Life Saving Medical Treatment Decided by Your Insurer and Not Your Doctor -- What is it Like to Negotiate for Your Life With Your Health Insurance Carrier?

A patient with the help of family members, one of which is a physician, is fighting with her health care insurer for medical benefits that are normally covered. Because the benefits are associated with a clinical trial that is outside of the system, the coverage is suddenly questionable. Fighting for their family members's life, the family staged a sit-in of support on Tuesday December 16, 2003. This sit-in caught attention of the CEO of the Medical Group when they refused to leave the building well after close of business. He has promised results by mid-day of Dec 17th 2003. The family is not convinced the insurer will do what is necessary. A life altering decision is at the insurer's mercy and stall tactics are being used to avoid providing care. Stalling long enough eliminates treatment options. Family is awaiting an eleventh hour decision and is prepared for round 2 of sit-in tomorrow afternoon December 17, 2003 if necessary.

(PRWEB) December 19, 2003 -- My name is Dr. Valda Crowder and I am a board certified Emergency Medicine physician that has a 46 year old aunt in Los Angeles, CA that was recently diagnosed with a rare form of brain cancer called gliosarcoma. I spoke with my aunt's primary care physician, oncologist and neurosurgeion at Cedar Sinai Medical Center who all admitted that they had never seen a case of gliosarcoma, were unsure of the treatment, recurrence rate, or prognosis. I researched gliosarcoma and found that it had a 6 mos survival and no existing successful therapies. I found several clinical trials for my aunt to consider. That is when the problems with insurance company began to surface.

My aunt was initially told that there were no clinical trials that existed for her disease. In addition,she was told that because she was in an HMO with Blue Cross (BC)/Cedar Sinai Medical Group that she could not go outside of Cedar Sinai Medical Group for any speciality care.

We found a clinical trial at UCLA with a Dr. Cloughesy. Dr. Cloughesy saw my aunt as a personal favor for me in his office since we did not have formal approval from the insurance company. He reviewed her records and determined that she would be an excellent candidate but that she would have to begin clinical therapy by Thurday December 18, 2003. This therapy could possible offer a complete cure as opposed to a 6 mos survival rate

I contacted her primary care physician and her oncologist at Cedar Sinai Group. After reviewing the information both her primary care physician and her oncologist both felt that the treatment for this rare tumor at UCLA was appropriate, medically indicated and not available within her Cedar Sinai Network. Both of her physicians last week requested authorization from her insurance company BC HMO/Cedar Sinai Medical Group for specialty treatment at UCLA citing that this treatment was not available and was potentially life saving.

We contacted Blue Cross HMO who said that Cedar Sinai Medical Group was responsible for authorizing the care. Of course, Cedar Sinai Medical Group said that BC HMO was responsible for authorizing care. On Monday December 15, 2003 we went to Cedar Sinai Medical Group Office (because we could not get anyone on the phone)and spoke with Yolando Grado a Supervisor for Claims Customer Service. She stated that insurer did not have the patients' best interest in mind and that it was really only about the money. She had us speak with Kelley Hart, Director of Utilization/Case Management. She state that she needed the medical record and the clinical protocol and that the process would be expedited given the timelines required for initiation of therapy with the study protocol. At the end of that meeting she promised she would call us the next day.

We immediately made sure that all of the requisite information was e-mailed and faxed to her office. Despite that we received no phone call as promised the next day December 16, 2003. We called her mid day on Decempber 16th. Ms. Hart confirmed that she had received all of the information required and stated that she would call us back at 4p that day. We received no return phone call so we as a family ( 8 people strong including my aunt who had just been released from the hospital 48 hrs previously after undergoing brain surgery)went to the Cedar Sinai Medical Group office with the intent of not leaving until this matter was given some attention and resolved.

We were seated in the conference room and Ms. Grado initially came down. We were told that Ms. Kelly Hart was not available and would not be able to speak with us. Ms. Grado gave us and 800 number for Blue Cross case management and advised us to go home and call that number. We told that we would not go home but that we would call the 800 phone number from the office.

