often ask me, “Will this be covered by insurance?”  As a medical student, my reply was simply “I don’t know” and as a resident physician I often had the same response.  I must admit with the advent of electronic medical records (EMR) along with more of a direct hand in patient care I have become more knowledgeable about the subject.[1]  When it came to signing myself up for health insurance, my approach was to ask those in a similar situation what they were doing (i.e. colleagues) and sign up for the same plan.  My wife had a similar approach to me.  Since my colleagues were signing up for the hospital insurance policy, called Sparrow Physician’s Health Network (SPHN for short) I casually signed up for the same policy. This tumor has given me a different perspective on the insurance process.

——————————- The Policy ————————————-

The day I was diagnosed with the tumor was a whirlwind: speaking to my primary care physician (PCP), seeing the neurologist, getting the MRI, and telling my family was a blur.  I do remember getting a phone call from my PCP to see how I was doing and him advising that I meet with the local neurosurgeon first, and then seek a second opinion if I was at all uncomfortable.  At the time I did not think much of the comment mainly because I anticipated I would proceed with the local neurosurgeon, ‘Dr. Smith’[2].  As we found out how rare this tumor was in this location, both my wife and I became more uncomfortable with the encounter with Dr. Smith, along with his expertise in the field[3].  Thus, in addition to some encouragement from family,  we obtained a second opinion from a neurosurgeon at the neighboring University of Michigan.  The neurosurgeon there gave us more time, acknowledged the rarity of the tumor, and despite his significant experience, recommended being seen by a pediatric neurosurgeon (a specialty not offered at Sparrow).  He stated “if it were my son, this is who I would want to do the surgery”. This was because my particular type of tumor and specifically its location were much more common in the pediatric population.  After seeing the pediatric neurosurgeon, and doing some background research on him, we felt more comfortable and scheduled a surgery with him – actually it was a no-brainer decision.

page 1/2 of the summary from my visit with 'Dr. Smith'
page 1/2 of the summary from my visit with ‘Dr. Smith’


page 2/2
page 2/2

The topic of payment came up only once prior to my surgery.   When we decided to get the second opinion from University of Michigan (called U of M here) my wife called the insurance company to clarify.  They stated treatment at U of M would be considered  “out of network” and we would be responsible for $5,500 deductible.   From what I read, even if a local surgeon could competently perform the surgery, if the patient decided to go to the University of Michigan, SPHN would cover all treatments that were deemed “reasonable” after meeting the deductible.  However, according to their policy, if the surgery was out of the scope of the hospital’s competency, they would indeed cover 100% of the procedure.  My thinking at the time was that because this is brain surgery I should go with the most qualified, and at the worst, my insurance company would cover approximately 80% of the surgery.  I did not have the luxury of time to sit and ponder my options. 

Now, with time to think about the process before and after the surgery I became more and more convinced that my insurance should cover 100% of the procedure.  This thought wasn’t because it would be easier on my wallet, it was the principle of the situation: by only covering part of the procedure, SPHN is making the statement that this procedure can be done locally.  If this is not true,[4] then it is possible that in the future, someone who suffers from a similar tumor might be swayed to have the surgery done locally and thus put his or her life at risk in the hands of an inexperienced surgeon.  Because of this thought I put in several appeals to SPHN to cover my surgery.

——————————— Meeting ————————————-

After several appeal attempts with my insurance, I was asked to attend an internal hearing regarding my case.  Their headquarters is located in the heart of Lansing in an inconspicuous building next to the hospital.  After arriving, I was warmly greeted by their receptionist who instructed me to wait.  After being called forth, I entered the room in which I would plead my case.  The room was a small one, just large enough to fit a round table with seven chairs around it.  Somehow even though it was a round table there were five people (those that would be assessing my case) all sitting on one end of the table.  My wife and I would sit facing these five people.  Thinking back, the setting and everything from the waiting room to the layout of the hearing room, was designed for intimidation, as this was a room designated to hearing appeals such as mine.[6]  Being in contact with several of the physicians in Sparrow, and having rotated through the neuro intensive care unit, to our best knowledge Dr. Smith had not performed any posterior fossa surgeries in the recent past and that he may in fact be falsely credentialed.  We made this clear in the hearing, and in fact requested they produce the number of posterior fossa craniotomies this surgeon had performed.  However our concern fell on deaf ears.  We were repeatedly reminded that this surgery could be performed locally, we were informed of such by writing, and that for this reason our appeal was denied.  I remember being extremely nervous for the hearing, suffering from a particularly bad episode of titubation and having to rely on my wife to retell our story.

About a week later I received a letter in the mail telling me that my appeal had been denied.

page 1/2 from an SPHN letter
page 1/2 from an SPHN letter
page 2/2
page 2/2

—————– The Bottom Line ——————–

 My thought is that the bottom line for all insurance companies is money.  I think that this is the case for most, if not all, companies.  The main question that comes to their mind is: does this make me money?  I do not blame them for such thinking; the CEO of Blue Cross Blue Shield is not thinking the he or she wants to help people with their medical needs, they’re thinking how do I make the most money possible?[7]  If I were in their shoes I cannot say I’d make a different call but in my eyes if this bottom line interferes or somehow has a detrimental effect on life then this is when the issue of money should become moot.[8]

In my experience not all the insurance issues have been negative ones. While still sustaining a large hospital bill, the majority of my surgery and stay at the University of Michigan was covered by insurance.[9] Once I transferred to Sparrow Hospital, all of my costs were covered.  Without SPHN I would not have been able to receive the outpatient therapy that I did.  To me health insurance provides some security in case bad luck were to strike.  And for the most part it is great for the community, providing people with the services they otherwise could not have.  But there are certain cases in which the security they provide needs to be questioned—unfortunately, in my case, the cracks in their foundation were revealed and these questions need to be asked.

[1] The EMR will often tell me, before I prescribe a medication, if it is indeed covered by insurance.

[2] I have changed his name to protect his identity.

[3] If you remember from an earlier post, when we asked Dr. Smith about the recovery process, he intimated that I might be in the Neuro ICU for a ‘few days’ (true) at which point I’d be transferred to a general medical floor (also true).  Then I would be discharged home (untrue).  He then predicted that I’d be back to work in 2 weeks (it is now over 15 months after the surgery and I have still yet to return to work).

[4] My wife and I have made several attempts to ascertain Dr. Smith’s operating room experience, including his expertise in the field of posterior fossa tumors but have been met with an incredible amount of resistance with no records to show for our efforts.

[6] Surprisingly, my chair was level with theirs as a classic intimidation technique is to have the attender’s chair lower than the person running the meeting, this can be subtle or even unnoticeable. 

[7]Of course, like with everything else there are exceptions to this rule: Steve Jobs and Bill Gates simply wanted to make computing accessible, the money that followed was a byproduct of this desire.

[8]for example in my case– if someone else were in my situation and was told that they should go to their surgeon, with him/her performing many of these operations I would hope this would be the truth.  Unfortunately it seems that in my case, ‘Dr. Smith’ was not truly qualified for this sort of operation and should not have been ‘suggested’ for the operation).

[9] The total bill (including anesthesia, surgery, consultations, and hospital stay) was over $100,000.

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