No matter where you are on your transplant journey, you have much to ponder. Regardless of what you might face right now, you probably never have a day when you wake up and feel excited to think about your insurance and medical finances.
I’m a nurse, so I’ve heard words like “insurance” and “reimbursement” for decades. I understand the basic idea and know it can get complicated. I’ve handled numerous phone calls from patients (and family members) who need a test or a medication, but their insurance company is giving them a hard time. I didn’t really get it until I spoke to Judy Maltz, Board Vice President of the Transplant Community Alliance.
Before I talked to Judy, I thought insurance reimbursement was like using a coupon at the grocery store. If Campbell’s soup is on sale at Safeway and I go there with my Safeway card and a coupon, I can get the Safeway discount plus some money off for using the coupon. But at Costco, my Safeway card and coupon are useless.
After listening to Judy, I realized insurance reimbursement is more like trying to do your taxes, only worse. It’s like trying to do your taxes in a world where instead of one IRS, there are hundreds of them, with countless pages of rules that are all different and constantly changing.
Who could keep track of all that? Patients can’t. So, it must be someone’s job, right? But Judy said it’s not. Physicians are busy caring for patients and learning about the latest treatments. Most transplant centers have a financial coordinator who will handle pre-transplant care and the transplant itself, but usually not the years following the transplant. Even though, as Judy says, “The needs don’t end with the procedure – it’s an ongoing thing.” Social workers can help investigate when things go wrong, but it’s not their primary expertise.
Regarding reimbursement, Judy says, “You need to know how to ask the right questions and get to the right people, or you get thrown around in the system.” Understanding everything that happens with insurance reimbursement is a full-time job. Judy understands it because it has been her full-time job. She has worked in this field for over 25 years – through the advent of HMOs and the introduction of Medicare Part D. She knows where everything started and what the changes have been. She has followed the laws affecting transplant patients since she began in transplants in 2005.
Judy is passionate about using her knowledge to help transplant patients get what they need to thrive. Sometimes she gets phone calls from social workers or transplant coordinators, and sometimes people reach out to her directly.
Many start with an upsetting and expensive surprise (Judy calls it a “short-term catastrophic situation”), like an unexpected bill at the pharmacy counter. Patients without any changes to their insurance or med regimen are suddenly told they have a copay of several hundred or even thousands of dollars.
Then Judy goes to work. She says, “I would never just give a patient a phone number and drop them into the black hole of Medicare.” Instead, she does the work herself. She may find something wrongly switched deep within the pharmacy benefit manager and get it corrected. She adds, “I just never stop. I will pursue something to the very end.”
One time Judy found that a patient had faithfully continued to pay his Medicare premiums – even after he was no longer eligible for coverage. She proved to Medicare that they should not have been billing that patient, and Medicare gave him his money back – a total of $7,500.
She said, “I need to be hearing more from our patients because I know these situations are out there.”
Luckily, transplant patients can reach out to someone warm, friendly, knowledgeable, and who wants to help. If you’re not sure you understand your insurance coverage, you don’t have to suffer through nagging worry while hoping for the best. If something seems wrong with your reimbursement, you don’t have to figure out the problem alone. You can focus on your health and let a specialist help you with the insurance. Just Call Judy.
-written by Andrea Perreault, RN