If It Happened To Me…It Can Happen To You
As an advocate whose profession is helping senior citizens protect their right to choose healthcare services, I understand how big hospitals try to keep patients from using services outside their system. So when I recently suffered a broken ankle, I began the process of vetting orthopedic surgeons and services that I believe would give me the best result. I wanted to be sure I was getting the best possible care for my health insurance buck.
I consider myself very well prepared when it comes to navigating today’s healthcare system. But even after researching physicians and gaining a clear understanding of my insurance coverage, my healthcare was nearly hi-jacked anyway. If you think managing your healthcare takes nothing more than research and preparation then you will be shocked to read the story that follows.
Let me set the stage and tell you how this healthcare situation developed for me.
While I was carrying out Christmas decorations to my garage, I tripped on a roll of duct tape that was left on the two stairs leading down to the landing. As my toe got caught in the center of the tape roll, my ankle twisted and I broke the bottom of my fibula and pulled ligaments.
After x-rays at the Emergency Room, It was determined I would need surgery and the Doctor wrote me an order to see an orthopedic surgeon.
On the following Monday I began making phone calls. The first was to my insurance company to find out what exactly I needed in order to be referred to an Orthopedic Surgeon. Second was a call to my Primary Care Physician from whom I needed the referral.
The next set of phone calls were made to various orthopedic surgeons that accepted my insurance. I wanted to find out which ones would take my case and which ones could get me an appointment quickly. After a little “shopping” around I decided to use an Orthopedic Surgeon covered by my insurance but outside of my Primary Physicians healthcare system. That little wrinkle would come into play later.
So off I went to my Primary Care Physician appointment. I knew who I wanted to do my surgery. I had all the necessary conversations and approvals. I just needed my Primary Care Physician to write me a referral.
The appointment went as expected. The nurse practitioner that saw me at the office read the Emergency Room Report, confirmed I had broken my ankle and agreed to make the referral to the Orthopedic Surgeon of my choosing.
Pretty simple right? It should have been.
Everything was going as planned until an office manager decided to intervene. I waited until afternoon on the next day to call the orthopedic surgeons office. More than enough time for my doctor’s office to process the paperwork and fax it over to the surgeon. But when I called the referral had not been sent.
On the follow-up call to my doctor’s office I was reassured by the medical assistant that answered the phone that my referral would be given top priority. I had no reason to distrust her so when I hung up the phone I was confident my referral would be sent at the earliest possible moment.
Little did I know the Medical Assistant’s supervisor was working behind the scenes to hi-jack my healthcare choice.
A couple of hours later I followed up again with the surgeon, confident they would have my referral and I would now be able to make my appointment. Instead they informed me they haven’t received the information.
How is it that my doctor’s office hadn’t sent the necessary information? Giving them the benefit of the doubt I assumed it was because they were busy.
On the next call to my doctor’s office I found something more nefarious was going on. I was informed by the Medical Assistant supervisor that my paperwork had been sent to another department and I would need physician approval to use an orthopod outside of the healthcare system.
Remember I mentioned before that the surgeon I wanted to use worked in a different hospital system than my Primary Care Doc. According to this supervisor it was hospital system policy to exclusively refer to doctors within the system. Even despite patient choice, even despite insurance coverage.
I knew then I had a fight on my hands.
I immediately asked to talk to the practice manager and informed her of the problem. She knew that under the Affordable Care Act I had the right to choose whichever provider I wanted as long as my insurance covered it regardless of the system they worked for. She instructed her staff to process the referral as I directed.
You can choose any available participating primary care provider as your doctor – via hhs.gov
So why did this all happen?
It Giveth, It Taketh
The answer is the double edged sword known at the Affordable Care Act. Yes it was the patient choice clause in the Affordable Care Act that gave me the ammunition I needed to convince my doctor’s office to send my referral but it also created the problem in the first place.
Everyone knows about how the Affordable Care Act gave birth to Obamacare, our countries version of universal healthcare. What most people don’t know is that the ACA (Affordable Care Act) also changed the way hospital systems were reimbursed? It changed the reimbursement systems focus to that of outcomes instead of volume.
Under the new system hospitals are penalized for readmissions or patients who return to the hospital with thirty days of being discharged. The government views readmissions as an example of a poor care outcomes. They believe that readmission wouldn’t have been necessary if the hospital had done an appropriate job screening the patient for all potential health issues.
For this reason hospitals are forced to try and control patient outcomes even after discharge. To accomplish this hospitals put policies in place to control who referrals are given too. The more they can keep the patient within the system the more they can control the outcome.
It was one of these policies that was the motivation for my doctor trying to keep my orthopedic surgery referral from going outside of the system.
Had I not known the law and insisted that patient choice be honored, I would have been referred to whoever the doctor’s office decided to choose rather than the surgeon I researched. Had I just threw up my hands and given-up, a medical assistant supervisor could have robbed me of my patient choice.
This experience, although extremely frustrating, only emboldened me in my mission to help seniors and their families. If a professional advocate like myself can nearly have his right to choose hi-jacked, I can only imagine what happens to seniors and their families on a daily basis.
If you have a story about how you struggled with the healthcare system send me an email at AnthonyFischer@elderadvocacygroup.info. For more information about how you can keep this nightmare from happening to you, REGISTER HERE to get emails from our experts.