Advertisement - Click to support our sponsors.
The state's strongest advocate for patients and doctors in battles with the Hawaii Medical Service Association now has a personal dispute with the insurance carrier. State’s patient advocate
in dispute with HMSABy Helen Altonn
Star-BulletinHMSA rejected a request by Arleen Jouxson-Meyers, Hawaii Coalition for Health president, to pay for a high-tech test to determine if a large polyp in her husband's colon was cancerous.
Her husband, Edwin, had the test Sept. 5 with the Positron Emission Tomography scanner at the Queen's Medical Center. It was done on an outpatient basis, involving about three hours for preparation and the scan.
The couple paid the cost -- $3,500 -- although Jouxson-Meyers said her husband is covered by HMSA's Preferred Provider Plan, "their Cadillac coverage."
'Finding no support internally,
the (HMSA) medical director went to five different
specialists in the community, several oncologists,
and no one would support use of a
PET scan for this procedure.'
Cliff Cisco
SENIOR VICE PRESIDENT, HMSA
"The great part of this is it was totally negative -- ruling out a malignancy," said the health coalition leader, also a pediatrician and lawyer. Her husband runs her business office."He can go forward with having it shaved off in a procedure that will take only a couple days. We have just saved HMSA many thousands of dollars."
Dr. Ronald Wong, colon and rectal surgeon who recommended the PET test, said the alternative was high-risk surgery involving six or seven days in the hospital and five to six weeks for recovery.
Instead of $3,500, the cost would have been "in the vicinity of $20,000 maybe," Arleen Jouxson-Meyers said.
However, HMSA told her by telephone that it was denying payment for the PET scan, although she has yet to receive a written denial.
She plans to appeal the decision with HMSA. If coverage is still rejected, she'll appeal to the state insurance commissioner under the patients' bill of rights that she helped to draft and get enacted into law.
Cliff Cisco, HMSA senior vice president, said an internal review of the PET scan request showed no evidence supporting its use for the condition involved.
"Finding no support internally, the medical director (Dr. Joan Kendall) went to five different specialists in the community, several oncologists, and no one would support use of a PET scan for this procedure," he said.
"To make sure we were doing the right thing, we went to an external review organization, the Center for Health Dispute Resolution, and they had a nuclear medical specialist review the case, and they also confirmed our decision."
Queen's PET scanner, which doubles the power of other scanners, is one of few in the world. It is used to assess patients for heart disease, strokes, Parkinson's and heart disease and forms of cancer without surgery.
"We have just saved HMSA
many thousands of dollars."
Arleen Jouxson-Meyers
PRESIDENT, HAWAII COALITION FOR HEALTH
Since it is new technology, Cisco said, HMSA bases decisions on its use on documentation and there was none for Edwin Jouxson-Meyers' condition.Arleen Jouxson-Meyers said HMSA's medical director sent the request to the independent review organization before calling her husband's surgeon and getting all the information.
"My charge against them is they have made this decision to deny it arbitrarily and capriciously. Obviously, they did not give specifics of my husband's case to the review organization."
Wong said, "This is the kind of stuff we deal with on a day-to-day basis with third-party payers."
HMSA has paid for some PET scans but is "very limited in what they will approve for rectal or colon cancer," he said. "The whole issue is the ability of third-party payers to control delivery of health care, which interferes with our decision-making."
Wong said, "We're not trying to abuse the system, but when information would be helpful in making big decisions, we order it ... This is a big deal in terms of a big operation or no operation."
He said a gastroenterologist removed several polyps from Edwin Jouxson-Meyers' colon through a scope but left a large one that was highly suspicious of cancer.
"I put it in the category of a 'funny-looking' polyp," Wong said. "In our experience, those are ones that could potentially harbor a cancer."
However, he said, HMSA "looks at it as a broad category of polyps" because "the vast majority are not cancerous."
Dr. Marc Coel, director of Queen's nuclear research department, said the PET scanner is being used about 90 percent of the time for tumor or cancer detection and monitoring after therapy to make sure it works.
Coel said he feels the PET scan was appropriate for Edwin Jouxson-Meyers and its use should be expanded in terms of insurance coverage. "But it's new ground for HMSA."
He said Robert Nickel, HMSA senior vice president, was involved in setting up criteria for the scanner.
The case of Edwin Jouxson-Meyers "is in a gray zone they haven't addressed yet," he said. "But HMSA has been very receptive to learning about PET and how it can be used."