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Greedy Insurance Company Backs Down: The Little Guy Wins!

A few months back, while we were on vacation in Washington, D.C., my 17-year-old son Noah sustained an injury at 1:00 a.m. I was asleep, but this is usually a few hours earlier than he typically retires. In our hotel room’s bathroom, he dropped a glass and then managed to step in the wrong place. A sharp shard sliced through the soft skin between his great and second toes. Blood was spurting wildly and he woke me up with a shout. He was spooked.

We gastroenterologists are experienced at stanching bleeding, although I was uncertain how to do so without some kind of scope in my hand. I reflected on my ACLS training, which is a comprehensive 2 hour course that my partners and I take every 2 years. In between those sessions, I neither think about nor practice any advanced life saving procedures. It doesn’t seem rational that a community gastroenterologist should be schooled in temporary pacemakers, when most of us haven’t interpreted an EKG in decades.

I still remember the fundamentals of life support, the famed A, B, Cs, standing for airway, breathing and circulation. I decided to apply this to the hemorrhage at hand.

Airway: the windpipe was open and functioning

Breathing: the kid was breathing

Circulation: BINGO!

After going through this brief but critical checklist, I now knew where to focus. No need to intubate him. No need to call the front desk to rush a defibrillator to the room. No need for chest compressions, at least not yet. I considered tightening a tourniquet around his waist to clamp the aorta, but opted instead to apply direct pressure to the wound. Luckily, this high class hotel was equipped with just the medical apparatus I needed - a wash cloth. Once the bleeding slowed and I was able to visualize the wound, I realized that this was no Scotch tape fix. It was time for a field trip to the ER.

The hotel front desk advised me where to take him and 20 minutes later we were in Sibley Memorial Hospital. The care was excellent and the sutures were applied expertly by Gregory Cope, M.D. Two hours after our arrival, we were back in the hotel room. I decided not to rouse the kids at 9 a.m. for our intended trip to Ford’s theater, a site that has been deferred for a future trip.

Nothing is certain but death, taxes and emergency medical care bills. I reviewed the explanation of benefits form I received, which are never easy for me to unravel, even though I am somewhat of an insider of the medical profession. One of the 2 charges that I am responsible amounts to $391.50. I phoned my insurance company, always an opportunity for stress management, and reached a living breathing human being. Of course, I was first greeted by a mechanical voice who assured me that my call was important to them. Melanie, the insurance company customer service representative (Any reader agree with me that the phrase customer service is a euphemism?) explained that I had selected an out-of-service facility and was charged accordingly. After some research, she determined that there were in-network hospitals in the Washington, D.C. region. See what I mean about stress management?

“Melanie, let’s forget for a moment that I am a doctor and that you are an insurance company tool. It’s two o’clock in the morning. I am 500 miles away from home. My son’s foot is spewing blood. While you might regard me as irresponsible, I never contemplated whether the hospital was on the formulary. Should I have researched this issue then? How would I have done this at that hour? It’s challenging enough to reach a living insurance company soul during ordinary business hours. I wonder what my son would have thought if I told him we had to wait for authorization before we could leave the hotel. I’m sure this would have elevated his opinion of me as a doctor and a father.”
Melanie checked with a superior who agreed that under these circumstances they would reprocess the bill as an in-network charge. Victory! How much will I save? Probably, only a few bucks, but some victories are not measured in dollars. I ‘stuck it to the man’.

I have learned an important lesson from this experience. The next time I’m traveling with kids, I’m bringing paper cups.


  1. Glad to hear everything worked out in the end. I agree with all of your sentiments except one - your calling the insurance rep a "tool". Melanie certainly did not make an out-of-network decision of her own accord, nor have any authority on her own to do anything other than what she has been trained and hired to do. She is likely making a fair, but relatively low wage. In the end she did check with her manager and in the end you did "win" and get an in-network charge.

    None of this qualifies Melanie as a "tool". She is a person working at an insurance carrier, and earning a living, and deserves a bit more respect, regardless of what you may fell about the policies and processes established by her employer.

  2. Terence, fair point re use of the 'tool' term. No disrespect intended. Still friends?

  3. Glad you prevailed here. Every time I deal with something like this for my own health care, I think about all of the poor folks who don't have the training we have or the expertise to deal with these non-transparent, complex insurance issues. I frequently advise patients how to advocate for themselves. It shouldn't be this way!

  4. Just follow this link

  5. If government had complete control of healthcare we would never have to worry about dealing with a large impersonal bureaucracy.

  6. @AB, I applaud your ability to see the silver lining!

  7. Not medico, but interesting.....

    Interstate fraud (Ohio/WV) via illegal compromising of the WV State computer

    Approximately two weeks ago [About Aug. 5th] I called the West Virginia Secretary of State’s office (304-558-6000) where we spoke of a number of properties in Ohio County, WV. that belong to a Rivertowne Limited, Inc (RLI).
    This Monday and today, August 17, 2011, I was told by the WV SOS office that they have no record of a Rivertowne Limited, Inc.
    In 2007, according to the Ohio County, West Virginia’s County Clerks office, the state of WV took over at least one property owned by RLI for taxes.
    I have in my possession a number of deeds and ownership records, from the Ohio County, WV Assessor’s office (304-234-3656) and the Ohio County, WV County Clerks office, show that a Rivertowne Limited, Inc. does exist.
    Rivertowne Limited, Inc is listed on the deeds as an Ohio company BUT I called the Ohio Secratery of State’s office and they, also, have no record of Rivertowne Limited, Inc. and perhaps Ohio never did BUT West Virginia did and now, they don’t.

    This is how things stood Aug. 17th, 2011.

  8. I share your frustration and applaud the victory...small but so sweet.

  9. It's amazing you got the to actually consider it in-network. My sister's insurance flat out denied it even after she had proof she was on a business trip 5 states over. I think insurance companies could hold their ridiculous rules if they at least provided better tools for clients. Maybe a lookup using a zip code or an emergency hotline where people can call so they can get an in-network physician. Bonus points if they can help you set up an appointment or let them know that you are on your way. Wouldn't you love to see something like that in action?

  10. Although I'm a physician, whenever I am a patient or the father of a patient, I am reminded of what my patients endure on a regular basis. Sick folks have enough on their minds without fighting with insurance companies, even though my 'call is important to them'.

  11. I am glad you were able to get some justice in this situation. It is ridiculous for insurance companies to expect people to consider their "rules" when their child is put in an emergency situation. Especially when most people do not know what these rules are. Thanks for sharing your experiences!

  12. hi Dr. Kirsch. I have experienced the brutaility of insurers rules and EOBs. I found Simplee pretty helpful. I hope it does wonders for your family as it has done for my life!


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