By Amy Silverman
By Olivia LaVecchia
By Monica Alonzo and Stephen Lemons
By Chris Parker
By Michael Lacey
By Weston Phippen
In September, the Lees called PacifiCare's member-services hot line to ask how to get a referral outside the network. The service rep told them to see their primary care physician, Dr. Willcox.
Willcox, of course, had already referred them to McLean. But, a month later, after more badgering by the Lees, Willcox finally asked PacifiCare to refer the Lees to Blackman because the Lees didn't want to see McLean--again.
Reason? "You must utilize the contracted facilities and physicians within your network. . . . Dr. Terry McLean is contracted in your network," the form letter, signed by Dr. Robert Sorrentino, a PacifiCare medical director, said.
Now PacifiCare--not just one of the doctors--had finally made a decision. David Lee made his first appeal.
Two weeks later, along with Blackman's analysis of Shawndra's most recent x-rays, Lee sent a letter to PacifiCare. "If my auto insurance allows me to take my car (with a projected life of 10 years) to the auto body shop of my choice . . . why can't an HMO allow me to take my only child (with a projected life of 70 years) to the doctor that I believe would provide the best care?" he wrote.
Lee even offered to shoulder some of the costs. "I've told them, 'If it's a matter of cost, tell me how much you're willing to pay, and I'll pay the rest,'" Lee says. "If it's a matter of plane tickets and hotel rooms, I'll pay that. I've made all these offers, and they just keep giving me the run-around."
In November, Lee got a letter from PacifiCare acknowledging his appeal, but warning that the HMO could take up to 30 days to make a decision. Lee called the hot line again to request an expedited appeal. Sorry, he was told. Only a physician, not a patient, can request an expedited appeal.
On the 30th day--December 15--PacifiCare sent back another denial. Reason? This form letter parroted the first: "The basis for this decision is, the member must use contracted facilities and physicians within the network."
What Lee didn't know at the time was that the man who decided his first appeal, Dr. Robert Elk, another medical director at PacifiCare, didn't even have Shawndra's records in front of him when he did it.
Lee sent x-rays and information from Blackman to PacifiCare as part of his first appeal, but Elk knew little about spinal surgery. In fact, none of PacifiCare's medical directors who reviewed the Lees' case have any experience in spinal surgery. McLean, who did, refused to get involved, saying he didn't want to be drawn into the appeal. He did not send Shawndra's records or his opinions to Elk when asked. So Elk, without any further research, denied the appeal. Elk never knew McLean had once suggested the less intrusive surgery "was certainly an option" for Shawndra.
By this time, Lee was getting angry. He still didn't know his daughter's condition was deteriorating. And he had yet to hear a medical reason why the surgery PacifiCare was offering was better than the surgery Blackman offered. Even PacifiCare's specialist had said it was an option.
The cycle was becoming vicious. Lee wanted a surgery available only outside the network. The HMO said no. Why? Because you have to stay in the network. To get out of the network, you have to appeal. Your appeal is denied. Why? Because you have to stay in the network.
So, after roughly six months of run-around, Lee called the hot line again. This time, he told the service rep he would appeal--again--but he also warned that he would be protesting with a picket sign in front of the HMO's offices, all through Christmas week.
For the first time, Lee got a call back from someone who was making decisions about his daughter's case. Dr. Kenneth Davis, another PacifiCare medical director, promised that he'd arrange for Shawndra to get a second opinion from Dr. Gregory White, another orthopedic surgeon.
"It's like they were playing musical chairs with all these medical directors, so you never know who's responding to you," Lee says.
On December 21, Lee and his daughter showed up at White's office. They were told PacifiCare had made the appointment, but hadn't provided a referral number, and if they wanted to see the doctor, they'd have to pay $270. Up front.
David and Shawndra left. They went home and began making picket signs. Shawndra called friends over, and they helped, even agreeing to picket the offices with the family.
The signs said things like, "The HMO That Stole Christmas" and "My Car Has More Rights Than My Daughter," Shawndra recalls.
Just before 5:00 that evening, Lee got a call from Dr. Elk, the medical director who'd turned down David's first appeal. Elk apologized for the mix-up and said that Dr. White would see them the next day.
Lee says Elk promised that if White recommended the new procedure, PacifiCare would cover it. Elk now says he may have made that agreement.
Lee was skeptical. He says his caller ID showed Elk was calling from White's office. Elk says he made the call from his own office, and White says no one from PacifiCare has been to his office.