Blue Cross: Transplant Candidate Fails for Marketplace

Frank Dungan of Madison needs a liver transplant, but his health hasn’t been the focus of the past few months. His focus was the battle between his insurance company and the hospital that left him without insurance coverage in the state’s only organ transplant program.

But as of July 1, Dungan has switched insurers and is getting the medical care he had to delay — and most importantly, he’s back to “active” status on the transplant list.

After Dungan’s hospital, the University of Mississippi Medical Center (UMMC), went out of network with his insurer Blue Cross & Blue Shield of Mississippi on April 1, Dungan spent months trying to get answers about what that meant for him. UMMC has marked him as “inactive” on their transplant list, meaning that if the perfect liver becomes available, he won’t get a call.

Blue Cross referred him to the transplant program in Memphis, which was more than three hours away from his home, a logistical and financial nightmare. He knew very little about the program and had spent years building relationships with his doctors at UMMC, which houses the state’s only transplant program.

Neither Blue Cross nor UMMC would give him answers about what his out-of-pocket costs would be if he received a transplant through UMMC while still out of network with Blue Cross. In May, Mississippi Insurance Commissioner Mike Cheney stepped in and sent a letter to the insurer and UMMC asking them to provide him with what he needed.

But Dungan said he couldn’t get definitive answers and never received anything in writing.

“It was to the point where it would drive you crazy. Every time the phone rang you were trying to figure out what other fucking problem we had,” he said.

UMMC and Blue Cross agreed to mediation to try to resolve the contract dispute, but more than two months after the hospital went out of network, a resolution still appears unlikely. Neither UMMC nor Blue Cross would talk publicly about how negotiations are going.

The dispute stems from disagreements over reimbursement rates, with UMMC insisting that Blue Cross is not fairly reimbursing the safety-net hospital for its services, and maintaining Blue Cross’s rate increases would require significant increases in premiums for members. Hospital reimbursement rates are not public.

In June, as he was pushing appointments with various specialists before the grace period for certain Blue Cross members’ continuity of care at UMMC expired on July 1, one of his doctors discovered something troubling. He had esophageal varices, a condition that requires a medical procedure that uses elastic bands to tie off bleeding veins. If left untreated, varicose veins can rupture and cause severe internal bleeding.

The condition usually occurs in people with serious liver disease.

Dungan said his UMMC doctor told him the bonding procedure would be “on my dime.”

Dungan was frightened. He worried when he went to bed every night that this would be the night he would bleed. He knew something had to change.

“I found an insurance consultant (Marketplace) and asked them if there were any options (for me)… See, my insurance agent in my hometown told me that you can’t get health insurance except in December, even he gave me the wrong information, Dungan said. “I was concerned about it, concerned about the premiums, concerned about the language … I didn’t understand some of the language (of the policies).”

He contacted an insurance broker trained in federal Marketplace plans and found out he didn’t have to wait until December to sign up for a plan.

“She walked me through the specifics of the policy and I found it covered what I needed,” he said. “She explained the deductible, the pocket and the premium, everything.”

Dungan, who had an individual policy with Blue Cross, is now covered by Ambetter, which offers health plans in the federal marketplace and is accepted by UMMC. He underwent two procedures to deal with esophageal varices earlier this month and visited his dentist to make sure he didn’t have any infections in his mouth — a requirement to regain his place on the transplant list.

Switching insurance is not an option for some people, especially those whose employers only offer Blue Cross to employees.

But he’s starting over with his insurance: He has a new out-of-pocket limit to meet of about $8,000. But his monthly premium dropped from nearly $1,200 with Blue Cross to $402 with Ambetter, he said.

“I came back confident that I was getting good health care and confident that my bills wouldn’t be outrageous,” Dungan said. “I’m confident (UMMC doctors) are keeping an eye on me.”

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