Friday, May 25, 2012

Real Authority vs. Pre-Authorization

Welcome back!  And welcome to the tale of our latest trip on Mr. Toad's Wild Ride.  It's been a humdinger.

As many of you know, late last month the doctors decided my son, K., would need another surgery.  They just could not say when they would be able to do it.  Every week delayed meant a reduced chance that he would be able to recover in time to regain his teaching post in the fall.  

Like most of you, we are not wealthy.  No job for K. means no paycheck, no health care coverage, no ability to make house payments, etc. Bleak prospects.  For K., the kind of surgery necessary would require approximately twelve weeks recovery time, due to the need for "scar tissue maturation" so that he could sit all day while teaching from his wheelchair.  We were running out of time.

Finally he was given two potential surgery dates:  May 21 or June 4. The June date meant he would not be ready to resume work by the beginning of his school year, which is in early August. They said there "might be an opening" on the May 21 schedule, but it wasn't looking good.  June 4 was the likely date.  Not helpful.  

With a May 21 surgery he could, just barely, make the school year start date and he had already been informed that his position was no longer assured, due to his continuing medical leave.
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Praying.  Waiting. Praying. Waiting. Praying. Waiting. ........

On Friday, May 18 at 3:00 p.m. we received a phone call from the surgeon's office that they had an opening on the Monday morning schedule - but oops - they had not yet obtained the required pre-authorization from the insurance company.  

Really?  Seriously?  They had known for over three weeks that he would need this operation.  How was this possible?  

The surgeon's office administrator (P.) asked if K. would call his insurance rep and request an expedited pre-authorization.  Whaaaat?

I worked in healthcare administration for over fifteen years and I had never heard of such a thing.  The patient asking the insurance carrier for his own pre-authorization?  And late on a Friday afternoon for a proposed Monday morning surgery?  Were these people crazy or just plain incompetent?  (Rhetorical question.)

But desperate times call for desperate measures and thus we began working the phones.  Literally, several times K. was on his cell phone while I was on the land line or my cell phone while we spoke with case managers, patient advocates, health care administrators, back to P. at the surgeon's office.  It was a two hour marathon which by necessity ended at 5:00 p.m. as all their offices closed then.  And we still had no pre-authorization.

Some people think that, if you are a Christian you sail on through these things with a plaster-saint smile plastered on your mug.  Dream on folks.  K. was furious with frustration, and I was on the verge of tears at any moment.

At about 7:00 p.m. the OR coordinating nurse from the local hospital called to confirm pre-surgery orders, no food or drink from midnight Sunday, etc.  We were told the OR was reserved and he was on the schedule for Monday morning. We hesitantly mentioned that we did not yet have the pre-authorization for the surgery.

"Oh.  Well, now that is a problem," the OR coordinator said gently.

I wanted to scream, "Ya think!"  But I did not.  Instead we said, "We understand, and we are working on it."

Saturday and Sunday were excruciating.  The hours crawled by while we waited for 8:00 a.m. Monday to arrive, so that we could once again make calls to try to obtain pre-authorization.  My son's usual case manager, a kind woman and experienced R.N. within his insurance company, who would ordinarily have been able to sort this mess out, was on days off and unavailable.  And for a very good reason.  She was out of town attending her son's college graduation from UC Berkley.  
Thus, on the last gasp Friday evening, the unknown case reviewer who could issue the pre-authorization had refused to do so, claiming he had not received the clinical notes from the surgeon's office.  P. at that office had faxed them - twice - so they were either floating out there in the ether, or they were buried under dozens of others in a fax in-tray somewhere.  And at 5:00 p.m. on a Friday, no one was going to go looking for them.  S-w-e-l-l-l......

At 7:59 a.m. on Monday morning we began the next round of phone calls.  Had the faxes miraculously appeared?  No.  Had P. called again, or faxed them again?  Yes.  More calls.

"They won't budge," P. finally told us.  "They now have the clinical notes, but say they have five to seven days to review the case and they plan to take the entire time."  P. had obviously dropped the ball, the insurance guy was ticked-off that he was being rushed and K. was caught in the middle.

At one point, K. said, "If only we could get to someone who has some authority."  I replied, "Son, I know Someone who has real authority."

