Don’t Fall Down

This is the last installment in what has turned out to be a series of articles detailing my experiences as an employee in a right-to-work state. I didn’t write these stories to complain or to get sympathy – although at this point, I wouldn’t turn down any kind of sympathy. This has been a tough time in my life, and I hope that my story will serve as an illustration of the extreme imbalance in employer-employee relationships. As in the title of my last piece, the game is rigged, and the house always wins.

Like a good liberal, I went to see Michael Moore’s film “Sicko” on opening night. A whole lot of that film resonated with me; I had a benign brain tumor in 2004, so the story of the woman who died of brain cancer after being repeatedly jerked around by an HMO made me cry. It also scared the crap out of me, and made me even more grateful that my brain tumor was a very small meningioma, rather than something more deadly.

Image: iStockPhoto

Like a large number of people, my health care has been provided by an HMO for almost two decades. I’ve never been able to afford the premiums for the PPO coverage since, for most of my working life, I have been paid less than $50,000 per year. At my last job, the premium that I paid for my HMO coverage was around $170 per month, about $88 per bi-weekly paycheck. The premium I would have had to pay for a PPO was double that, so I remained covered by an HMO, PacifiCare, through their parent company, United HealthCare.

Once you’re a member of an HMO, it is up to your medical group, in my case Regal Medical Group, to determine what care you should be provided. Of course, there is the standard operating procedure of the visit to your PTP (Primary Treating Physician), who then can either treat you or refer you to a specialist – that is, if your medical group approves. In theory, this is reasonable; but in practice, it adds up to delay after delay in receiving treatment. Most doctors who are contracted with HMOs have brutal caseloads, because it’s a fact of life for HMO doctors that in order to make a living treating HMO patients, it’s a numbers game, you know, quantity over quality, as the contracted rates the doctors are paid are often far lower than rates paid by cash-only patients or PPO patients.  The same applies with getting referrals to specialists; again, their practices often involve a huge volume of patients, so getting an appointment can often take as many as three to four weeks.

I never thought I’d have my own Sicko story to tell, but I do. In December, 2010, I noticed that my left ankle was swollen and painful. It was also wobbly and unsteady. I don’t remember any particular incident where I might have injured it; but it was swollen to the size of a softball. I called my PTP, and was told that the first available appointment was three weeks away. I had only two other options: to go to the doctor’s office, sit and wait for an opening or no-show, or to go to urgent care. I chose to go to urgent care, because I could go after work (rather than taking the entire afternoon off).

I went to one of the local urgent care facilities contracted to Regal Medical Group, where I had my ankle X-rayed and was seen by a doctor, who provided me with an Ace bandage and told me that he could not read my X-rays and that I would have to have them read by a radiologist. This took three days, so after three days, I went back to the urgent care and picked up my X-rays along with the report.

Since the radiologist could not find any bone injury, I was back at square one.

I called my PTP and made an appointment – three weeks away. In the meantime, I decided that I was fortunate that I live in California where it doesn’t snow – since I could not wear any type of closed shoes over my swollen ankle and foot, which was made even larger by the swathe of Ace bandage. I wore open Birkenstock sandals all through the rainy months of December, January and February while waiting for the appointment with my PTP, waiting a week for my referral to an orthopedist (a doctor who treats injuries to the musculo-skeletal system), waiting another three weeks for that appointment, waiting another week for approval for an MRI, and then, finally, waiting a further two weeks for my MRI appointment.

I finally had my MRI the last week of February, 2011, where it was determined that I had small tears in my talofibular ligament (the lower of two sets of ligaments on the outside of the ankle connecting the foot to the ankle joint and leg bones) and the peroneus brevis tendon, which stabilizes the ankle on the outside, along with a small cyst in the joint space.  The orthopedist prescribed physical therapy.

I waited another two weeks for my referral for physical therapy treatment, where I was allowed four sessions. After that, my physical therapist requested more sessions. After a week, I received authorization for two more sessions. Again, after those sessions, my PT requested more sessions. This time, I got a delay letter, in which Regal told me that they did not have enough information to determine medical necessity, thus authorization for more treatment was delayed until a determination could be made. This time, I had to wait approximately four weeks before six more sessions were authorized. Again, after those sessions were done, my PT requested more. Again, delays.

This scenario repeated itself approximately four times throughout the summer and fall. Whatever benefit I received from the physical therapy was, unfortunately, lost in the weeks between treatments.

