Health insurance provider approves post-surgery hospital stay after I-Team's Call for Action gets involved
BOSTON - A Cape Cod woman reached out to the I-Team's Call for Action after struggling to get her health insurance provider to approve an overnight hospital stay for a major surgical procedure.
Trigeminal neuralgia is a painful condition that sometimes requires surgery to treat. Lynne McGraw says, for her, the pain was debilitating. "I have constant pain as if somebody has stabbed me and left the knife there," Lynne said. "It feels like I'm being electrocuted. So, very painful."
Operation involves neurosurgeon
Drugs and a less invasive procedure did not work for Lynne. She needed the delicate operation that involves a neurosurgeon making an incision in the back of her head and putting a pad between the affected nerve and the arteries to relive the pressure and the pain.
If successful, Lynne would get immediate relief. But it is not always permanent. The condition is chronic, and Lynne did have the surgery once before years ago. In June the pain came back. Lynne says her only option is to have the surgery again. "I can't do anything to feel better," Lynne said. "I can't put ice on it or heat because it makes is worse."
The problem at first, Tufts Health Plan, Lynne's provider, did not have an in-network doctor who specialized in the procedure. After a little back and forth, Tufts agreed to let Lynne go out of network for a surgeon. Relieved, Lynne thought she was all set. But there was another problem. Lynne says Tufts would not pay for an overnight stay at the hospital. "They approved it but I had to be an outpatient - you are going to put a hole in the back of my head and send me home the same day," she said. "That didn't sit well with me, and the surgeon wouldn't do it anyway."
Frustrated, Lynne and her surgeon tried for months to get Tufts to approve the inpatient stay. Lynne told the I-Team's Call for Action, "It's like I'm in tears every day. There were days I didn't want to call there because I'd end up in tears. I had to hang up on a guy because he was telling me everything had to be resubmitted. I really have a feeling they wanted me to just quit and just oh OK I'll stay in this kind of pain for the rest of my life."
That's when Lynne reached out to the I-Team's Call for Action.
Tufts Health Plan response
After we contacted Tufts Health Plan, a company spokesperson said in an email:
"We routinely process thousands of such requests every year without any issues for our providers or members. For this particular request, this issue was parallel requests being submitted by the provider and the facility at different times. The request for inpatient level of care at the hospital should have been included with the request for the surgical procedure or submitted subsequent to the approval of the surgical procedure."
• Our team reached out to the provider on Monday, October 14, requesting the date of the planned procedure, which is required to issue an approval for the inpatient stay. We are still waiting for this information from the provider.
• Our team is reaching out to the member today alerting them that this will be approved once we receive the date of the procedure from the provider.
• We will also make reasonable efforts to re-educate the provider / facility about the appropriate process for similar requests so that such outcomes can be avoided in the future, as best possible.
Tufts approves surgery as inpatient
The next morning, Lynne heard from staff at her surgeon's office, telling her things change day to day, and that Tufts approved her surgery as an inpatient. "No, I think it was an email from you that changed day to day," Lynne said.
Lynne recently had the surgery and is recuperating and doing well. Her doctors say it will be several months before they will know if the procedure worked.
