THIS TIME ON CODE WACK!
Imagine having to fight with your HMO insurer about compensating your surgeon who doesn’t belong to your provider network, but happens to be a specialist in a particular procedure that you want because it has fewer side effects. Could you afford to cough up a few thousand dollars to pay the surgeon while hassling with your HMO? But the story doesn’t end there. What if you then needed a followup procedure that is relatively new but has a 98% chance of a positive outcome? But the surgeon you want – who invented it – is not in your state, never mind your network?
We recently spoke to Rand, a commercial property manager, writer and father of three in Southern California who shared the formidable health and insurance challenges that he’s faced with us. Rand asked that we not use his last name for this interview. This is the first of a two-part series with Rand.
SHOW NOTES
WE DISCUSS
Tell us a little bit about yourself. Who are you and what do you do?
“I am a commercial property manager, and I also, in my spare time, enjoy writing. And I’m a father to three lovely children. I live in beautiful southern California. So I enjoy getting outdoors and going for a run or walking, you know, along the beach or the bay, or just sitting out and enjoying nature.” – Rand
Several years ago you started having some medical issues. Tell us briefly about that –
“…I was having more and more difficulty urinating. So getting up once a night to go pee turned to two times, turned to three times, and sometimes four times a night. And I just didn’t have the full stream. . .
“So I saw a urologist in 2020 and this doctor said, ‘no problem. Here’s some pills.’ … I did a lot of research on the drug, and Google doesn’t tell you much … it tells you what, what the drug manufacturer wants you to hear, which is, ‘it’s totally safe,’you know, there’s not a lot of research that has been done on this. And all the studies are by the drug manufacturer. So I was a little nervous and anxious being on this drug.
“…and [over time] things have progressed, not in the right direction. I realized I probably … will need surgery. And I did a lot of research and realized that, geez, I wish I had looked into this years before because what the doctor did not tell me was that .. the bladder is like a muscle, and like any muscle that has to work harder, it gets bigger and thicker …
“Eventually I would’ve gone into renal failure where my bladder would not be able to contract and I’d have to have my bladder removed, which means I’d have a tube coming outta me the rest of my life. I would have to pee in a tube through a tube the rest of my life. And I’m way too young for that and active for that. So that was a huge jolt of reality. So then I really began looking for solutions in earnest, and that’s kind of how it started and which led me to having a need for surgery.” – Rand
That doesn’t sound good. Tell us more –
“The prostate is really deep inside your body.. anything that’s done has to be invasive and unfortunately, it’s not like one single thing that’s like, ‘oh, this is what we do. This is the best…’ because of the nature of being invasive, there’s really not great outcomes on any procedure.
“So I wanted to look for the best procedure, the one that offered the best outcome. And I decided that there’s one procedure in particular that was relatively new, and only one doctor in San Diego County did it.
“So I chose that and insurance denied it … and the reason why they denied it is because their doctors didn’t do it, didn’t know how to do it.
“They wanted me to use, you know, go to their doctors. And I didn’t … this is an accepted procedure, medical procedure, they have to approve. Well, that was a big fight.
“So long story short, … they accepted the procedure and paid for that. But they haven’t paid me back for the doctor yet. I’m still fighting with them for that. So how can you approve a procedure that only one doctor can do … is licensed and has the experience and equipment to do and not pay for his bill?“ – Rand
Helpful Links
Health Maintenance Organization (HMO): What It Is, Pros and Cons, Investopedia
Tips for When Your Medical Insurance Company Will Not Pay, Very Well Health
Different Types of Health Plans: How They Compare, Web MD
Types of Male Urinary Dysfunction, NYU Langone Health
Episode Transcript
Read the full episode transcript.
Biography: Rand
Rand lives in Southern California with his wife and a big goofy dog named Riley. A lifelong student of personal growth and human behavior, Rand enjoys writing about happiness, mindfulness, and what is possible for all of us.
In everything he does, Rand strives to positively impact people through his words, deeds, and way of being, and in so doing, be an agent for positive change in the world.
Get Involved / Take Action
Subscribe to Code WACK! to catch all our weekly podcast episodes.
Subscribe to HEAL California for health policy news with a California focus
Join Healthy California Now – a coalition working toward a California single-payer system. Individual and organizational memberships available
You can also find us on ProgressiveVoices.com and NurseTalk Media.
This podcast is powered by HEAL California,
uplifting the voices of those fighting for healthcare justice.
____________________________________________________________________________
HEAL California is an independent news and information hub focused on the Medicare for All movement. We highlight the on-going injustices of our broken healthcare system and amplify the voices of those who are most impacted by it, with non-partisan news, views, podcasts and videos,
Our Podcasts shine a light on the failures of America’s healthcare system, while explaining how Medicare for All could help.
Our Media page offers connections to experts and additional resources including links to legislation and studies.
Keep up with the Medicare for All movement!
Follow us on Facebook, Twitter, and Instagram.
Subscribe for email updates, action alerts and more!
