Medical Insurance

It started out as an innocent ride on my motorcycle. I've been riding motorcycles for more years than most people have been alive, so this ride shouldn't have been any different. I never made it out of my driveway. My driveway is gravel and I did a nice 360, dumping the bike on its side and injuring my knee.

Suspecting that I had torn one or more ligaments, something I have done before, I decided to go to the emergency room at the local hospital. Seems simple enough - right? Wrong! I'm in Colorado for the summer and out of my HMO's medical coverage area. I'm only covered for life-threatening emergencies and must get approval from my primary health care physician for emergency room visits. I called my doctor in Pennsylvania. I'll call her doctor X

It was Sunday evening in Pennsylvania where Doctor X lives, and I did not have her phone number. I got on the Internet and found her office number. I called it, it rang, and then nothing. No answering machine, no recording. I called again and this time a message told me to call another number if it was an emergency. I called the other number. It was a service. The woman took my information and said she would call Doctor X.

About 20 minutes later Doctor X called me. She was washing dishes. I explained the situation and she said to go to the emergency room, but if I needed any further medical care, I should call the HMO for direct referrals. Satisfied, I called the hospital to tell them I was coming. Then I tried to master the art of driving a truck with a right leg that was in pain and didn't bend very well. I safely traversed the 20 miles to the hospital in spite of having to use my left foot for the clutch and the brake.

At the hospital I spent so much time filling out forms that I thought my knee might heal before I finished. Once I had given all my HMO information, medical history, accident details, etc. they took my blood pressure - which was higher due to the forms I had to fill out. X-rays revealed nothing abnormal - which was not particularly reassuring since I was already missing my posterior crucial ligament from an operation six years ago.

Doctor Y was the emergency room physician on call, and he manipulated my leg in every possible way to see what made me scream in pain and what didn't. His conclusion was what I already knew - that I probably had ligament damage and I should see doctor Z, an orthopedic surgeon. Dr. Z had a practice 60 miles away, but he came to the local hospital every Tuesday. I should call the hospital's clinic in the morning to make an appointment. I would have skipped the emergency room visit altogether and just seen Dr. Z, but then I wouldn't have been covered by my HMO because it wouldn't have been considered an emergency.

Wearing an immobilizing leg brace I left the hospital and discovered that I couldn't even get into my truck, let alone drive it while wearing the brace. I removed it and managed to get home. Ice packs, ibuprofen and rest were my activities until Monday morning when I called the hospital clinic to schedule an appointment to see Dr. Z. The clinic told me I had to call Dr. Z directly and gave me his number. I called and made the appointment. I started feeling better, not realizing that insurance was going to cause me a lot more problems than my knee.

My next realization was that this was a "motor vehicle" accident and that I had insurance to cover me other than my HMO. I called the hospital and gave them my USAA auto insurance information. Later I remembered that I had switched my motorcycle insurance to State Farm, so I had to call back the hospital and give them the new insurance information. They now had information on three insurance companies. Surely one would cover me.

A call to my State Farm agent in Pennsylvania got me a recording saying to call back during business hours. It was 10:30 AM there, and their hours on Mondays were 8 AM to 5 PM. Hmmm. I left my phone number on their voice mail and called the national toll-free number to report the accident. With a claim number now in hand, I called the hospital and gave it to them. At noon, my State Farm agent called to tell me that my policy, because I live in Pennsylvania, doesn't cover my medical expenses, but if I injure someone else, they are covered. This news made me really want to injure someone else, but I wasn't sure whom. I read my policy and called back my agent. Conclusion: I'm paying $210.40 for "bodily injury," but not for my body.

I called the hospital and informed them not to submit any claims to State Farm - send them to my HMO. Then I called back my HMO about getting a referral to Dr. Z. and they informed me that they don't do referrals. I must call my primary care physician, Dr. X., if I want a referral to Dr. Z. As I'm calling back Dr. X, I'm thinking that she should have known that. Of course I never, in this whole process, got to talk to Dr. X again. She has office workers to handle such things, and thank God for that, because she obviously doesn't know how the system works. Dr. X's assistant tells me that they can't refer me to Dr. Z unless Dr. Z is in the HMO network. I must call Dr. Z and find out if he is in the network, get his ID number and call back.

Of course, Dr. Z is not in the HMO network. I get on the Internet and go to my HMO's web site to search for orthopedic doctors in the network. There isn't an orthopedist or any other kind of doctor in my HMO network within 200 miles. I call my HMO and explain this. They put me on hold while they rechecked what I just told them. Then they told me that my primary health care physician, Dr. X, must call the HMO's Patient Management office and request approval to refer me to a non-network doctor.

I again called Dr. X's assistant and gave her the information along with Dr. Z's name, address, and phone number. She told me that I needed to have the hospital fax her the medical records from my emergency room visit before she could request approval for my referral. I called the hospital and was transferred to the records section where I got an answering machine message saying they were at lunch. After lunch I called and the records person said that the transcriber had not yet transcribed my records, and perhaps she could get to them tomorrow. I explained that I needed them faxed that day in order to get the referral approved in time for my appointment. She says she would call the transcriber and see what she could do. I hung up and start thinking about my phone bill. I was up to 12 long-distance calls already. What would I have done if my mouth had been injured instead of my knee?

At 2:15 PM the hospital records section called me to say that they had transcribed Dr. Y's scribblings and faxed them to Dr. X. I then called Dr. X to confirm that they had received the fax. They had received it and had called the HMO to request the out-of-network referral. Amazing. But wait, the HMO is a large, formalized bureaucracy, and it was already 4:30 PM in Pennsylvania. The chances of getting the referral approved this month were pretty slim. Getting it before noon the next day would be tantamount to winning the lottery.

I won the lottery! That is to say Dr. X's office assistant called me at 9:30 AM the next morning to tell me I had been approved for one visit to Dr. Z. Small victories are satisfying, even in a big war, so I felt a slight measure of success. However, if I needed any follow-up visits with Dr. Z, he had to call my HMO directly and request permission for me to see him.

At 1 PM I got to see Dr. Z, who was excellent, and made me feel better about being injured - the true measure of a great doctor. I am to see Dr. Z again in four weeks, but this time it is he who will be making the long distance calls to my HMO. Of course I still have to call him long distance. I expect that my HMO will not pay for the hinged knee brace that is being made for me, so I may get to speak with them at least one more time.

The complexities of all that has happened may, in hindsight, be insignificant compared to what could happen next. I switched my HMO two months ago and the change goes in effect in 24 days. That means my next two visits with Dr. Z will be under my new HMO who knows nothing about any of this, and who also has no "network physicians" in the area. Like trying to change a bobsled team in the middle of a race, it is too convoluted to even consider. At least my phone company will love me.