5/3/14 Patient Advocacy Chapter 2

After my hospital adventure with the kidney stone, I return home on Tuesday, April 22, pain medicine in hand, to wait it out until I went to see Uroman, my long-time urologist, on Friday the 25th. He knows me well and is a friend as well as my physician. He has always been helpful, lays out my options, makes his recommendations, then lets me make the final decision. If I am making the wrong one, he advises me of that, too, but then declares that he will support me by whatever means available to him. I’ve had him a long time and think I’ll keep him. He has already looked at the CT scan and the x-ray the hospital took while I was there and is ready to discuss my case.

“It’s a 5mm stone. About an inch down in the ureter. You can probably pass this one, or you can have the lithotripsy if you want to get rid of it,” he said.

Of course, I want to be rid of it, but I’d rather pass it now, not an agonizing later. I don’t have the ability to force the stone to move by my sheer willpower. It will move when it decides to move. “Let’s see if I can pass this one,” I said.

“OK. You’ve got pain meds and can come to the hospital if the pain gets to be more than you can stand. You have my number. Call me if you need me or need to go to the hospital and I’ll have it all set up for you when you get there,” he said.

We shake hands and I head out to his business office, an appointment date for 4/30, and another pain med prescription in hand. His very busy office is very efficient, or has been. That could change sine he and his partner urologist are no longer in private practice, but have sold their clinic to Anderson Regional Medical Center (ARMC) where they have become employees. This is happening more and more as physicians abandon their private practices due to a whole host of economic and regulatory reasons and become employees of much larger organizations. I detest this consolidation. I understand the economies of scale, but in the long run we are going to mourn the loss of private practitioners and the growth of corporate health care, which will turn into monopolies, or where we have cities with only two major players….Hospital A and Hospital B, where they are competitors but only competitors in name…colluders is perhaps a better word than competitors.

Right now, Uroman has admitting privileges at both hospitals in Meridian. Ultimately, he will only have those privileges at one since he works for the one and not the other. His choices for his patient’s health care will be more limited, but the paperwork and record keeping will fall under the umbrella of the larger ARMC entity.

My appointment with him, as I said, is on April 30. Before I go to see him I must go by the hospital for a KUB (an x-ray of my Kidney-Urinary-Bladder area), as both Uroman and I need to know the progress of the stone towards its final destination. The X-ray has been a routine occurrence many times, but this time it was completely different. Let me explain.

I have insurance. I have always had insurance. It was formerly good insurance, then took a turn for the worse by imposing an annual limitation of $100,000, which is a bit shy of what one needs for cancer treatment, or heart surgery, or even a broken leg that requires surgery. I know this from personal experience, because going through chemotherapy I exceeded my annual limitation. If I had had a cancer that also required extensive surgery, I would have had debt that would have been nearly impossible to pay.

Thanks to the ACA, and in this case I do mean thanks, the annual limitation is now abolished as required by the law. This removal of the annual limitation would have happened three years ago except my insurance, through the International Brotherhood of Electrical Workers, managed to get waived from compliance just like a lot of other unions. These waivers expired December 31, 2013. Health and Human Services (HHS) had said that they would not extend the waivers beyond that period, and they stuck to their guns. I did not expect them to, since so many other parts of the ACA have been waived or delayed because of political reasons, but the waivers really did expire. Now, my insurance is good again, at least as long as it lasts, thanks to the ACA. Eventually, though, my plan will be gone and we will all be on the exchanges. I really have a forlorn feeling about that eventuality. Time will tell, and it will tell the truth.

Before my 2:15PM appointment with Uroman, I must go to ARMC for my KUB. This has been a routine experience, but part of the routine experience is that, for some asinine reason completely mysterious to me, ARMC sets up a new account for every visit, no matter how minor. Why they do this is a marvel of inefficiency. At MDAnderson (MDA) in Houston, I am not only known by my name, I am Patient #77XXXX. Some say it feels inhuman to be referred to by a number, but it saves a lot of confusion. While it may be unfair to make any comparison between a world class facility like MDA and a regional medical center like ARMC, the comparison begs to be made just the same.

At MDA, I can log on-line at their patient web portal as #77XXXX, look at all my medical records, look at my bill, look at my insurance status, read pathology and lab reports, read doctor notes and reports, look at my own X-rays and CT scans, review my living will and medical power of attorney, submit new ones if necessary, schedule appointments, all simply because I am #77XXXX. Not so at ARMC. They have accounts listed under J Christopher Sharp, John C. Sharp, John Christopher Sharp, Chris Sharp, Christopher J. Sharp, J. Sharp, J.C. Sharp, and still set up a new one with every visit. I have to give them my ID and insurance card every visit, and am consistently greeted with the question, “Hmmmm! Mr. Sharp, have you ever been here before?”

