No PET for you

I woke up to my phone vibrating this morning. Unfortunately I was in bed and the phone was in the other room so I didn't have any chance of getting to it before it went to voicemail.

Honestly it was a moot point because the message was the same. My PET scan was canceled because the insurance denied the authorization. Case closed, sorry to be the bearer of bad news.

In the USA many medical procedures and medications require what's known as "prior authorization". That's a fancy way of saying that the insurance company gets all of the relevant details from the doctor's office and makes a determination on whether or not they'll pay for the procedure or medication. In a perfect world there would be a short appeal process to determine what happened and correct this. In our world it means that the procedure was already canceled and now we'll have to reschedule.

After a few phone calls (props to MESSA once again for being there to answer on the first ring.) I found out what happened. Apparently the "clinical information" wasn't sent with the request from Cancer Care Associates. Without that information the authorization was automatically denied.

On the one hand this seems like an oversight of Cancer Care Associates. But on the other hand this also feels like a lot of bureaucratic nonsense. It's not like I'm going to go get a PET scan for funsies. Maybe there are folks who really enjoy their nuclear medicine but I'm betting the majority of folks are going to steer clear of it if they can avoid it. But our fallen world dictates that we optimize for trying to keep people out of expensive procedures.

I'm sure things will get sorted eventually, but it's one more delay in figuring out what is going on with my cancer and how the Lonsurf is working. This was going to be the first scan that I'd have after several months of Lonsurf administration. I'm optimistic that a new scan is forthcoming but tomorrow would have been perfect. I have a break from taking the Lonsurf and no other appointments to speak of. If the PET is in the next few weeks I'll have to schedule it around chemo and tell them that I'm currently taking Lonsurf and any other drugs that I'm using to manage symptoms.

The "mother, may I?" of our current insurance system is pretty maddening. It's not like the insurance company can't paint a picture of what is going on with my treatments since they're the ones authorizing the payments for it. I already have a board of doctors (known as the "tumor board") reviewing my case, but now I have the insurance company to appease as well.

Anyone who has become a ward of the medical and insurance complex in the USA has a similar story to tell. I consider myself lucky because we have fantastic insurance (one of the few perks of JoDee being part of the education system). And I'm a recent addition to this pool of folks who are on a first-name basis with insurance company call-centers and billing departments trying to figure out how to pay for all of this stuff and still get treatment. There has to be a better way to approach this without making something routine like PET scans for cancer patients into an ordeal. Unfortunately we've created so much complexity around this that it becomes an ordeal to even think about fixing it. We reflexively shut down and seek the solace of experts in the insurance industry who are so ingrained in how things currently work that they can't picture the paradigm shift necessary to imagine how it could be done better.

I offer no solutions here because I'm just a computer programmer without deep-seated knowledge of the medical system. All I know is that this system is broken and I'm not sure where to file the bug report. So I'll do the next best thing and blog about it in the hopes that whomever is having an issue with our medical system and finds this on their search-engine of choice can nod sagely that they're not alone.