“Is your insurance agent also your travel agent? ”
I was recently reminded me that I am not completely in charge of what happens to my patients. A 3 -year-old was admitted for complications related to abnormal blood vessels in his brain. This condition is rare, with a reported incidence of 0.086 per 100,000 patients, basically one in a million. However, it can lead to multiple brain strokes, causing brain damage, or even death.
Many hospitals may have seen one or two children with this diagnosis, but larger referral centers that specialize in pediatric subspecialty care see higher numbers, and learn from those experiences. What is learned is then disseminated to the rest of the medical community through peer-reviewed publications.
Neurosurgeons throughout the country read about these cases and discuss them at national meetings in order to bring the most current information back to their hometowns.
In Albuquerque, we have excellent neurosurgeons who perform advanced care for multiple complex conditions. But due to New Mexico’s small population, we do not see high numbers of rare conditions in children. Therefore, we decide on a case-by-case basis which conditions are best treated here at home, and which patients would be better served by getting transferred to a referral hospital out of state. And here’s where the insurance companies come in.
Why? Because this level of complex care, surgery, transport and prolonged hospital stays is expensive. If your insurance company doesn’t agree to pay the bills, you will have to pay them.
For my patient, we predicted six weeks of hospitalization, with two weeks of intensive care and two surgeries. That could easily generate a six-figure bill. Fortunately, insurance companies recognize that some patients will need to transfer out of state for certain complex conditions. The solution is financial contracts between New Mexico’s third insurance companies and referral hospitals. Each payer has its own method of selecting which out-of-state hospitals it is willing to do business with. If your child needs specialized heart surgery, or a liver transplant or specialized brain surgery, your insurance company will decide where that can happen.
My patient’s family was told by their medical team that the best surgeon for their specific problem was in California. Naturally, they wanted to go to California. The doctor in California agreed and began participating in his care by telephone. But the California hospital would not accept the patient without a guarantee of payment from insurance.
Unfortunately, the patient’s insurance company did not have a contract with the California hospital, because they say the rates are too high. Instead, they have a contract with a children’s hospital in Illinois, which offers similar services – similar, but not exactly the same. And no one on our team knew the doctors in Chicago, so we could not provide any useful information for the family. This put the family in a very difficult situation, caught between doctors saying they should go to California and the insurance company saying they would only pay for Illinois.
So, how can parents be certain that their child is getting the best, most personalized care, while also being certain that the care will be covered by insurance?
First, know the details of your insurance coverage. Call customer service and ask specific questions about coverage and limitations. Ask which insurance agent is in charge of your case and how long the process is expected to take.
Second, talk with your child’s doctors. These conversations help us understand what is important to families, and helps families understand what is important medically. Together, we’ll make the best decision for your child.
Third, talk with the Case Manager. Their job is to know how insurance companies work, understand what is required medically and then factor in a family’s specific circumstances to find the best solution for each child, each time. They meet with our families daily and update them as new information comes in. They fill out all the paperwork required by insurance companies and call them to resolve problems or delays. They are advocates for your child and for you.
For parents who want to do their own research, there are not many resources. One is the U.S. News and World Report Best Hospitals. It is an annual ranking that includes Children’s Hospitals, divides by specialty and is available online. This is only a starting point and parents should still apply the three-step process described above. The link is https://health.usnews.com/health-care/best-hospitals/articles/faq-how-and-why-we-rank-and-rate-hospitals.
Anjali Subbaswamy is a Pediatric Intensive Care Physician at UNM. Please send your questions to her at firstname.lastname@example.org.