Patients who can’t remedy red tape have laws and advocate groups at their side.
The Orange County Register
Jack Redmond needed an injection of a prostate-cancer drug, so he called his doctor’s office. But no one picked up the phone.
KPC Medical Management, the Anaheim-based doctors group that was treating Redmond’s cancer, had gone belly-up and closed the clinic.
For two weeks, I spent solid days on the telephone, trying to figure out how I was going to get my next shot,” says Redmond, 65.
I’m cussing around the house. My wife thought I was going crazy.”
Redmond’s primary-care doctor could do nothing for him until he got his records from a locked KPC facility in Arcadia. And no one whom Redmond thought to call knew how to track his records down.
With the crumbling of KPC and other groups, thousands of local patients are now adrift in the murky sea of health-care coverage. But new organizations have cropped up to help protect patients and navigate them through the system.
During one of Redmond’s telephone rants, a harried Blue Shield representative gave him the number for one such organization, the California Department of Managed Health Care‘s 24-hour call center. Redmond thought it was a stalling tactic.
It was just another phone number to me. A shot in the dark,” says Redmond, of North Hollywood. I spoke to a lady there, and she said she’d get back to me. I thought, Sure you will.’ But believe it or not, the next day someone called me, and within a few days it was taken care of. I got my shot. It was a week late, but I got it.”
The department’s case managers hadn’t asked anything that Redmond wasn’t asking.
But they’re trained to dispassionately tread bureaucracy, and they get answers.
Also coming to patients’ aid are new state laws:
As of Jan. 1, patients who are denied health care by their HMOs have access to free reviews by medical experts outside their plans.
On denial-of-care letters, health plans are required to print in bold the Department of Managed Health Care‘s hot-line number.
Another law allows people to sue their health plans if they were harmed by the plan’s failure to provide care. To make sure those laws work, the department and other patient-advocate groups keep an eye on HMOs and champion patients’ rights.
The new department was established (six months ago) because situations like KPC were predicted,” says Daniel Zingale, director of the Department of Managed Health Care, which licenses and regulates HMOs.
Sometimes it’s as simple as letting people know they still have insurance, even if their doctors’ group goes bankrupt,” he says.
Medical-group and HMO bankruptcies displaced or disrupted care for 1.7 million Californians in 1999, Zingale says.
The following year, the department opened for business.
So far, the department has issued $275,000 in fines against HMOs, which some patients and physicians say isn’t enough.
The department has also received criticism for not getting more involved with physicians’ groups.
Many patient advocates say medical groups would be less likely to crumble if the department regulated payments between the groups and HMOs.
The medical groups should be fair game to the department because they’re part of the delivery of health care,” says Jamie Court, a spokesman for the Los Angeles-based Foundation for Taxpayer and Consumer Rights.
Zingale says he agrees, and plans to require independent financial audits of medical groups later this year.
AN OUTSIDE VOICE
Advocacy groups don’t advertise, but patients find them. And people like Redmond say they help.
The department’s call center averages 14,000 calls per month. Last year, the Virginia-based Patient Advocate Foundation aided 29,000 people. And the California Consumer Health Care Council says it intervened on behalf of hundreds of struggling patients in 2000.
Not all patient problems are solved, but those that can be are usually resolved within a few days.
It’s amazing how sometimes just getting an outside voice involved makes a huge difference,” says Patient Advocate Foundation case manager Beth Darnley.
I don’t know if it’s that the insurers really don’t want to tarnish their reputation or want something to be made public,” she says, or if an outside, trained individual can ask the right questions.”
The demand for people like Darnley is only going to grow in coming years, says John Metz, chairman of the California Consumer Health Care Council, a patient-advocate group based in Sacramento.
Metz predicts more doctors’ groups will founder and many millions more people will be left without medical help.
There’s no way in the world these doctors’ groups can survive because doctors have an oath to care for patients even when it’s against their own financial interest to do so,” says Metz.
When those doctors’ groups do fold, Metz and others say, they’re ready to help.
You’re supposed to be given what you’re promised,” Metz says. Getting the run-around is not a minor thing at all. It’s often life or death.”
Disruption in care is one of the main reasons former physicians’ group patients call the Department of Managed Health Care, says case manager Jodi Pope.
There were a couple of calls where surgery was scheduled, and the patients were told it was going to be canceled because of the KPC issue,” Pope says. They were still able to have the surgery.”
After the KPC bankruptcy the phone lines at the department and at patient-advocacy groups buzzed with questions about prescription coverage, pending appointments and access to specialists.
People who called advocates learned that a health plan can’t force them to drive long distances to a specialist within the plan if there is a doctor outside the plan who works 15 miles or 30 minutes away from the patient’s home.
Patients have right to continuity of care, the burden is on the health plan to figure out how to provide the continuity of care,” Zingale says. The health-care helpers say they’re happy to lend a hand. But ultimately, Pope says, the best thing people can do is stand up for themselves.
Thomas Clay, 52, is trying. He launched his own defense campaign a half-hour after waking from surgery to remove a lung-cancer tumor that had spread to his brain.
Clay’s surgeons operated under the assumption that the Long Beach oil-refinery machinist had authorization from CIGNA Health Care of California.
Clay says that while in the recovery room, he was told that his insurance company said it hadn’t authorized the surgery and wouldn’t pay for it. He hasn’t called any advocacy groups but has been in constant contact with the insurance company.
We work all our lives, pay out good money for an insurance company,” he says. And then when you need them, you’re suddenly abandoned.”
CIGNA spokesman James Harris says the company is working on reimbursing Clay and covering his expenses.
Our records indicate nothing being denied,” Harris says. Of the bills he’s sent us, we’re in the process of paying. He’s not sent us the other bills.”
Clay, who is slowly regaining the 100 pounds he dropped during treatment, says hospitals and treatment centers still send him bills and tell him that the bills sent to the insurance company have gone unpaid.
I’ll send them the bills again. A big envelope of them that I’ll have to probably put $1.50 postage on,” Clay says.
This time, I guess I’ll mark on there, Pay the damn thing.’ ”