When The phone Rings II
Posted On March 23, 2019
Yesterday was a roller coaster day. My sons cell rang and it was the transplant center. He was back up to a recipient who needed both kidney and pancreas. He would be called if the donors pancreas was not acceptable. That was at about 11:00 am. The wait begins. One possible cloud hung over the whole thing. Our primary Insurance had changed January 1. We went from Aetna to BCBS of Illinois. We had notified the transplant center of the change but our coordinator was not nor was the financial coordinator. We were told that due to the changes in healthcare that the insurance companies have now become very picky about how the handle Transplant. They could even refuse to pay for it if they were not notified beforehand and the medical records sent to them for review. Even then they could deny payment if they found anything that didn’t meet their requirements. This was infuriating and I made it known to the coordinator that he was to be transplanted whether BCBS would pay or not. I said I would make arrangements to meet the financial requirements.
This was so aggravating because we had done everything that was required of us. My Son has waited for four years been transferred from pediatric to adult transplant due to age. He ended up on dialysis 3 days after his 21st birthday and is unable to find employment due to his therapy. He does Home Dialysis at night and is on his cycler for over 8 Hours. Employers look at this time restriction as not acceptable They want a candidate that can close and be back to open When the stores close at 10 – 11 PM and reopen at 6 am it does not give him time to go home do his therapy and double back i n 6 to 7 hours. (Doors may close at 11 PM but Employees don’t get out til 11:30. Doors open at 6 AM which requires employees to be in by 5:45 AM)
The reason for this article is not a political statement. Some of the difficulties are caused by the Laws passed by congress and signed by the 44th President. While I believe in the access to medical care to all, when the government (Federal State or Local) starts trying to control it and make rules so that everyone has Insurance they open the doors to increase costs for all. The regulations were written with loopholes and penalties for not getting insurance yet did nothing to create a free market by allowing insurance companies to sell across all states. Then with thier Government run Healthcare marketplace that all the insurance were eager to see happen until the federal regulations made it impossible for those Big companies to keep a positive bottom line they began to pull out of different states. leaving only one choice which eventually pulled out leaving none.
This also allowed Insurance companies to begin to increase the denial of claims base on the federal regulations and the changes requiring more specific diagnosis codes. (I know this as I have experience in Medical Billing and Coding of emergency Room charts. The billing company was constantly having to make adjustments to the way a coder coded the chart and the documentation required to justify the Diagnosis code. Then the Change from ICD 9 to ICD 10 codes, a regulation by Medicare to make Medicare claims more diagnosis specific. This allowed the commercial insurance companies to follow the more rigid guidelines and make rules to be even more specific than required by CMS (CMS =Medicare) and make requirements to qualify for coverage when there is a change from one insurance company to another. As i said above Our insurance changed jan 1 due to the Company My wife works for Healthcare coverage. Yes we had been through all the insurance company’s required testing to qualify for coverage to pay for a transplant. Three years with Aetna made no difference to BCBS of Illinois the could had denied the coverage of the Transplant because they had not reviewed the chart and decided if it met their requirements.
As it turned out My son did not get the Kidney, but the silver linning is that this was the second call for backup in less than a month. It means that he is getting close to the top of the list where the next time the “PHONE RINGS” it could be for him to be the primary. If you have questions about transplantation or Organ donations please feel free to leave a comment or question and I will gladly supply you with as much information that is available.
If you wish to comment on this article please feel free, I only ask that all comments remain civil and non-politically motivated.