Pain in the Neck

How a Doctor Persuades HMOs To Pay

Dr. Jordan Stern treats cancers of the neck and throat. But the surgeon also has another specialty: getting managed-care companies to pay his patients' bills. As Stern puts it, the illnesses he deals with "aren't among the choices listed in their computers." And as a result, says Stern, insurers routinely refuse to pay for the treatments his patients need— things like feeding supplements, dental work, and various therapies. "They think all these little extras are luxuries," says Stern. "But for people with serious conditions, this is basic medical care."

In response to such denials, Stern sometimes calls the HMOs' medical directors to advocate for his patients. He is a compelling speaker and, no doubt, puts forward a convincing argument. But Stern knows that what makes his arguments most persuasive is the fact that he tapes them. "I tell them I'm going to record the call for quality assurance purposes," says Stern. "Ninety-nine percent of the time they change their minds after that. But it takes hours of my time. And my blood pressure doubles every time I do this stuff."

Aggravating though they may be for him, Stern's efforts have made life easier for many of his recovering patients. "He's God-sent," 70-year-old Frank Foertsch says of Stern.

Earlier this year, Stern removed a tumor on Foertsch's neck. As part of such procedures, the surgeon also routinely removes a patient's teeth, which can cause serious infections in radiated patients. But Foertsch's HMO, Aetna U.S. Healthcare, refused to pay for the dental work. Richard Bernstein, Aetna's senior medical director in New York, acknowledged that "most of the time when people ask for dental extractions, the first level reviewer would deny it."

In Foertsch's case, however, there was some urgency. According to Stern, infection was imminent because Foertsch's head and neck had been exposed to high levels of radiation. "This was not a cosmetic procedure," says Stern, who had to write Aetna a letter explaining the medical necessity of the tooth removal.

Bernstein insists it was only logical that the company would need such information before approving the claim— which it eventually did.

At $750, Foertsch's dental bill wasn't particularly high. But it's the regularity with which such requests get denied that especially infuriates Stern.

Elizabeth Riiska, another of Stern's cancer patients, has also had bills for his treatments denied by her HMO, Empire Blue Cross and Blue Shield.

Riiska, 61, has been unable to speak since Stern removed her voice box along with a tumor last July. But as her husband, Charlie, tells it (while Elizabeth scribbles notes), he put up a fuss before Empire paid for certain "extras," including some prescription drugs, nursing care, and a pump to clear the mucus from Elizabeth's lungs. "They're unfamiliar with her problems," says Charlie. "The first girl I talked to didn't even know what a laryngectomy was. She thought it was a tooth extraction." (Empire did not return calls about this story.)

Stern has been helpful getting these bills paid, and the Riiskas are especially pleased with his suggestion that they request letters from Empire promising— in advance— to cover treatment. "Without them, we would have been in deep yogurt," says Charlie.

The Riiskas are not yet entirely out of the yogurt. Elizabeth, who communicates with her husband through lip-reading as well as notes, still requires therapy so she can learn to speak using her esophagus. When Charlie goes out at night to his part-time job as a cleaner in the local public schools, Elizabeth is left alone. And Charlie worries. "She can't call anyone on the phone, because what would she say?"

According to Charlie, an Empire representative has told him that speech pathology is not covered under their policy. The Riiskas are nevertheless confident the company will ultimately come around and pay for the therapy, which costs $90 for a 45-minute session.

When the Voice contacted Blue Cross and Blue Shield of Illinois (which provides the Riiskas' health care through Charlie's Illinois-based former employer), media relations manager Tony Rau acknowledged that Elizabeth Riiska is entitled to vocal therapy. "All I can say is there was probably some sort of mix-up in the paperwork and where it was sent," says Rau. "She is absolutely covered."

Stern, of course, applauds the Riiskas' get-what-you-deserve approach, but he insists it's the exception rather than the rule. "The insurers will try to get away with paying the least amount of money they can," says Stern. "And most people just let them."

slerner@villagevoice.com

 
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