Word: liverance
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What precisely caused Hunter's liver to go bad would never be firmly established, though his doctors speculated that an antiseizure medication he had been taking might have played a role. What was important was that he was getting sicker. His doctor at Greenville Memorial decided that Hunter should be in a hospital where liver transplants are done. The nearest one was the Medical University of South Carolina in Charleston. The question of insurance was not a consideration in his decision...
...MUSC, Hunter became a patient of Dr. Adrian Rubin, who agreed with the Greenville doctor that Hunter needed a new liver but who also recognized that insurance was very much a factor. Rubin consulted with the hospital's financial staff, which confirmed that MUSC did not have a liver-transplant contract with Hunter's carrier, Physician's Health Plan. But, Rubin was told, Duke, where he knew the liver people, did have a PHP contract. So the physician recommended that Hunter go there. Rubin placed a call to Duke hepatologist James Trotter, explaining that he had a seriously ill transplant...
...went smoothly, to perhaps $1 million, if complications arose. The precipitating error apparently took place in the back offices of MUSC in Charleston, where someone misidentified Duke as a PHP contractor. One possibility is that PHP's contract with Duke to do bone-marrow transplants was misconstrued as a liver contract. Another is that Physician's Health Plan was confused with another provider that is also sometimes referred to as PHP: Partners National Health Plan, a North Carolina insurer that does have a liver-transplant contract with Duke. "It's an alphabet soup out there," complains Karyn Bowie, director...
...wife Kim, along with his parents, followed him to Durham, where they all checked into a double room at the Brookwood Inn, about 500 yds. from the Duke Hospital entrance. On Friday, a biopsy revealed that Todd was deteriorating fast, headed toward "fulminant hepatic failure." Without a new liver soon, he would die. The family was in no mood to learn, as they did that afternoon from Trotter, that PHP wanted Todd moved to a hospital where it had a capitation contract limiting their financial exposure. Trotter would not tell Kim exactly where they wanted...
...didn't ask that Hunter be sent to Chapel Hill, N.C., in the first place and why PHP's "authorization" was not a simple solution to the problem say a lot about managed-care coverage. O'Connor was unaware that his own company had a liver-transplant contract with UNC because it was really not his company that held such contracts in the first place. In the managed-care business, general-health insurers like PHP often farm out high-cost specialties like organ transplants to secondary insurers who "carve out" coverage of these procedures and do separate deals with hospitals...