How having an HMO for health insurance has failed my child

How having an HMO for health insurance has failed my child

From my two previous posts, Ice skating: 4 skates, 2 wrists and an E.R., and Trichotillomania, left wrists and dislocated thumbs: why this mom totally lost it today, many of you know that my girls got hurt 20 minutes apart the very first time they went ice skating.

This should be the final installment in this series, at least until the fallout from this blog starts. <Heavy sigh>.

When I last checked in with my girl's health status, we were still in a bit of limbo; no longer.

The short version for my youngest is that she is not broken - PRAISE GOD! - and only has a sprained wrist. Whew.

As for my oldest, we were told by the local orthopedic that she had a dislocated thumb and may need surgery to fix it. So, they placed her in a cast, and we were referred to a pediatric orthopedic specialist.

If you are unfamiliar with how HMO's handle these things, I'll explain...

 1. You must choose a primary care physician (PCP)

2. You must go to the PCP for everything, or get a referral to see someone else. (Yea, good luck).

3. If you are fortunate enough to get the referral in less than 10 days (especially if you just happen to call, or are seen on a Thursday or Friday) you've done well.

4. If you do anything without a referral, your HMO may not cover anything. Excellent.

Because my girls' pediatrician is part of a massive co-op of doctors which includes several specialties, I was able to take them to see the orthopedic without a referral from their pediatrician, as long as I stayed within the group. I was at the mercy of whomever happened to be available to see us - our choices were limited.

After seeing the orthopedic (whom I felt was a bit dismissive - he looked really tired, too), we were referred to a doctor that floats between Rush-Copley in Aurora, IL and Advocate Children's hospital in Oak Lawn, IL. (Perhaps other places, too, but those are the only two I am aware of).

Rush isn't too far from home, but Advocate Children's is nearly an 80 mile round-trip for us.

So here's the timeline and why I've chosen to write this blog:

  • 04/04 - both girls fall ice skating hurting their wrists.
  • 04/05 - take both girls for x-rays and eval at the ER. Both get splints.
  • 04/07 - finally get an ortho appt set for my oldest.
  • 04/10 - my oldest is seen by the ortho with the results I explained above.
  • 04/10 - I send in (via online scheduling) a request to be seen by the specialist.
  • 04/14 - I received a call from the scheduling department and received the earliest possible appointment on April 22nd, but I had to have the referral from the first orthopedic's office in hand or my daughter wouldn't be seen.
  • 04/17 - I take my youngest to the same orthopedic's office as my oldest, but get a different doctor. She's cleared with a sprain, but the referral for my oldest was still not available.
  • 04/18 - I finally receive a faxed copy of something from Kim (the only one I felt advocated for me at this time) that looked like a referral, but said on it that it was not a referral.
  • 04/21 - The actual referral arrives in the mail; the day before our appointment with the specialist. (Nothing like waiting until the last minute).
  • 04/22 - I pull my oldest out of school for the day, we drive nearly 40 miles one-way, deal with a hospital under major re-construction, end up in an outpatient waiting room with a "cattle-call" feeling to it, then are escorted to an exam room after about a 10 minute wait. (Not a bad wait).My girl's cast is cut off, she is examined by a physician's assistant and what I believe to be a resident. The doctor we had the appointment with never set foot in the exam room, and never saw my child.

    We were then told that she had a severely sprained thumb, that she would need a spica splint for 2-3 weeks.

    They gave us a prescription for said splint and told us to come back in three weeks if she wasn't better. (I still don't understand this, because it would probably take me another two weeks to get an open appointment).

    We drove all the way back home with a stop on the way at the specialty splint place to get the splint that was prescribed for her.

    Let me make this clear, though. The staff at the children's hospital cut a cast off my child, then made us leave without a splint of any kind. Nothing. It never dawned on me that what happened next would happen.

    The splint place said that they needed another referral in order to make the splint, or our HMO insurance wouldn't cover it. The prescription did not constitute a proper referral.

    They told us that they were willing to make the custom splint for her right then, but that without the referral we'd be stuck paying the full amount out of pocket.

    While sitting in the parking lot at the splint place, I started making phone calls. When I finally got through to a person, Darlene was wonderful and lovely. She worked really hard to find an answer for me regarding a referral.

    Then, I was put on the line with another wonderful, lovely person, Deanna. She worked really hard to find out more info for us, but said that she wouldn't have an answer right away, and we might as well go home. Swell.

    When I got home I googled the splint name and found that first splint my youngest received in the ER was similar to the type of splint my oldest was prescribed, so I put her in that one "temporarily" until we could get the custom-made one she was supposed to have.

  • 04/24 - Yes, two days later, I still hadn't heard anything about the referral we needed for the splint, so I called the ortho's office and asked for Deanna. Deanna was out of the office and no one else would help me - not one person. Grrrr....
  • 04/25 - Deanna called me back at 4:30pm, explaining that they still didn't have the office notes from the specialist's office and that it may take as long as a week after they get the notes for the referral to be approved. SERIOUSLY? She was sweet and apologetic, but her hands were tied until the outpatient staff at the children's hospital cooperated.

Essentially, my daughter might get approval for the splint she was prescribed when she no longer needs it.

The HMO system of referrals is broken. It does not work. I'm sure if the situation was more life-threatening, and if I hadn't seen the significant, God-produced healing of my daughter's thumb, I would have been more aggressive pursuing those office notes from the children's hospital outpatient staff.

The point is this - I shouldn't have to. I should not have had to make any calls if the outpatient staff at the children's hospital had done their jobs in the first place.

So, to you Dr. Prasad Gourineni for never seeing my child and for having staff that is uncooperative, to Dreyer Medical Clinic for partnering with and referring patients to uncooperative physicians and staff, and BC/BS Blue Advantage HMO for having a referral system that makes it unnecessarily difficult to get good health care -  you have failed my child.

Shame on all of you.

***UPDATE***  04/28 - Just received a phone call from Deanna, the gal working so hard to get us the referral for the splint. The referral is finally at the splint place a full 7 days after my daughter was supposed to have it. Thank you, Deanna, because without your hard work, we may have still been waiting for it.

Matthew 18:21-22 (ESV)

21 Then Peter came up and said to him, “Lord, how often will my brother sin against me, and I forgive him? As many as seven times?” 22 Jesus said to him, “I do not say to you seven times, but seventy-seven times.

Psalm 118:8 (NIV)

8 It is better to take refuge in the Lord than to trust in humans.


Have you ever had a similar experience with HMOs? Tell me about it here!!

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