My standard answer is, “Yes, I have been here before. I was born here. I have had dozens of emergency room visits, well over a hundred stitches at various times, surgeries, x-rays, chemotherapy, lithotripsies, MRIs, bone marrow biopsies, hospital stays, lab work, broken nose repairs, and various and other sundry visits.”

The clerks always look puzzled and then asks me my social security number. Now if they feel that assigning me a patient number is dehumanizing, then why does my social security number seem to trigger a computer recollection? Their immediate response is, “Well, it seems you have been here before.” They say this as if they did not believe me when I told them so. Now, I recognize I am dealing with low level clerks in admissions, which is not to denigrate them at all since this is how they identify themselves if you have any questions outside the norm, or really, anything to say besides, “Good morning.” They are not in a position to answer any questions and always seem reluctant to locate someone who will.

“I am just a clerk, sir,” they say, as if that is an answer that should satisfactorily answer my question. It does not, will not, and will never do so. They continue to enter information.

“What is your address?” they ask me with my ID right in front of them.

“What is your date of birth?” they ask with my ID right in front of them.

“Who is your insurer?” they ask with my insurance card right in front of them.

“Isn’t all that information right in front of you on the screen you pulled up when you asked for my social security number?” I ask.

“Yes, sir. But we have to enter it all over again,” is the standard answer.

“And if I come back tomorrow, we’ll do this all over again?”

“Yes, sir.”

No wonder health care costs so much money. Why is this necessary? The asininity of this awkward system is evident and the wisdom of those who have put it into place has been put under my personal scrutiny and found to be missing in action. Maybe they should print up some of those MIA bracelets. “ARMC Wisdom. MIA for decades,” it might read.

After the admissions process, I am then usually sent back to x-ray, they file my insurance, then they send me a bill for the retail amount, then my insurance makes all the PPO deductions and pays their portion, and a revised bill is sent to me, the balance of which I owe and promptly pay. This time, they have a new policy. I was not prepared for it and its in-your-face bluntness. God bless those clerks who inevitably are taking the brunt of executive policy decisions made by those executives who have never laid eyes on a patient other than to facelessly pass them in the hallways as they go to lunch or important, relentless meetings, and there seem to be lots of lunches and important meetings when one has questions needing answers. When there are not lunches and meetings, there is always the screen of voice-mail which they can hide behind. When there are no difficulties, I’m sure that the executives are all as available as redbugs in a pine thicket.

The clerk tells me, sheepishly, not looking me in the eye, almost fearfully, “Mr. Sharp, the charges for the x-ray are estimated to be a hundred and fifty dollars. Your portion of this is your 20% co-pay, so you will have to pay us thirty dollars up front.”

“Well, this is a new development,” I say. The clerk must have known that I would have some sort of protest. She immediately began explaining it to me.

“Our new policy is that payment is due when services are rendered. You are required to pay your portion of the co-pay and any unmet deductibles before we can do any procedures or admissions,” she explained. “This started January 1.”

“Your estimated charges are not correct. After the PPO deductions, this x-ray will cost about fifty dollars. Twenty percent of fifty dollars is ten dollars,” I reply.

She looks terrified, but I said it very matter-of-factly, not in a raised voice, but as calmly as I could muster. She actually said, “Well, this is my last week here. I am going to work for Dr. ______, so I should just let you go on in without worrying about it. This is all a lot of trouble if you ask me.” She seemed unsure what to do. She pondered for a minute then picked up the phone, asking someone about my PPO discount.

Another, more senior clerk came over and said, “Sir, our insurance department handles that. We are admissions.” That was supposed to get me to shut up. It failed.

“Well, ma’am, you have my insurance card in front of you. You are a Cigna provider. I am a Cigna insured. Get your insurance department on the phone and ask them what the PPO discounted charges will be.”

“Sir,” she protested, “Our policy is that you must pay your co-pay of the estimated charges,” she said.

“And, ma’am,” I replied, “My policy is that I will only owe you and will only pay you the twenty percent of the discounted price. Call your insurance department and find out what it is.”

This generated more phone calls to more clerks in the admissions. No one knew what to do. A third lady joined the free-for-all, which no doubt seemed to them like a battle, but if they thought so, then it is their own fault. I was not being rude, just persistent. There is a difference.

The third lady said, “Mr. Sharp, we do not have the billing code for the procedure, so we cannot find out what the PPO charges are. You will just have to pay the thirty dollars and then insurance will refund you any overpayment.”

“No, ma’am,” I said. “They won’t have to refund me anything. If you have enough of a code to tell me what the estimated retail charge is for a KUB, then you have enough of a code for insurance to find out what the PPO discounted charge will be. Please find out, then I’ll be glad to pay you the twenty percent, which will amount to ten dollars, not thirty dollars. I have had many x-rays done here, and your final PPO discounted price is fifty bucks, not a hundred and fifty. I’ll wait until you call them.”

