Frank Dungan of Madison needs a liver transplant, but the focus of his past few months has not been his health. His focus has been a battle between his insurance company and his hospital that left him without insurance coverage at the state’s only organ transplant program.
But as of July 1, Dungan has switched insurers, and he’s getting the medical care he’s had to put off – and, most importantly, is 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 marked him as “inactive” on their transplant list, meaning if the perfect liver match became available, he wouldn’t get a call.
Blue Cross directed him to the transplant program in Memphis, which was over three hours away from his home, a logistical and financial nightmare. He knew very little about the program, and he had spent years building relationships with his doctors at UMMC, which houses the state’s only transplant program.
Neither Blue Cross nor UMMC would get him answers about what the out-of-pocket costs would be if he got the transplant through UMMC while it was still out of network with Blue Cross. In May, Mississippi Insurance Commissioner Mike Chaney stepped in and sent a letter to both the insurer and UMMC asking they provide him with what he needs.
But Dungan said he couldn’t get definitive answers and never received anything in writing.
“It was to the point it would drive you crazy. Every time the phone rang, you were trying to figure out what other freaking problem we had,” he said.
UMMC and Blue Cross had agreed to mediation to try and settle the contract dispute, but more than two months after the hospital went out of network, a resolution still seems unlikely. Neither UMMC nor Blue Cross will speak publicly about how the negotiations are going.
The dispute stems from disagreements over reimbursement rates, with UMMC insisting Blue Cross is not fairly reimbursing the safety net hospital for its services and Blue Cross maintaining rate hikes would necessitate a substantial increase in member premiums. The hospital’s reimbursement rates are not public record.
In June, when squeezing in his appointments with various specialists before the continuity of care grace period expired for certain Blue Cross members at UMMC on July 1, one of his doctors found something concerning. He had esophageal varices, a condition that requires a medical procedure that uses elastic bands to tie off bleeding veins. If untreated, the varices can rupture and cause severe internal bleeding.
The condition commonly occurs in people with serious liver disease.
Dungan said his UMMC doctor told him the banding procedure would be “on my dime.”
Dungan was scared. He worried when going to bed each night if it would be the night he’d bleed out. He knew something had to change.
“I found a (Marketplace) insurance adviser and asked them if there were options (for me) … See, my insurance agent in my hometown had told me you can’t get health insurance except in December, even he gave me erroneous information,” said Dungan. “I was concerned about that, concerned about premiums, concerned about the language … I didn’t understand some of the language (of the policies).”
He connected with an insurance broker trained in federal Marketplace plans and found out he did not 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 out of pocket, and the premium, everything.”
Dungan, who had an individual policy with Blue Cross, is now covered by Ambetter, which offers health care plans on the federal Marketplace and is accepted by UMMC. He underwent two procedures to address the esophageal varices earlier this month and has visited his dentist to ensure he does not have any infections in his mouth – a requirement for reclaiming his spot on the transplant list.
Switching insurances is not an option for some people, especially those whose employers only offer Blue Cross to employees.
But he’s starting from square one with his insurance: he has a new out-of-pocket limit to meet of around $8,000. But his monthly premium dropped from almost $1,200 with Blue Cross to $402 with Ambetter, he said.
“I’m back confident that I’m getting good health care and confident that my bills are not going to be outrageous,” said Dungan. “I’m confident (the UMMC doctors) are keeping an eye on me.”
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