Health Net - Physician Group Elderly woman ripped off by insurance misrepresentations. Left without any long term care Van Nuys California

May 24, 2008

THE STORY

My mother was having trouble with pain in her back, chest, ribcage and shoulder blade areas. Upon scheduling an appointment through her regular primary care physician my wife became aware that she was turned down to see the regular spine care physician in our local medical facility. Further investigation revealed that my mothers Medicare had been cancelled and replaced by the aforementioned insurance HMO. When we questioned my mother she said this company had contacted her and they offered her "additional long care coverage and better prescription care". When my wife and I checked this out we were informed that my mother had in fact had her Medicare cancelled and now was covered by this HMO carrier with NO long term coverage.

To add insult to injury (literally) they were requiring that she go to another doctor unfamiliar to her approximately 20 miles away to have her pain evaluated. I took my mother to this doctor. He took about five minutes looking at her and looked at her x-rays. He determined in these five minutes that she had a compression fracture in her spine and a simple in office procedure would cure her. He advised she should get an MRI. This was in spite of the fact (in my presence) that she complained of "excruciating pain" in her back, rib cage, chest and shoulder blade areas. He determined there was nothing he could do and she could sometime later see a "pain management specialist." When my wife went to schedule an MRI at the local medical care facility, she was told it was not covered and the only option was another facility about 20 miles away! And this facility could not see her for over a week. When she inquired about seeing a "pain management specialist" she was told nobody knew what she was talking about. This all occurred on the same day. The next morning my mother was in such severe pain that we decided the only viable option was to go to the emergency room.

At the emergency room/hospital they ordered an emergency MRI and sought the original spine care doctor that Health Net denied. They determined that she had a tumor entering into her spinal canal and that she was in imminent danger of paralysis. Emergency surgery was performed to remove the tumor. During surgery they determined that the tumor was malignant and also was in her lung. A portion of her lung was also removed. Six days later she had to have another 5+-hour surgery to put a "cage" on her spine and fuse T3-T7 thoracic vertebrae.

THE REAL TRAGEDY

Yesterday I visited my mother in ICU. She was in average condition having just had a major surgery three days prior. During this visit I met with the 3 physicians who were attending to her. They informed me that she would need approximately another week in the hospital and then 3-5 weeks of rehabilitative care. After she was through with that we would re-convene to discuss cancer treatment options. A woman in the hospital who said she was the case manager met with me and told me to go visit a few of very limited selections because the Health Net company was only contracted with a few skilled nursing facilities. The local facility was not among them. I got to work about an hour later. This same case manager called me and seemed a bit frantic. She explained that something had changed and that my mother had to go to the skilled nursing facility at that very moment! I exclaimed my outrage and demanded to know who would make this kind of decision? How I asked could someone go from ICU to a nursing facility? She told me that if I didn't concur with her that she would have to tell Health Net I was refusing and that they would deny my mothers insurance coverage. I told her that this was completely unacceptable and that I was not refusing, I wanted to know who it was that had made this decision. She then said it was my mother's primary care physician. I told her that didn't make any sense since I had just spoken to him and he told me she would not be moved for about a week. I demanded that she have the primary care physician call me immediately to discuss this. She called back in about fifteen minutes and said, "I got you 24 hours" and asked that I get up at 8AM the next morning (Saturday) and go visit the nursing facilities and check back by 10 AM. A short while later she called to inform me that they were moving my mother out of ICU and into a regular room for the night and there would be no room for her after that.

THE TRUTH STARTS TO UNFOLD

The next morning I went to the hospital and asked to speak to another case manager. I expressed to her how my mothers insurance had been changed without her complete knowledge and that the provider had convinced her that she was not changing her insurance but rather was supplementing it with long term coverage and better prescription coverage. I explained while we stood over my mother who was wearing an oxygen mask and outfitted with IV's etc. that I did not feel comfortable with the situation and I wanted to file an appeal and to find out who in the insurance company I could speak to in order to file a formal complaint. I then had to go to the nursing facility to check it out. The case manager asked me to give her some time and come back after visiting the nursing facility.

I went to the nursing facility to discover that the only thing they were seemingly interested in was making sure I understood that Health Net/Hills Physicians was in a day-to-day approval mode. Meaning, they could decide on a day-to-day basis when they would cut off the care and leave me with a long term care financial obligation due to the fact that they did not have her covered by long-term care. I told the woman at the facility that the surgical doctors who had performed the surgery on my mother told me she would need 3-5 weeks of ongoing rehabilitation as a direct result of the two recent surgeries. She again wanted to make sure that I understood that Health Net/Hills Physicians would make that determination. I asked who specifically they had making that very important decision. She said it was a woman on contract who was also an RN. I asked what ability I had to disagree with her? She said none! So I said, what if she decides after 3 days that they no longer consider her treatment as part of the surgery? She replied that the coverage would stop and I would need to be responsible for payment.

Now I go back to the hospital to meet with the case manager. When I arrive the primary care physician is there. He tells me that he did not advise to move my mother and that he still felt she need to stay at least until the middle of the next week. At this point I am between distraught, pissed, confused, upset and ready to sue.

As I sit here typing this story, I am bewildered as where to go to try to right this terrible wrong. I may be in a very difficult place because of a heartless company and endless bureaucracy. Just look at their website and see if you can figure out who these guys are. I only have days before this situation blows. If anyone can provide an agency, lawyer, federal office or otherwise, please help.



Casey
Pleasanton, California
U.S.A.