THIS TIME ON CODE WACK!
What questionable justifications did a major insurance company give to repeatedly deny coverage to treat a baby’s brain tumor? What would have been the financial impact on the family if they had to pay for their baby’s treatment out-of-pocket? What specific health policies could we implement to avoid situations like this?
To find out, we spoke to Dr. Eunice Stallman, a psychiatrist in Idaho and mother of two-year-old Zoey, who has suffered seizures and developmental delays because of a brain tumor discovered when she was an infant. This is the second episode in a two-part series.
SHOW NOTES
WE DISCUSS
You shared with us how Blue Cross of Idaho repeatedly denied coverage of a medicine for your daughter’s brain tumor, and how the medical reviewer was using incorrect guidelines to deny coverage. Tell us about that –
“…we looked up the specific NCCN [National Comprehensive Cancer Network] guidelines that they [had] been citing, and it was the adult brain tumor guidelines. They weren’t even looking at the right ones for how you treat brain tumors in kids. They were looking at how you treat brain tumors in adults, which is a completely different protocol.
“… So we had written several grievances and … we said, ‘well, why was it denied all these times in the first place? And ‘prove to us that you did take a look at the pediatric guidelines.’
“Well, they weren’t able to do that. …” – Eunice Stallman, MD
So you started a GoFundMe page. How expensive is the medicine she needs?
“… we started the GoFundMe . .. to raise money to be able to pay out of pocket for the first month or two of medications in case [approval] did take that long.”
“… we’ve kept that pocket of money, you know, for her copays, which are still very high with her medication. We’ve also had to use it for different medical equipment and things….
“…when she was eight months old, [Lorlatinib] was $15,000 a month if you were to pay out of pocket. The bigger she got, the more expensive it was … At her current weight, I think if we were to pay out of pocket, it would be about $20,000 a month for her medication. [And her co-pays] were about $4,000 a month until we reached her max out of pocket, which is about $10,000 per year. – Eunice Stallman, MD
It seems like sometimes our health lies not in our doctor’s hands, but rather in our insurance company’s hands. What bothers you the most about this experience and what should we do about it?
“I think what bothers me the most is that her doctors have experience and they’ve had years and years of training … And then someone or some groups of people who don’t have nearly as much experience in treating patients and/or treating Zoey’s tumor to have the power to say, ‘oh, that’s not needed, or that’s not necessary, or it’s not urgent enough,’ I think that’s just, that’s unacceptable <laugh>. It should be that people who have experience can, you know, review that and say, okay, yes, or, you know, maybe try this. But there was no, there was no other knowledge. It was just, ‘nope, she doesn’t need it.’
“I think one of the things [to consider doing about it] is that Medicare and Medicaid have moved towards streamlining prior authorizations and who can do the approvals and who can do the denials. And so what they have now is that only MDs or DOs [A doctor of osteopathic medicine] …are able to do denials, and they should be in the same specialty as the treating doctor.
“And I think that’s a great thing that needs to be implemented across commercial insurance plans too…” – Eunice Stallman, MD
Helpful Links
Treatment for Baby Zoey’s Brain Tumor, GoFundMe
Unforeseen Health Care Bills and Coverage Denials by Health Insurers in the U.S., The Commonwealth Fund
Analysis: Health insurance claim denials are on the rise, to the detriment of patients, PBS
When health plans delay and deny, they must say why, American Medical Association
The Problem of Insurance Company Physicians Blocking Medical Care, The Psychiatry Resource
How Cigna Saves Millions by Having Its Doctors Reject Claims Without Reading Them, Propublica
Episode Transcript
Read the full episode transcript.
Biography: Eunice Stallman, MD
Eunice Stallman, MD is a psychiatrist for the State of Idaho and clinical faculty at the University of Washington School of Medicine and the University of Washington Boise Psychiatry Residency Program.
She also writes narrative medicine essays and poetry on topics she is passionate about, and her pieces have been published in JAMA and KevinMD, among others.
She is a mom of four young kids, and her youngest, Zoey, was diagnosed with an infantile brain tumor and is still undergoing treatment.
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