Word: transplant
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...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...
SEPT. 3 A phone call from Joe Robbins, a Duke financial coordinator, to Jackie Brown, PHP's transplant coordinator, was the first anyone at the insurance company knew of Hunter's whereabouts. Both recognized that the patient was "out of network," but it would be weeks before anyone would sort out how it was that Hunter ended up in a hospital with no plan to pay for an operation that could cost anywhere from $80,000, if the procedure went smoothly, to perhaps $1 million, if complications arose. The precipitating error apparently took place in the back offices of MUSC...
...patient could stay at Duke through the weekend, but if he stabilized during that time, PHP wanted him flown to Tuscaloosa, Ala., on Tuesday. O'Connor also told Trotter, according to the insurer, that if Hunter's condition worsened over the weekend, Duke was "authorized" to perform a transplant...
...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...
...already cleared Duke to do Hunter's transplant, why move him at all? Because PHP's go-ahead was offered on its terms, which put a cap on the amount of money the insurer would pay Duke, no matter what the operation ended up costing. While neither side has been willing to reveal what those terms were, it's a good bet that the number was on the low end of what Duke was likely to spend; on average, Duke's bill for a liver transplant runs about...