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the statement is NOT true in ALL cases

Posted By: Carole Ward meta_seperate Date Posted: April 16th, 2010 meta_seperate Category:

I have Chronic Kidney Disease, I have insurance, my nephrologist wishes me to have a premeptive kidney transplant. She gave me BJC’s number as well as SLU. I called both, received packets from both, but, as BJC is “number 1,” I chose you…had my paperwork sent in, received call from the transplant coordinator, Susan……ONLY to be called by the insurance person to inform me that BJC doesn’t “work” with my insurance and maybe I need to seek out SLU…my heart is hurting as money is the issue! And you “make medicine BETTER??????? But you refuse clients based on monetary gain..WOW!


6 Comments


Comment By: Rebekah meta_seperate Date & Time: April 16, 2010 at 12:16 pm

That's awful news! I don't know if it's like this for a lot of insurers, but any time my insurance hasn't wanted to cover this or that service, they say it's because they don't work with that particular doctor, not because they don't work with a whole company across the board. Like there are some Wash U docs who work with my insurance and some who do not, but both of those docs practice at BJC hospitals. That's what happened with one of my surgeries, anyway.

I hope you can find a great doctor wherever you go, though. All the best for your surgery and recovery.

Comment By: Tiffany Sewell meta_seperate Date & Time: April 16, 2010 at 3:10 pm

It's not about monetary gain – it's about protecting you, the patient.

The Director of BJC Managed Care posted in the past, "we insist on written contracts between BJC and the insurance company that are satisfactory to both parties." A written contract sets "the rules we will be required to follow, such as the process to get approval to provide your care, limits on your coverage, how to submit bills, etc."

A contract also stipulates what the insurance company has to pay for versus what you, the patient, are responsible for. Without a contract, the insurance company could (theoretically) "OK" your surgery, then decide afterwards that they don't want to pay what they originally agreed to – leaving you AND the hospital hanging out to dry.

Although the insurance company told you that BJC "won't work" with them, I'm willing to be they wouldn't agree to a contract that protects all parties.

Comment By: Carole Ward meta_seperate Date & Time: April 21, 2010 at 1:58 pm

and of course, you would say that! You are protecting your employer, and that is fine! I am not angry, only sad, that your statement simply does not ring true in ALL cases….therefore, same should be changed to reflect that in some cases, you do not work with some insurance agencies as they refuse to sign contracts that (as you say) would help protect me. And the company did not say anything to me, it was BJC that told me, they did not "work" with my insurance and maybe I should try SLU…and that is a direct quote.

Comment By: Rebekah meta_seperate Date & Time: April 21, 2010 at 2:13 pm

Carole, I'm sorry, I'm confused… in your original post you said the insurance company said they do not work with BJC. And in the comment you just posted, you said it was BJC who said they do not work with your insurance company.

In any case, a lot of the decisions about who will work with whom come down from the doctors who provide the care, not from the hospitals where the care is provided. I've had to change doctors before because my old Wash U doc suddenly didn't like working with my insurance company anymore, for whatever reason. And I was able to transfer my care to a different Wash U doc whose practice accepted my insurance. Both doctors performed surgeries at BJC hospitals… and it seemed like as long as my insurance was okay with the doctor doing the surgery, it was okay with BJC.

Have you spoken with any of the physicians' offices directly? They might be able to provide some clarification as to why this is happening. I've never gotten the best answers on things like this when I talk to the insurers.

Comment By: Jason Vander Weele meta_seperate Date & Time: April 22, 2010 at 11:11 am

Carole,

I'm sorry to hear that you've had these problems. I understand what you are saying, and I think I'd probably feel the same way if I were in your position. You just want to get better, and there are hoops you're having to jump through to achieve wellness.

I think the problem is not that people don't want to help, we know they do, but that the system that has come to be is a burden on so many. Every interest is in some sort of position, whether it is you trying to find a way to get a transplant, the hospital trying to be sure their costs are covered, or the insurance company trying to satisfy the investors. Everyone in the situation has something to gain, and something to lose.

This is the sort of stuff that shouldn't be political, that should be able to be solved, somehow. I think across the country there are a lot of people working on ways to find solutions to problems like this.

I have no clue how this came to be, but I imagine it probably does have something to do with money. Perhaps the insurance company said they would only pay for 50% of the costs of the transplant, while the hospital said eventually they'll go bankrupt if only 50% of the cost is covered for surgeries like this. Whatever it may be, I'm sure there were understandable reasons, on both sides, as to why they could or couldn't do something.

I hope very much so that you are able to get what you need to be healthy from somewhere. I wish I could tell you where that will be, but I know very little about how things like this work. I wish you the best, Carole.

Comment By: Craig Stevens meta_seperate Date & Time: April 23, 2010 at 9:13 am

Does anyone out there have any creative suggestions for Carole to pursue. Sounds like she needs some help.