I was home following my hospital stay, trying to modify my lifestyle and attempting to adjust to new medication to help me deal with my angina (chest pain due to heart disease) when the 5 page letter, using words that only a lawyer could love, came from the health plan.
“We have reviewed information received about your care and specific circumstances using the MCG criteria for Inpatient and Surgical Care. Based on this review, coverage for the requested admission is denied.”
Happily I did not take the denial letter seriously. If I had I would have been at risk for readmission to the hospital with more chest pain and shortness of breath. My first reaction was to think this was extremely funny. I know how these issues work, and also know that my diagnosis of unstable angina (increasing chest pain related to heart disease while on medication) with an abnormal stress treadmill test fit criteria for coronary angiography, an invasive procedure to see my coronary arteries. I had, indeed already received health plan “approval” for the cardiac procedure. I also knew that the best practice algorithm from the American College of Cardiology, for unstable angina called for “admission to the hospital for bed rest with continuous telemetry monitoring.” All that had happened correctly. I assumed that somewhere along the line, despite more attention being given to documentation than to actually doing anything (see my last blog post), something had been lost in translation. My cardiologist, a very exacting person when it came to do a cardiac procedure was perhaps less exacting when it came to filling out the paperwork. The hospital department that submitted the documentation may have missed the boat in communicating what was really happening in my life when I was forced to enter the hospital – a step I loathed taking.
But then I stepped back. What if I had received that letter and did not have the knowledge I had? Would I believe that my doctor did something wrong or did not treat me correctly? Would I curse my health plan and accuse them of being uncaring and incompetent? Would the anxiety of potentially getting a huge bill I could not afford create more stress when I was trying to deal with the stress of having ongoing heart disease? And would I believe that MCG criteria were some magical code that determined whether I would live or die?
My knowledge of the facts made me see the humor in this and not be stressed by the game of telephone that occurs when physicians and hospitals try to communicate medical needs to the health plans. I knew that MCG stood for the Milliman Care Guidelines first developed by an old friend, Richard (Dick) Doyle who was a brilliant physician and consultant when he worked for Milliman, a respected actuarial consulting firm. I used to joke that the first generation of the Milliman guidelines were made up by Dick Doyle with his feet up as he looked over the Pacific Ocean in his house in San Diego rather than by any scientific method. It felt like the use of only the initials, in the denial letter, made these guidelines have so much more weight than they really were meant to have – making their use in the denial letter almost comical. Milliman Care Guidelines are used by many health plans and even by government plans to judge efficiency because of their operational ease, not because of their scientific rigor. They are not meant to be nuanced and rather are guides to what can be achieved in the perfect world that those who practice clinical medicine rarely see. My cardiologist, who admitted me and did the coronary angiogram, was well trained, smart and caring and did everything right clinically. The people in the health plan were all caring professionals trying to uphold the plan requirements in a fair way. All these people are good people doing the right thing and yet the letter that was sent to me seemed to say that my care had been wrong and would not be paid by the health plan. It was communicated to me, the patient, in a heavy-handed way that said that what I had done was “not medically necessary” according to those magical guidelines.
Upon further investigation, I discovered that the contract that the health plan has with this hospital calls for these admissions for unstable angina to be billed as observation unit days, rather than admissions. I was lying in a bed in a room as an inpatient and this contracting fiction that drives payment was meaningless both to me and to the hospital staff who cared for me (or who cared for the computer as I speak about in my previous blog). I, as the patient, will be held harmless and not have to pay for this purported mistaken admission driven by my acquiescence to supposed “sub-standard” care since the mistake did not occur and the denial was just due to the financial relationship between the health plan and the hospital. Now that my investigation is done, which I took on as a form of entertainment, I will go back to focusing on my own health issues.
The good news is that my cardiac procedure did not show any critical lesions but instead showed disease that is readily managed by lifestyle modification and proper medication. I am also fortunate to appreciate the irony of the whole episode. I get the inside joke that others may not. My goal is for everyone to have someone at their side who also gets the joke and who is able to understand health care and health benefits. That person – in my world the Accolade Health Assistant – knows how to navigate the system and help people through the decisions, the documentation, and even the denials when they come. I don’t want anyone with heart disease or any other medical issue to be at risk for new medical problems due to “payment fear” related to accessing health care just because they don’t have my knowledge. Everyone needs a health assistant and with the experience gained from this medical interlude, I will continue my efforts to make that happen.