I have an HMO. I can hear you all groaning – and yes, this is my story, which is disgustingly typical.
I noticed that my left ankle was painful and swollen in December, 2010. Because I play by the rules, I called my primary care physician (PTP) to find out how long it would be before I could get an appointment for Xrays or for an MRI. I was told that the first available appointment was in approximately 3 weeks. Three weeks?? My ankle is so swollen that I can’t wear closed shoes – I have a bulky Ace bandage wrapped around it, and I’m wearing open Birkenstock sandals in December. Granted, this is California, so December isn’t so bad here, but still, we had a lot of rainy and chilly weather – and I’m walking around in open sandals.
Now, my HMO covers a visit to urgent care; the co-pay is $25, instead of $15, so I figured it would be worth the extra ten bucks to get Xrays and a diagnosis. So I went to urgent care and had my ankle Xrayed. Unfortunately for me, the doctor on duty at the urgent care center told me that he was not qualified to read my Xrays. So I had to come back the next day and pick up the films and then make an appointment with my PTP to have the films read. So, I made an appointment, for which I waited 2 weeks. More rain. Me wearing Birkenstocks.
So my doc says what I expected him to say, that I had to be seen by an orthopedist. He sent in a referral request.
I waited 2 weeks for the referral to an ortho. I called the ortho’s office for an appointment – in 3 weeks. By this time, it’s early February. I’m still wearing birkies and an Ace bandage. So the ortho referred me for an MRI. I made an appointment – in 2 weeks.
So from my first visit to urgent care to the day I got my MRI, it was more than 2 MONTHS. I had to wait another couple of weeks for a second appointment with the ortho for him to read my MRI, and he tells me that I have a small tear in the ligament and another in the tendon on the outside of my ankle, along with microfractures and a subacromial cyst. He prescribed physical therapy.
Since I work in Workers’ Compensation defense, I recognized what’s going on in my orthopedist’s office: it’s a treatment mill for applicants. The waiting room is overflowing and the epidurals are flying off the shelves. The doctor breezed into the exam room (after I had waited for over an hour), poked my ankle once, handed me a tube of Voltaren gel, sends me off for PT – all this in 30 seconds flat. I recognize a hack when I see one, so I requested a new orthopedist.
Because I have no choice in the matter, the new ortho I am assigned to is 25 miles away. I take a half a day off for my initial visit, and he confirms the prescription for PT. I like this doctor better, so I decide to keep him.
I wait another 2 weeks for my referral to a physical therapist. I get authorization for 4 sessions. I go, it helps. I use up my 4 sessions. My PT requests more sessions. I wait 2 weeks for authorization. I get 2 sessions. I go. It helps. My PT requests more sessions. I wait 4 weeks, because my medical group “requires more information” before they can authorize more sessions. I wait another 2 weeks. I get 6 sessions. I go, it helps. I use up my 6 sessions. My PT requests more. I wait 2 weeks.
Are you getting the picture? This dragged out through the entire summer and into fall. I’d have a few sessions of PT, and then I’d lose any healing I had gained from my sessions because I had to wait 2 or 3 weeks without any PT until my medical group got around to approving a few more.
I tried calling my medical group (Regal) a few times, and it was always the same story: that my PT had not sent in the required paperwork. This was false, because at every “final” session, I watched my physical therapist (who had become a friend) send off a request to Regal for more sessions.
I lost my patience some time in August and fired off a letter to United Healthcare, the parent of my medical group, Regal. I was pissed off, because my ankle wasn’t healing and I was racking up those $15 co-pays for every session of PT and I was still wearing birkies and an Ace bandage. I get a letter back telling me that they had opened a case and they were looking into it. I asked my PT how many sessions I would need for optimum benefit, and he told me I needed 16 sessions.
OK, so there’s an open case now. Maybe something will change. I passed the information about the 16 sessions on to United Healthcare.
A week or so later, I got an authorization for 8 sessions, with the promise of 8 more without delay.
I’ll bet you know what happened next. I finished up my 8 sessions, my PT requested the promised additional 8 sessions…and a week later, I got another delay letter, telling me that Regal “needed more information” in order to approve the treatment.
I lost my temper. I sent another letter to the person at United Healthcare who had responded to my initial letter. This was September 27th. I received no answer.
I discussed my ankle with my PT, and he told me that there was really nothing more he could do for me. So I called my orthopedist and requested a follow up appointment. They tell me I need to call my PTP and make an appointment with him to get a referral. I get mad. But I hold my temper and tell the ortho’s office to just try – because I have made myself such a colossal pain by calling Regal on 3 or 4 occasions and sending off the 2 letters to United Healthcare, I figured they’d approve a follow up.
They did. So, how, we’re already in mid-January and I finally had my follow-up with my new ortho. He pokes my ankle, which is still the size of a softball, and tells me that my condition can now be termed “chronic” – and that the only cure is surgery. He describes arthroscopic surgery, where they go in and scrape/repair the tendons and deal with the cyst.
I fired off another letter to the “quality control” person at United Healthcare. I hear nothing.
Finally, last week, I picked up the phone and called United Healthcare. I ask for the quality control person, and give my case number. To my complete astonishment, Linda, the person I was speaking to, told me that my case had been closed. What?!? Closed?? How could my case be closed? She told me that if I had a “case number,” that meant that the case had been closed, and that I’d have to open a new case.
Yes, really. Linda asked me to fax the information to her in order to open a new case. So I wrote yet another letter, in which I expressed my anger and frustration over the fact that I’m now facing the choice of spending the rest of my life with a painful swollen ankle or surgery. I also expressed frustration over the fact that I had realized that because my apartment is on the 2nd floor of my building – up 4 flights of narrow stairs from the garage and up one long flight of narrow stairs from the front lobby – having surgery and being on crutches would render me basically unable to take care of myself. There is no way in hell that I could make it up either flight of stairs with groceries or laundry. I would be on disability, which would represent a loss of income. With my latest letter, I also faxed Linda copies of my previous letters and the emails by which I had cc’d Regal. Nine pages.
I was pissed. I don’t know how this story is going to end, but here it is, 14 months – FOURTEEN MONTHS! – after I first went to urgent care for Xrays of my swollen and painful ankle.
This is our wonderful healthcare in America. This is crap. And yet, this is what the Republicans claim is more than I deserve, and want to take away from me. Go figure.
If I was rich, this would never have happened. But because I’m just a wage slave and I’m currently making less than I was several years ago because I got laid off from my job because my company was hemorrhaging money because the economy was being flushed down the crapper, I can’t afford the $200 per month it would cost me to have a PPO plan, this is what I get: the runaround, delayed, screwed over, ignored, blown off.
I’m not sure yet what I’m going to do; neither of my options is appetizing, but unless I want to wear flats or sandals for the rest of my life, surgery is the only answer.
I’ll keep you posted.