When I heard that Aetna would not be offering individual insurance coverage in California starting January 2014 I was concerned. After all, Gabriela’s primary insurance since 2011 has been AETNA and here we are so close to a major surgery that holds so much promise for her!
By the end of October I had spoken with UCLA neuroscience and was assured that primary coverage by Medi-Cal would be acceptable, not just for Gabriela’s surgery but for the follow-up and office visits to Dr. Stern afterwards.
One of the things I‘ve learned about insurance over the last few years is that Medi-Cal operates on a county level as a Health Maintenance Organization (HMO). This means we would have to select a primary care physician (PCP) who would then need to refer and get an approval for Gabriela to continue to see Dr. Stern.
I started this process in November because I knew we would need time to work through any problems we might encounter … like a PCP that might want to reinvent the wheel or Medi-Cal not considering the surgery a necessity. Not to mention that January 2014 would be the first date that the flood gates would open due to “Obamacare” and there could be thousands of new insured’s all vying for attention and draining the resources of the local Medi-Cal HMO (called “Cen Cal”).
Step one was to make Gabriela’s selected PCP official. Despite Gabriela having seen this PCP for over a year, there is a limit to the number of Cen Cal patients this facility will accept and the approval process can take several weeks. I successfully argued with Cen Cal that there was a preexisting relationship with this doctor and within days the approval was granted.
We set an appointment for November 6th at 4:30 PM with the PCP. I had tried to impress upon Gabriela the importance of the initial appointment and I called the doctor’s office to caution them that we may be a little late (just covering all our bases). Despite my best efforts, we arrived 20 minutes late and were naturally turned away.
The next available appointment was December 3. We had already lost one month but I kept in mind the reason I had started this process two months early was to accommodate delays even if they were completely of our own doing.
We were the first appointment on the 3rd. The doctor entered, greeted Gabriela then we made our introductions. Gabriela explained that we were there to get a referral to her existing neurologist, Dr. Stern at UCLA. The doctor explained that she would not be able to oblige because Gabriela would need to be seen by their in-house neurology who would evaluated her to determine if a trip to UCLA was necessary.
Both Gabriela and I tried to explain the situation but the doctor took the position that her hands were tied and if this was so important why had it taken us so long to see her.
I tried to calmly reason with the doctor pointing out that it was within her control as the PCP to refer to a UCLA neurologist and citing the long relationship between Gabriela and Dr. Stern and the upcoming surgery. I also pointed out the fact that UCLA was an “in network provider”. She held up her hand to stop the conversation telling both of us she would research the possibility of referring outside of the clinic and let us know but that we should make an appointment with neurology at the desk on our way out.
It was difficult to keep quiet and remain respectful … but I repeated silently to myself this is why we started the process so early, bumps in the road were to be expected.
Gabriela and I stopped at the desk and found that appointments with neurology were scheduling out to the end of January. The lady at the desk understood our urgency and that waiting till the end of January put the timing of the surgery at risk so she agreed to discuss getting an earlier appointment time with the doctor and call us.
In the car we looked at each other and then vented about the appointment and the clear display of disinterest on the part of the PCP.
Before we pulled out of our parking slot I called Cen Cal and spoke with our representative, Joanne. We discussed the problem the doctor felt she had in making a referral outside of her clinic. Joanne explained that the doctor was probably not familiar with the referral process so she put lengthy notes in Gabriela’s file explaining the guidance needed when this doctor called about referring to Dr. Stern.
I also began the process of filing a complaint with Joanne about the PCP citing her lack of interest and concern and her down-right rude demeanor. Joanne said she would call me back later in the day to finish things up.
Then I called the doctor’s office and left a message with the PCP’s assistant saying that we had spoken with Cen Cal. I explained we had confirmed that the doctor was able to refer us directly to Dr. Stern because UCLA neurology was an in-network provider and if there were any questions then Joanne at Cen Cal was very willing to help.
By late afternoon Joanne called back as promised. She had completed the paperwork to get the complaint filed and in the process checked Gabriela’s file. She had noticed the referral request had been placed by Gabriela’s PCP immediately after our call to her assistant.
I held off on the complaint.
Now I had to start tracking the referral through the approval process. My first instructions from Cen Cal were that the approval or denial should happen by the end of the week. Ozzie was my Cen Cal contact during this process. When I called on Friday Ozzie told me that the referral had been denied! The explanation was Aetna had apparently coded Gabriela as an active member which turned Cen Cal into secondary insurance making the referral unnecessary. Ozzie told me to do a couple of things; the first was to get a letter of termination from Aetna that he could submit internally and, second, to contact the “Ombudsman.” He gave me the phone number and told me to explain the situation to them because they can usually work with Aetna and Medi-Cal to get the coding changed quickly. We agreed to talk again Monday morning.
It was too late to call Aetna, so I went directly to the Ombudsman and left a message. They returned the call and said the coding should be corrected by Monday and when everything was verified they would let me know.
Before dinner I went to Aetna’s website and sent an email to customer service asking that they send a letter of plan termination via email to me. Then I sent an email making the same request to Aetna’s customer service supervisor who had managed to get my reimbursement payments sent.
By Saturday morning I had received a plan termination letter from Aetna and a plan coverage certification indicating that the plan had ended 11/01/2013. I realized that my skills in responding effectively to insurance problems from those early days to now have completely changed.
Monday morning the Ombudsman called. She had confirmed the coding was now correct and Aetna was no longer primary insurance. I faxed the two letters from Aetna to Ozzie at Cen Cal and he also confirmed the code changes. Gabriela’s referral to UCLA and Dr. Stern was approved.
Then I emailed UCLA and asked what additional assistance they would need now that the referral was approved. The emailed response I received was “we’ve got it from here.”
Last but by no means least, the thought had occurred to me that because Gabriela sees a psychiatrist and therapist who are both covered by Aetna but neither by Cen Cal I would ask Medi-Cal/Cen Cal to do a single case agreement for both of these providers. I started with Ozzie at Cen Cal and asked if he could help. He explained that Cen Cal does not handle the behavioral health aspect of Medi-Cal but gave me the phone number to C.A.R.E.S. in Santa Barbara.
I called, “Hi, I was given your phone number by Cen Cal who has been my daughter’s secondary insurance for years and has recently become her primary insurance because her Aetna plan ended at the end of October. We have successfully taken care of coverage for all of her medical needs however she has both a psychiatrist and therapist who she has been working with for years who are not Medi-Cal provider. I would like to begin the process of establishing single case agreements for both of these professionals in order to insure continuity of care. Can you help me with that?”
Response, “uh, oh.” Then a short silence. “ You will have to call quality, they will be able to help you.”
The customer service agent gave me a phone number and I asked her what I should say to them?
Her response: “Do just what you did … Do that, it’s perfect.”
Learning to speak fluent “insurance” is essential. Because I now understand the process it took only 20 days to completely move Gabriela’s coverage and make sure every “I” was dotted and every “t” was crossed. The date for Gabriela’s surgery is looking like somewhere between end of January and the beginning of February.
I’m very optimistic about Medi-Cal coverage for Gabriela’s on-going behavioral health providers … it’s all about understanding the plans and speaking the language.