In May, 2011, I first wrote to United Healthcare to complain about the numerous delays Regal Medical Group had imposed upon me with regard to getting treatment for my ankle. I received a letter from “Quality Assurance” representative, Lucy, who advised me that a case had been opened on my behalf.  I also called Regal directly and was assured that there would be no more delays.

Nothing changed. I did request a referral to a different orthopedist, and saw him for the first time in August, 2011. I continued with physical therapy, which continued to be interrupted with delays by Regal.

In September, I wrote to United Healthcare a third time, once again complaining about the delays in my treatment and requesting a formal arbitration. I received no answer.

Finally, in January, 2012, I went to see my new ortho, who told me that my ankle condition could now be considered “chronic,” and that the only remaining option was surgery. In early February, I wrote another letter to Lucy at United Healthcare, and enclosed the letter I had written in September, 2011. I received no answer. I followed up with a phone call on February 21, 2012 to United Healthcare, where I spoke to Linda in the Quality Assurance department.

Linda informed me that my case had been closed. What? I had not closed my case, nor had I received any sort of satisfactory answer – or any answer at all – from United Healthcare. And yet, my case was considered closed, which is why I had received no answer to my letters. She also told me that I would need to open a new case.

Drowning in red tape image via 123rf

A few days later, I received three form letters in the mail from United Healthcare, informing me that yes, United Healthcare took my complaints very seriously and that yes, they were handling it and no, they couldn’t tell me what (if any) the outcome of my complaint. Very useful information, right?

As Linda had told me that I would have to open a new case, on February 23rd, I wrote another letter detailing the circumstances and once again, enclosed the previous letters and emails I had sent to both United Healthcare and to Regal Medical Group. I told them that I was angry about the incredible bungling and delays to which I had been subjected by Regal, and that because of those delays, my sole remaining option was surgery. I requested a referral without delay to an orthopedic surgeon who specialized in ankles.

I received my first referral a week later – to a foot surgeon, who informed me that he did not treat ankle injuries. I called Linda at United Healthcare and informed her that I had (once again) received an incorrect referral, and she promised to straighten it out. I received another referral from Regal, this time to a podiatrist – a foot doctor who did not perform surgery at all. Another call. Another referral – to a different podiatrist.

On March 1, 2012, I was fired from my job for using company property for personal use. The specific “personal use” cited as the reasons for my firing were my personal phone calls (to United Healthcare and Regal) and my use of the fax machine to send letters to United Healthcare.

Aside from the trauma of being fired from my job, this added an extra layer of urgency to the effort of getting the proper care for my ankle. I thought I was going to have to try to arrange to have surgery within the 30 days of coverage I had left on my insurance policy. I waited a week for another referral, this time to an orthopedic ankle surgeon – in Riverside, California, a town located approximately 100 miles from my home. I made another call to United Healthcare, and arranged a referral to a local ankle surgeon, a Dr. F.

I called to make an appointment, and was told that Dr. F was out of the office until April. I placed another call to Lucy at United Healthcare. She called me back two days later with a referral to a Dr. A in Simi Valley, 35 miles from my home. I was able to make an appointment to see Dr. A for Monday, March 19th. Lucy requested that I call her after my appointment with Dr. A to let her know how it went.

This doctor was a breath of fresh air – a young doctor who actually knew his stuff. He took X-rays of my ankle while I stood on it, which showed far more detail than a non-weight-bearing X-ray. He looked at my feet, and told me that because of my extremely high arches, I was especially prone to repetitive strain injuries to my ligaments and tendons and microfractures to my bones due to the extra stress placed on my feet and ankle joints caused by the high arches. He told me that surgery could be performed, but really wasn’t indicated at my age. He was no-nonsense, and gave me a cortisone shot in my ankle, which has helped with the pain.

He also warned me that my bone density was not good, and that I should be given a prescription for a drug called Fosamax, which increases bone density in post-menopausal women, and sent me on my way.

When I got home, I called Lucy at United Healthcare and told her what Dr. A had said. She told me that Fosamax was not in their formulary (which is HMO-speak for “not covered”) and she asked me if there was anything else she could help me with, because she was going to close my case.

I told her that yes, there was something she could help me with – she could help me get the proper treatment that I deserved after the 15 months of delays, errors, bungling and incompetence. She told me that no, she couldn’t help me, because after all, my insurance coverage would be cut off as of March 31, 2012.

In despair, I asked her, “I’m worried about my bone density – I’m afraid that I’ll fracture a hip or something – what am I going to do?”

Her answer was worthy of any of the moments in Michael Moore’s “Sicko”:

“Don’t fall down.”


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