From 8:00 a.m. until 8:45 we called every one in the chain of authorization we could think of.  One loop hole was that we could go through the emergency room admitting, rather than regular admitting, and technically an emergency admission does not require a pre-authorization.  But it was risky, and if denied the "loop hole" would be on the insurance company's side - they could deny the claim, and we would be ruined with an astronomical bill that was not covered by the insurance.  We were due in admission at 9:00 a.m.  The surgery was scheduled for 10:30.

At 8:50 K. looked at me and said, "Mom, what do we do?  Do we go down there or tell them to cancel it?"

I took a deep breath, gave God the outcome, and said, "Let's just keep going until someone says 'stop.' "

He lives just a mile and a half from the hospital, so we were rolling into admitting at just after 9:00.  We began the paperwork, handed them his photo ID and his insurance card, she pulled up the case on her computer screen and looked at us with a puzzled frown.

"I see you on the surgery schedule for this morning.  But I don't see your pre-authorization in here."

We briefly recounted our dilemma, and said that we had been told that if we admitted through the emergency process rather than through the general admission desk, pre-authorization would be waived.  We realized it was unorthodox but delaying the surgery really did carry the risk of infection to his open wound (he had already had three such infections over the prior months) and other ancillary risks.

Just then, a lady walked up behind the admissions desk, smiled, and leaned down to the woman entering the information on the computer and said, "We got it.  It just came in."

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Someone once told me that when you take a leap of faith, God always catches you.  But he often waits until you are "two inches from going splat."
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We were under great pressure, far beyond our ability to endure, so that we despaired even of life.  Indeed, in our hearts we felt the sentence of death. But this happened that we might not rely on ourselves but on God..."  (II Corinthians 1: 8-9)

Perhaps, you are "two inches from going splat" today.  Maybe you are under great pressure beyond your ability to endure.  If so, please know that God truly does care and He is there to help you.

Even if there is no miracle, there may yet be a wondrous exception to the ordinary rules.  It happens.  Yes, it does.  Until next time, when we continue with "the comeback tale"... your fellow endurance partner, Marsha


    But, I can't wait to hear the rest of the story. I pray Rick is doing well and recouping as hoped.

  2. Wow Marsha.. your stories make me just hold my breath! God said don't stop, you didn't and He came through. But oh boy... a pound of flesh in the process, and a deeper knowledge that He is there.

    What a blessing you 2 are... I am so touched by your day in and day out handling of all these details. "The system" frustrates the best of saints!! :)

  3. I was hanging onto the edge of me seat----wow. The blessings of your faith and persevrance are now being reaped. A real lesson and inspiration fo us all! My goodness- you do run the race that is set before you with endurance, better than anyone I know.

  4. Amazing post!! Praise God.......

  5. Let's hope the surgery has gone well and the stressful situation doesn't hamper his recovery.

    1. The surgery did go well and he is making a good recovery. thanks!

  6. What a great example of moving forward in faith and God supplying your need, Marsha! Life (and insurance companies) can be such a struggle at times!

    1. connie - thanks so much. Yep "life and insurance companies" - yeesh!

  7. Whew! I didn't exhale till the end of the post! My goodness! Your faith was certainly tested and you came out victorious! What an example you are to others. Praying that the surgery went well.
    Sorry for all the exclamation marks...that's what your posts do to me!

    1. Thanks, Pat. I have put in a few days that seemed like they were just one long exclamation point! :)

  8. Once upon a time, when I was a young RN and full of myself, I had a patient who wore me out. She spoke only Polish and was demanding and fussy and incontinent. Around the 4th bed change that shift, with her in the bed and unable to get out and me making it up around her, my teeth were grinding and I spoke unkindly to her but only in my head. That still voice that sometimes is not so still or small came and informed me with the utmost clarity that if I could not make an effort to understand what it might be like to be a sick old lady with watery bowels and no English who was completely at the mercy of others, He was determined to provide me an opportunity to gain that knowledge firsthand. I believed Him. Anna got fresh sheets, a hairdo, a hug and lipstick. I wish the joy and terror of such knowledge on every other health care and related workers especially the one's in your world.