Don’t Ever Get Sick: Insurance company woes

I recently received an explanation of benefits form from my insurance company showing that it would not pay my most recent oncology appointment. They did pay for part of the blood tests the oncologist ordered, but they refused to pay for the other blood tests. I am nearly two years out from my pancreatic cancer diagnosis. I have seen the same in-network oncologist all of the way through my treatment. This is just the latest in a long line of refusals as I have gone through this process of cancer diagnosis, treatment and recovery. It is cruel to treat patients the way I and so many others have been treated. Here is a look at some of the highlights from the past year.

In 2013, I switched doctors because my old primary care doctor was completely unresponsive to my complaints. My new doctor was fabulous and ordered some tests to determine why I was having some symptoms which concerned me. As we learned that I had a pancreatic tumor of some kind that needed to be removed, I started researching pancreatic surgeries. I learned that the mortality and morbidity rate for these surgeries continues to be much higher at hospitals that are considered to be low-volume for these procedures. I determined that study after study has recommended that patients have these surgeries only at high volume hospitals. Kaiser has none of the top PC facilities in my network. I found a highly regarded PC surgeon just one hour away. My primary care doctor did a lot of work seeking approval for me to see this noted surgeon, but my insurance company refused to allow me to go. My primary’s office fought this for a while, but the clock was ticking. My GI doctor said the tumor needed to come out ASAP. I did not have time to fight. I gave up and had surgery locally. In essence, Kaiser was willing to allow me to have surgery with no regard to potential outcome and without regard to the clinical evidence that high volume hospitals are safest for patients.

Prior to my surgery, the GI doctor thought the tumor was pre-malignant. When the tumor came out, part of it was found to be adenocarcinoma. I have always wondered if it was cancer all along or did it just become cancerous while we waited and fought with my insurance company?

Following my surgery, Kaiser would not allow me to go out of network to a pancreatic cancer oncology specialist. I received a message from a Kaiser rep telling me that she was not aware of any PC oncology specialists. There ARE PC specialists in this country. There are a couple of PC specialists an hour from my home, but they would not have been covered. When you go to a PC specialty facility, they give patients access to GI doctors, endocrinologists, and dietitians as part of a team treatment plan. Finally, two years after surgery, I have an appointment with an endocrinologist. I am beyond grateful for it, but wish I had not had to wait this long.

I saw and continue to see the same local oncologist. He ordered a PET scan. That was rejected. My oncologist made a referral to another specialist for an issue that has developed following treatment. That was also rejected.

Shortly after getting home from the hospital, as I was in the middle of a flurry of rejections for my pancreatic cancer treatment, I got a letter from kaiser reminding me that I needed a mammogram and a pap smear. While I agree that those tests are important, I resented the fact that my lady parts seemed to be of more importance to my insurance company than my pancreas, which was currently trying to kill me.

My OB/GYN ordered a breast MRI. That was rejected. It was appealed and rejected again.

Following my abdominal surgery, I developed some back issues. The body tends to become weak after being cut straight down the middle. I started seeing  a physical therapist. Even though I have had visits authorized, Kaiser has rejected payment on every single claim. I have called at least 8 times now, and each time I have been told, “We will pay this.” I have documented these calls along with reference numbers each and every time. Within a week, I get another EOB where payment is refused. If they did not want to pay for Physical Therapy, they should have rejected it out of hand, rather than authorize the visits and then refuse payment each and every time.

Yesterday, I got another PT rejection notice. In the same envelope, I got a notice of the refusal to pay my oncologist and for some of the labs. I called Kaiser again. The rep had no idea why the oncology appointment was rejected. She said there was absolutely no reason for it. Then she saw the list of PT rejections and thought that maybe the oncology appointment was rejected because they were just rejecting ALL of my services.

I have been exceedingly polite, but I have lost all patience with my insurance company. The powers that be demonstrated early on in this journey that they had no regard for actual medical science when I requested a surgeon that was out of network. What this comes down to is greed and a total disregard for patients AND for their doctor’s expertise. When you are dealing with an illness where the survival rate is 6%, there is no margin for error. Patients should be granted the leeway to go to specialized facilities. In fairness, the Kaiser representatives have all been polite and they seem to be doing their best to be helpful. I do not know who or how payments and authorizations are determined, but it seems that the new normal is simply to reject EVERYTHING out of hand.

There is a lot more to this story. I have a stack of rejection forms in a binder that I started back when this journey began in 2013. Kaiser was great when I was healthy. They are fine when all you need is a physical and a flu shot. Heaven help anyone who has them for an insurance company if they actually become seriously ill. When will this madness end? This is part of the gift of cancer. Not only do you have to fight for your life. Apparently you are sentenced to a lifetime of fighting for insurance benefits that you have paid for during the all of those years of good health.

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3 thoughts on “Don’t Ever Get Sick: Insurance company woes

  1. Tonia – we don’t know each other but I stumbled upon your blog somewhere and I’ve been following you. This post infuriated me but I am not surprised – this has become increasingly common. My suggestion is to contact your Congress person. I have known people who have had success this way. Also, see if there is a consumer reporter on a local tv station or it he biggest newspaper in your area. They may be very interested in speaking with you.

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    • Hi Joan- thanks for following me and for your comment today! I am considering my next steps. I never wanted to go public with this stuff, but yesterday was the final straw. It is exhausting to have to keep fighting. It is also cruel that we put people who are fighting a deadly illness in this position. I will keep everyone posted on where this goes.

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