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After several years in which Lauersen monitored her condition, Canfield's symptoms worsened to the point that she "couldn't even go over a pothole in a taxi without tears," as she puts it. In February of '96, Lauersen used lasers to remove all the painful growths he could find inside heran operation that could also be done to increase the chances of getting pregnant if someone were trying to have a baby.
The operation was a success, as treatments for endometriosis go. ("Now my cramps don't prevent me from doing what I need to do," says Canfield.) But Canfield's HMO, Empire Blue Cross and Blue Shield, refused to pay her $7620 claim for the surgery, sending her a form letter that read: "Based on the information provided to us, we find no medical necessity for this service."
When recently contacted about Canfield's case, an Empire spokesperson added, "The provider in this case was just indicted by a federal grand jury for committing health-care fraud. We believe the indictment speaks for itself." But Canfield, who says she is on the pill and doesn't want children for another few years if at all, insists that her surgery was absolutely necessary. To prove it, she repeatedly sent Empire voluminous evidence, including letters from two doctors other than Lauersen confirming the surgical diagnosis of her disease and a video documenting the growths inside her abdomen. Nevertheless, she has been unable to get the company to pay her bill.
According to the Endometriosis Association's Mary Lou Balweg, Canfield is not alone in her predicament. "Whether or not women are pursuing fertility treatment, the insurance companies often say [endometriosis treatment] is just fertility treatment," says Balweg.
And the gray area extends beyond endometriosis into a number of conditions. That's because in the bodyif not in the insurance policy handbookgynecological health has everything to do with reproduction. So, like surgery for endometriosis, removing uterine fibroids could be done to improve a women's fertility or for pain relief. The same could be said for removing adhesions left over from pelvic infections.
Even what might be considered run-of-the-mill gynecological care, such as treatment of a sexually transmitted disease or monitoring of an ovarian cyst, has direct implications for fertility down the road. If a patient happens to be trying to get pregnant when she seeks care for these kinds of problems, then the billing questions can get even murkier.
From Lauersen's point of view, insurance companies have unfairly capitalized on this ambiguity. In a letter to Canfield this past April, the doctor wrote that "Blue Cross Blue Shield is attempting to deny payment for all procedures and services performed by this office, claiming that they are all fertility-related and thus not covered....Has anyone seen The Rainmaker, which features a very similar insurance scheme?"
With reference to the recent movie based on a John Grisham novel, Lauersen suggests insurers may be attending to the bottom line before health. But, of course, Lauersen's not the only one suspecting treachery. The prosecutor has listed witness tampering among the other charges, accusing the doctor of urging patients to lie on his behalf in front of a grand jury. All those claims and counter claims are scheduled to be hammered out in a trial this May. Meanwhile, Lauersen's office is open for business.