Perserverance Pays Off

Back in May when I was the unwitting victim of some handbag mischief, the folks at the ER told me that while my finger was indeed broken that my knee would be fine in a few days. So it had been nearly a few months and my knee was still not fine. I was fairly happy to "wait and see" as long as it was getting progressively better, but in late July it seemed to be as good as it was going to get on its own.  I opted for medical intervention. 

Of course, being on a Medicare Advantage HMO, one of the big advantages is that I do not have to make the decision to see a specialist on my own. I guess my mental capabilities must be diminished, so my primary care physician gets to decide whether or not I should see a specialist. I'm okay with that, even though I consider it an unnecessary step put in by the insurance company to make sure that treatment of the actual problem is delayed and to ensure that the folks who work in my doctor's office have plenty to do. The economy must be dependent on this extra step. 

It's not a problem. Of course the doctor initially referred me to someone who was "out of network" but it was relatively easy to find a doctor who was "in network." We had that sorted and an orthopedic specialist was seen in a matter of days. The real trouble started when he ordered an MRI. Of course he sent the order to an imaging center that was out of network. When they called to schedule my appointment they were very quick to tell me how much the MRI would cost since they were not in network. I'm glad they did because I'd have been really unhappy if I'd been hit with a $400 charge when I'm only supposed to pay 20% of the total. Needless to say, I declined the appointment and went to Aetna's website to find an "in-network" imaging facility. I found that the closest "in-network" provider was over an hour away from me. It's not like I live in the middle of nowhere, but there wasn't one single provider listed in my county (unless you count the places that do mammograms). Not even one. 

This must be a mistake. Perhaps Aetna's website needed updating. I phoned up Aetna's customer care line. A young man we'll call Adam, explained that since I was in the "prime"plan, that "out of network" providers would treat me as though I were "in network" as long as my primary care physician wrote the referral. I saw a problem with this right away. My primary care physician had already referred me to a specialist. Writing orders and diagnosis codes for bashed up knees is not what he does. That's why he sent me to the specialist in the first place. Although the young lady in my doctor's office gave it her best shot, when the facility called again to schedule the appointment, once again they pointed out that out of network charges would apply. Once again, I declined to make an appointment. 

I called Aetna back. This time I spoke with a woman we'll call Ann. Ann told me that someone at Aetna would have to process the request through a company called Evercore. She said we would could get my primary care physician's office on the line and we could have it all taken care of in a matter of minutes. But it was lunchtime. My doctor's office closes for lunch. They were not going to answer, but Ann wanted to try anyway. As predicted, they didn't answer. So Ann told me that she could put in a request which would probably take seven to ten days or I could call back later and start again from scratch. I opted for the 7 to 10 day wait. (Having to repeat the same information over and over becomes tedious.)

Somewhere around day eight, I decided to see how they were getting on with it. I spoke with a young lady we'll call Kanesha. She said we would need to get the specialists office on the line to see if they had filed the paperwork with Evercore. So she called while I waited on the line and someone at the specialist's office told her that they had NOT sent the paperwork to Evercore because they'd been informed that I wanted to go "out of network".  

"Who told you that??!!??" I did not want to go out of network. I wanted someone near me to be in my network. Kanesha asked me what I wanted to do. 

"I want to get an MRI someplace where I don't have to drive for over an hour. I'm on Medicare. That means I'm old. I also have a bad knee. I shouldn't have to drive that far."

She asked if I'd like her to see if the provider who was 20 minutes away would like to join the network.

"I don't care. It's your network. I expect it to have providers who are local to me. It doesn't matter to me whether it's this provider or another one. I just don't want to drive for over an hour."

She told me she didn't think she could do anything to help me so I asked her to get someone who could help me on the line.

So Kanesha says, "Would you like to speak with a subject matter expert or a supervisor?"

"Which one is more likely to help me?"

"I couldn't say."

"You expect me to say? I have absolutely no idea."

"You need to tell me who you want to talk to."

"How about the CEO? Can I talk to the CEO?"

Silence on Kanesha's end. So I said, "I didn't think so. Why don't you just connect me to whoever you think will be able to help me."

I ended up talking to a subject matter expert who sort of explained the Evercore thing to me. (It seems it's just another way of putting clerks with high school educations and no medical training in charge of medical care.) Bottom line was that I was to call the specialist's office and asked them to put the paperwork for my MRI through to Evercore. 

I really wanted to get the MRI done before we went to England. We were going to be gone for three weeks. The "out of network" facility called to let me know that they didn't hold the orders forever and that they would be trashing my order unless I booked the appointment. I noticed that the price had come down from over $400 to $250 but that was still more than I wanted to pay. I mention it here because it's an indication of how long they'd been fooling around with this. 

The Monday before we were scheduled to leave I gave Aetna another call. This time I spoke with someone we'll call Maria. Maria basically said that under no circumstances could you ever go out of network. I told her about my previous calls and what I'd been told. She seemed genuinely surprised and said she would look into it and call me back. 

Maria did not impress me as someone who would follow through. She also left me feeling that she had no idea what my problem was, much less how to solve it. No sooner did I put the phone down than I picked it back up and redialed Aetna. 

We'll call this next person Susan. I explained to Susan that this was not my first call. I also told her that I did not believe the person I'd just spoken to understood my problem. And then Susan did what no other person charged with helping me had done - she pulled up the notes from the previous calls. After asking me a few questions she said - "leave it with me." 

And so I did. That was on Monday. On Wednesday afternoon I got a call from North Star Imaging, a facility located only 20 minutes from my house. They could do my MRI that day - would I prefer 5 PM or 7 PM?  Before I hung up, the facility that had been the first "out of network" choice phoned to let me know they had approval from Aetna to treat me as though I were in network. They could do it the following day. I was going to be on a plane the following day and I'd already booked with North Star for that evening. I thanked them for getting back to me and explained that I'd already scheduled an appointment with another facility.  From zero to two in a matter of minutes. 

I went to North Star. Got it done. She said she didn't think there would be a charge, even though I'm still expecting one. But just glad I don't have to worry about chopping through all that red tape when I get home.

You just have to persevere until you find a Susan.