Sighs and grunts were heard all around. I wasn’t budging and they were required to do something out of the ordinary. I assure you that any patient, any patient, who asks for something out of the ordinary, who will not roll over at the first refusal, is considered to be difficult, and I certainly fit the bill by their definition of difficult. If persistence means difficult, then I am difficult.

“Mr. Sharp,” said the judge as he banged the gavel, “This court finds you guilty of difficult. Sheepless difficult is not a trivial matter. We expect your compliance like water washing over stone. It is the water that eventually wins, Mr. Sharp, not the stone.”

“Your honor, it is a stone that got me here in the first place,” I said.

A loud bang of the gavel and the judge said, “The defendant will refrain from any remarks and rise for the sentence.”

I rose.

“You are hereby sentenced to one 2mm kidney stone per week for the next six months as a fine. The defendant will deliver said stone, properly sized, to the bailiff’s office every Monday morning at 9:00AM. Sentence to being immediately. So orders the court.”

“Bang, bang, bang went the gavel. Dang, dang, dang, defendant said,” I sang to myself but hearing the voice of Judy Garland.

The two senior clerks disappeared, leaving me with the young junior clerk. I made some small talk and asked her if she was married.

“Engaged,” she said, showing me her ring, glad to be talking about anything other than the difficulties I was making for the three clerks, now possibly more if they were talking to others on the phone about me. I laughed to myself as I imagined the names they were using for me among each other as they talked on the phone.

“When’s the big date,” I asked the junior clerk, who was a lot younger than my own daughter.

She sighed a deep sigh. “I don’t know,” she said, “I can’t get him to set one. ‘One day’ he always tells me. I’m beginning to wonder if we will ever actually get married.” She went on to describe all the conditions he had set for their marriage…which included buying a home as a prerequisite. That sounded pretty harsh to me. Whatever happened to rent?

We chatted a while, then her phone rang. She spoke to the person on the other end, received her instructions, then turned to me and smiled. “Mr. Sharp, all the people in insurance are gone to lunch, but our supervisor said that we are to collect $10.87 for your x-ray today. Will that be OK?” she asked with the greatest hope in her voice.

“Sure,” I said, “That is exactly what I asked for since that is what I will owe you. I’m not so certain about the eighty-seven cents, but we won’t quibble about that.”

I handed her a twenty dollar bill. She looked exasperated and asked me, “Do you have a credit card? It would be much easier to put it on a credit card.”

I looked back at her, not exasperated, but not amused, either. “Yes, I have a credit card, but I’m paying in cash.”

Apparently, making change for cash in the admissions department is unusual. The clerk who keeps the cash box was at lunch. No one could make change for me. The young clerk disappeared. She returned about ten minutes later with my change and handed it to me. “OK, Mr. Sharp, you are all set,” and she handed me my x-ray admittance papers.

“I’ll be needing a receipt,” I said and was met with another sigh and look of exasperation. I just would not go away. She made another phone call asking someone how to get to the print receipt screen on her computer. There was much instruction from the other end and much confusion on the receiving end. Finally, she printed out the receipt and handed it to me, requesting that I sign it.

“Miss, that’s not the way a receipt works. I gave you the money. You sign the piece of paper saying you received it from me.”

“But you are supposed to sign it,” she said.

“No, ma’am, you are supposed to sign it,” I persisted.

She thought it over and then signed it, then pointed out a place where I was supposed to sign it, too. The place where I was supposed to sign read as follows: This is an estimate of charges only. Actual charges may be more or less, depending on the services required and any conditions of your health insurance.

Let me applaud ARMC for at least being able to answer one of my pet peeves, which is the medical community’s former complete inability to tell you in advance just what charges you may expect. And let me condemn them for simultaneously telling me that whatever they estimated means absolutely nothing as far as what they actually may charge you. They are free to charge at will. I am free to not like it.

I also wonder how many people paid the thirty bucks that same day. Did the clerks get official authorization for the $10.87, or did they just give up because I was persistent (difficult)? I hope the former, not the latter. If the hospital is going to play this game by these rules, then let them be fully committed. I think it is one of my duties to help them. As it turns out, I am not through helping them…they will see me again before the day is over.

I’m sure they all rolled their eyes when they saw my name for the second time later that same day.

“There he is again,” they likely said. “Who wants him?”

No one likely said a word.

It’s your money and your insurance. You use it like you want to. Don’t settle for the rules and policies set by other people that concern your assets. Everything is negotiable, but you must persist and get to the right person. That person is the either the one that lacks the authority but chooses to violate the policy and ask for forgiveness later, or that person is the one with the actual authority to waive the policy…either way, you got the person who served you, even if they did so while thinking that you are an asshole.

Chapter 3 coming right up.

I know you are breathlessly waiting.

 

 

©2014 Mississippi Chris Sharp

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