Frank Dungan, a former disaster and emergency planner for the federal government, is used to solving problems. The 61-year-old Madison resident helped communities recover after being blown away by tornadoes or flooded by hurricanes. He maintains a tough exterior – and a sense of humor – that doesn’t dare show any vulnerability.
But the situation he finds himself in has him both stumped and defenseless.
After being diagnosed with end-stage liver disease in early 2020, Dungan underwent dual hip replacement surgery, numerous procedures on his esophagus and tests by an array of specialists in order to qualify as a liver transplant candidate at the University of Mississippi Medical Center, the state’s only organ transplant program.
But because of the ongoing contract dispute between his insurer Blue Cross & Blue Shield of Mississippi and UMMC, he is currently ineligible for a transplant at the hospital. Meanwhile, he can’t get straight answers from either Blue Cross or UMMC about how much a life-saving surgery could cost or how he should proceed.
“I’m scared I’m going to freaking die, but that’s hard to say,” he said.
He lists out the array of people and agencies he’s reached out to – the governor, members of U.S. Congress, the insurance commissioner. Staffers for Sen. Cindy Hyde-Smith and Insurance Commissioner Mike Chaney made a few calls on Dungan’s behalf, but nothing has materialized.
“I’m not getting any help.”
Dungan previously spoke with Mississippi Today about the situation on the condition of anonymity out of fear of retribution from UMMC or Blue Cross. But after weeks of struggling to get clear answers about his health care from either side, he expressed desire to go on the record to tell his story.
Over the past month, Dungan has tried to get an estimate from UMMC of what a liver transplant would cost as well as an estimate from Blue Cross of the amount it would cover. (Blue Cross members can direct the insurer to send them the in-network benefit amount which they can then use to pay UMMC, though members are responsible for the difference in what Blue Cross pays and UMMC charges.)
He’s had no luck.
And because his case manager at Blue Cross directed him to get on the transplant list at Methodist Transplant Institute in Memphis as a result of UMMC going out of network, he asked the insurer whether the full cost of his transplant in Memphis – including follow-up care and rehabilitation – would be covered.
He can’t get an answer to that either, he said.
“What they’re doing to him is wrong,” Mississippi Insurance Commissioner Mike Chaney told Mississippi Today. “He has simply asked for what his estimated cost would be for a transplant. Both parties owe him an answer.”
Marc Rolph, executive director of communications and marketing at UMMC, told Mississippi Today transplant candidates “should be able to get a good faith estimate” of what a transplant and follow-up care would cost, though it won’t happen “overnight.”
It’s unclear why Dungan has not received that estimate as of Friday.
After soliciting help from everyone he could think of, Dungan is at a loss. He even considered purchasing health insurance off the public marketplace, but the language is unclear and he’s not confident in the coverage.
Plus, he’s already met his $7,000 yearly deductible with Blue Cross. If he started all over on a new plan, he’d be out thousands more dollars.
He asked one of his physicians this week to make the referral to the Memphis transplant center, but he worries he won’t even be accepted as a candidate.
“What if I go to Memphis or Birmingham for evaluation and they catch me on a day I’m not that bad?” said Dungan, whose Model for End-Stage Liver Disease (MELD) score, a determinant of the severity of the liver disease, has wavered up and down. “I just want to stick with UMMC because they have watched this rollercoaster in my MELD score … and they understand it.”
Now Dungan, who pays nearly $1,200 a month for his insurance plan with Blue Cross and has developed relationships with his UMMC providers over the years, is facing a tough choice. And despite the fact the two parties recently agreed to mediation, it’s not binding – meaning either party could drop out at any point.
Dungan could wait for Blue Cross and UMMC to settle the dispute, but there’s no guarantee the two parties will, and there’s no deadline for them to do so. His other option is to move forward with a complex evaluation at an out-of-state transplant center he knows little about – and that may not even accept him as a candidate.
Dungan would prefer to continue his care at UMMC, where he is familiar with his doctors, has had numerous procedures on his esophagus and seen an array of specialists, including psychologists. He also doesn’t want to move to Memphis, nor does he want to pay for lodging, food and gas costs he would incur traveling back and forth.
Blue Cross doesn’t seem to understand the burden – both physical and financial – that getting on the transplant list in Memphis would be, he said.
“They trivialized it, is what they did in my mind. It’s a big deal to drive three hours for me,” he said, noting that he often has to pull off the road on long trips to rest because of fatigue associated with liver failure.
When he asked if the company was going to help offset the costs, he was dismissed, he said.
“They kind of guffawed at that,” said Dungan.
Cayla Mangrum, manager of corporate communications for Blue Cross, said she cannot answer questions about Dungan for confidentiality reasons. But she pointed to federal law that requires hospitals to continue providing care for certain patients and accepting in-network payments for a certain time period.
“This would be applicable to transplant patients,” Mangrum said in an emailed statement.
UMMC, however, told Mississippi Today transplant candidates are not considered under this law because a transplant recipient’s care extends far beyond 90 days and requires a lifelong prescription of expensive immunosuppressant drugs.
“You do not want a patient to get a transplant tomorrow and then their insurance (coverage) be gone by July 1, then they’re facing extremely high costs and have no recourse,” said Rolph, UMMC’s spokesperson. “That is just not responsible. It’s in the best interest of the patients to be listed with a facility they have confirmed … that they will receive coverage for the entirety of their care.”
The disagreement between the state’s largest hospital and insurer stems from UMMC’s request for an overall 30% increase in reimbursement rates for its services and Blue Cross’ refusal to provide that. The dispute has left patients – particularly those receiving care not available anywhere else in the state, like Dungan – as collateral damage.
UMMC has the state’s only organ transplant center in addition to the only children’s hospital, Level I trauma center, Level IV neonatal intensive care unit and other advanced specialties.
And because the details of the contract are confidential, it’s impossible for patients and policyholders to decipher much about what is going on. While specific Blue Cross reimbursement rates are private, studies show commercial reimbursement for inpatient and outpatient services in Mississippi is the lowest in the country.
Blue Cross is by far the biggest private insurer in Mississippi, with about 56% of the market. United, the second largest, claims only 17%.
According to UMMC, Blue Cross has essentially offered no increases in reimbursement rates since at least 2014. After an overall decrease between 2014 and 2017, the hospital negotiated a 1% increase in 2018, according to Marc Rolph, executive director of communications and marketing at the hospital.
Blue Cross officials disagree with UMMC’s claim but say they can’t share any specific information.
“The information provided by UMMC is not factual. However, we cannot comment further because the terms and conditions of the mediation agreement are to be kept confidential,” said Mangrum. “In addition, the underlying agreement requires confidentiality. We are disappointed UMMC has not only discussed the mediation but misrepresented the facts in doing so.”
As the back and forth between the hospital and the insurer continues, Dungan is trying to take care of his health and advocate for himself as best as he can. He recently bought a property on a lake where he goes fishing.
His diagnosis and this experience have changed his perspective on a lot – including fishing.
“It’s not about catching the fish – it’s getting to go,” he said.
The post ‘I’m scared I’m going to freaking die’: As UMMC and Blue Cross dispute continues, Mississippi man can’t get answers to life-and-death questions appeared first on Mississippi Today.