When we called the 800 phone number for BC case management we were told that my aunt's case had not been submitted to their department for review. With that information we asked to speak with Ms. Grado again. When we informed her that the 800 number she had given us was not helpful she just shrugged her shoulders and said that that was all she could do and that we should go home and wait. We again refused to leave the conference room.

By now it was getting late and office staff realized we were actually not leaving. Ms. Kelley Hart then suddenly became available to speak with us. She came in with a peice of paper authorizing a one time visit to Dr. Cloughesy at UCLA for the next day. She could not promise when a final decision would be made. In addition, she again referred to the fact that is was not their decision but instead Blue Cross's decision. And I reminded her that Blue Cross has stated that because she was in a capitated HMO it was the medical group's decision not theirs.

Again we refused to leave the conference room stating that we needed more than just an approval for an initial visit. We needed a timeline for when the decision would be made and an approval for all clinical visits and tests that needed to be obtained while we were waiting for a decision so as not to eliminate this potentially life-saving therapy as a treatment option. The clinical protocol requires treatment to begin within a certain number of days from the time of the brain surgery.

We continued our sit-in and refused to leave the Cedar-Sinai Medical Group Offices. Ms. Hart threatened to call facilities managment and the LAPD to have us forcibly removed. While in the conference room we also contacted Human Resources at Flynt Productions ( my aunt is an accountant for Larry Flynt). The Human Resource Deparment contacted the insurance brokers ( Steve Hudson) who sold them the health insurance product. Mr. Hudson along with a supervisor also contacted the insurer to determine why this treatment was not being authorized.

We waited in the conference room for facilities management or the LAPD to arrive to forcibly remove us. Then a tall older gentlemen came in to the room and asked us what was happening. He was Thomas Gordon the CEO of the Cedar Sinai Health System Medical Network Services. After explaining the situation to him he stated that if we could go home and get a letter from Dr. Cloughessy at UCLA accepting my aunt into the trial and fax it to him tomorrow he would handle the matter and get us an answer within 1 hr. We thought that was very helpful but did not feel that we needed to leave the conference room for this to occur.

We paged Dr. Cloughesy from the conference room during our sit-in and asked him if he could send us a letter as soon as possible. We explained to him that we were in having a sit-in at Cedar Sinai office building and appreciated him expediting this for us. Dr. Coughesy sent a letter to Mr. Gordon within about 15 minutes. Mr. Gordon showed us the letter and provided us with copies. He also stated that because of the late time (by this time it was about 8p) he could not reach the appropriate people. He promised to make all phone calls first thing in the morning and to have an answer Wednesday morning Dec 17th. We promised to be back in the Cedar Sinai Medical Group offices again in the afternoon for round 2 of the sit-ins if the decision was delayed or if authorization was denied.

We are uncertain of what my aunt's outcome will be. However, we know that what we have been experiencing occurs everyday in our health system. Unfortunately, most patients and families do not know their options, are intimidated by the system, and have not clue as to how to fight for care that is rightfully due to them. Often people think that access is denied to those that are uninsured. My aunt has had this same insurance carrier and primary care doctor for over a decade and has never had a major illness. She never knew how vulnerable she was until she actually got sick and need the care the most. We as a family are preparing for another sit-in Wednesday afternon December 18th at Cedar Sinai Medical Group office on 200 N Robertson. We are hoping that it is not necessary. We have enough to deal with as family given the recent news of my aunt's illness. However, until she is actually in the clinical trial we are prepared to sit-in, resist and push anyway we can for her to get the health care she desparately need.

As an emergency medicine physician, I am embarrased at the state of our health care system. The degree of 'passing the buck', 'stalling' and 'avoidance' that is occurring with insurance carriers everyday trying to do anything and everything they can to avoid caring for their patients is disgrace for our community and our values as a country. My family, particularly my aunt, feels strongly that the public needs to be made aware of what is occurring with people's lives everday in this country. Please on her behalf forward this to anyone that is committed to helping us shine a light on the dark side of our health care system. Something must be done to change the way we do provide care and do business in the health care community. Thank you. Valda Crowder, MD, MBA

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