Today we tried to find out if Stanley’s CAT scan was authorized and if so, when. Diana, the scheduler from Dr. Gagne’s office, said she was frustrated because she hadn’t heard anything from Oxford yet other than it was under medical review. So I asked her for the referral number and called Oxford to see what was going on. Oxford has always been very good about approving diagnostic tests—in fact, when Stanley was prepping for his first heart valve replacement with the bypass, an MRA was approved and, to this day, we still can’t figure out why one was even ordered since the surgeon didn’t need it and the decision to replace the valve and do the bypass had already been made. MRAs are, from what I’ve been told, are pretty far up there expense-wise.

So I called Oxford and spoke with a customer service rep. She told me that the authorization for the CAT scan had been denied on June 13. I asked her why, and she said she didn’t have that information on her screen. So I asked her who did have that information, and was told the doc’s office did. I said they didn’t, because they would’ve told me already. She then said the authorization dept. had the info, so I asked for the number and was told they don’t talk to patients, only doctors and related medical people, so I could not get the denial reason from them. I asked why not, since I’m the one paying the bills.

I told her that Stanley’s calf clot needed removing and they would’ve done it in the hospital but they decided he was undergoing enough trauma and decided to wait and have him see Dr. Gagne after he was discharged. We followed the treatment plan. And I told her that Stanley couldn’t return to work until it was fixed. I think she picked up on the looming hysteria and said she would call authorization to find out what the story is if I would just hold.

Ten minutes later she told me that the authorization was denied because the medical reviewers needed some more medical information and she mentioned somethng about a doppler, which I assume is some kind of blood flow test but I’m not sure, and neither was the rep. I asked her what we could do about the denial of service, and she said we could submit an appeal, but said the appeal would take about 15 days to get processed. I was dismayed—Stanley has to limp around for at least two or three more weeks? He can’t go back to work with his leg like that.

So I asked her: “If I had to take Stanley back to the emergency room because of the unbearable pain in his calf from just walking, the CAT scan would get done and the clot would get treated right away, wouldn’t it? And Oxford would have to pay for it all plus the ER costs because we’ve already hit our out-of-pocket ceiling, right? So if a CAT scan gets approved in mere minutes in the ER, why does an appeal take more than two weeks? There’s gotta be a way to get it done faster.

She checked for me. (I really do like the Oxford customer service people—even when they claim something is impossible, they always seem to manage fixing things that are broken even if it is impossible. Plus they’re nice on the phone, even with a wife about to lose it.) Turns out there is an expedited appeal, with a two-day turnaround, and they have to notify me within 24 hours if they are not going to hear the appeal. She gave me the instructions for setting it in motion and recommended that I also get Dr. Gagne’s office to fax an expedited appeal.

I called Diana at Dr. Gagne’s office, who said she’d get right on the appeal (I told her about the reason for denial, which she said they were never told about and I believe her—that group has a good reputation for getting things done.) And we wrote the fax up and got that off. It was about 5:30 when we sent it so I don’t imagine we’ll hear anything until Wednesday morning (hopefully not—which would mean they accepted the appeal for review). I expect to know one way or the other by Friday.

Stanley really wanted it taken care of while he was in the hospital, but the docs decreed otherwise. I hope the medical second-guessers at Oxford just authorize the damned test—they don’t cost that much, but a lot more than we can afford to pay ourselves right now since we’re out so much money already. And he needs the problem fixed—it’s not getting any better. And I will take him back to the ER if I see him in the kind of pain he was in on May 22, or even half the pain he was in then. I suspect the denial was the result of the hospital report not being included with Dr. Gagne’s request. I have to remember to fill out the paperwork to get all of Stanley’s medical records.

Today’s dealings took two hours. Dealing with this kind of stuff takes up so much time ... just figuring out who to call and what information you need to have at your fingertips is a challenge.

Posted by .(JavaScript must be enabled to view this email address) on 06/19/07 at 05:11 AM
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