I was playing tennis with my friend David on a beautiful San
Diego summer morning when the phone rang. We usually ignore our phones on the
tennis court, but with medical appointments pending and the need to get
treatment scheduled, I decided to stop and take the call. A nurse from our
health plan was calling to tell me the HMO had turned down my request for an
“out of network” second opinion. Instead, they scheduled an appointment with a
surgical oncologist within their own group. Disappointed, I explained that the
surgeon I found for a second opinion was a nationally known expert in the type
of rare cancer the HMO’s own top gastrointestinal cancer surgeon believed I had,
a GIST or gastrointestinal stromal tumor. We had already scheduled an
appointment for the following week with the out of network GIST expert.
Before I go further a disclosure, a confession of sorts. For
some reason being turned down for an appropriate second opinion upset me out of
proportion to the real effect of the denial. Until the HMO informed me it would
not pay for a second opinion outside of its network I had been doing pretty
well. I was managing my emotions and staying focused and positive. The cost of
the second opinion was just under four hundred dollars. We could pay for it if
we had to. But that was not the point.
When I went home and checked on the HMO’s in-network choice
for a second opinion I found out he was, indeed, a board certified oncology
surgeon. But his principal expertise, experience, and practice were in treating
breast and thyroid cancers. So I called the HMO’s nurse back and asked who was
responsible for denying the outside second opinion. I asked if it
would it be possible to speak with that person. She told me it was a physician and
gave me her name. The nurse said she would set up a phone call for me to talk
directly to the person responsible for the denial.
Doctor “no” and I spoke later that week. It was a conference
call that included the doctor herself, and other members of the HMO staff. My
wife, Jan, also joined the call. It became clear quickly that the HMO would not
change its decision. If I wanted a second opinion out of network I’d have to
pay for it. My emotion and indignation grew more intense during this short
phone call. How could they not see the absurdity of referring me to a breast
and thyroid surgeon for a GI tumor? And I asked repeatedly, why didn’t they want me to see a doctor with
expertise in the cancer I likely had? The conversation was going nowhere fast.
My wife wisely suggested we end the call. I was informed I could appeal the
decision but the doctor who turned me down would not change her mind.
I appealed the denial through the HMO’s own system and was
turned down twice. I wrote emails to the CEO of the healthcare organization of
which the HMO is a part. Although gracious in his replies, the CEO would not
intervene. He said it was a clinical decision and that he, who is not a doctor,
did not get involved in clinical matters. I told him I respectfully disagreed;
it was not purely a clinical decision but was also a business decision. In the
end, the HMO did pick up the bill for the second opinion with the doctor who
would wind up taking over my care. But it took an appeal to the California
Department of Managed Health Care to get the HMO to do what it should have done
from the start. Now it was clear, time to change insurance.
To be continued.
My experiences are in many ways different from what others
with cancer endure. This is one patient’s experience, nothing more.
