Well, that did not take long at all.
In order to go up to Detroit and see Dr. Chugani last week, and have it covered by our insurance, we had to show that PET Scan's could not be done at Nationwide Children's Hospital here and that Dr. Chugani was a renowned expert in Infantile Spasms who should be consulted with.
The insurance company, taking these things into account, granted us an exception to go 'Out-of-Network' and permitted that the trip could be treated as if it was actually 'In-Network' as far as how it all affects our Out-of-Pocket expenses and obligations for the year, which go up by 150% if you go 'Out-of-Network'.
I didn't understand how it played out then, don't now. Some kind of a mumbo-jumbo loophole I neither understand nor care to, I was just happy to get the visit covered and get Bennett up to see the doctor there.
Got a call from the insurance company yesterday. Not sure what prompted it, I think maybe it was routine or something, the nurse case manager doing the required follow-up on Bennett's case and checking to see how it went in the Motor City. It was explained to us, very politely (she is actually a very nice woman whom I do not hold responsible, she is simply relaying policy) that going BACK to Detroit for any further testing, or surgery, would not be granted the same exception.
It would be considered an 'Out-of-Network' option.
What does that mean? Well, allow me to explain, though I have very limited knowledge about such things. Like most good husbands, I just give all my money I earn to my wife and she handles all the bills and stuff.
What it means is that our annual co-pay goes from, say...$5.00 (let me be a little vague about being specific about actual numbers here, so I am using placebo numbers), to around $14.00. We've already hit our $5.00 annual co-pay and so then we would need to come up with the other $9.00. Not a bad situation actually, when you look at it like that.
Yer thinking...DUDE...WTF? You are actually worried about spending $9.00 more a year by breaking the rule of the insurance company and going 'Out-of-Network'? Are ye DAFT, man? Don't you care about getting the best care for your son? $9.00 be damned?
Well, if it were $9.00 only, I'd find a way. It isn't like I have $9.00 sitting in my buttcheeks I can just squeeze out at will, but I could put $9.00 together if I had to, and fairly quickly, you'd be surprised. Hell, I might even say I could MAYBE come up with twice that in a hurry if I absolutely, positively, had to. Favors, selling some stuff off, I could find a way.
Here's the catch.
It isn't just that expense. Get this...the insurance company has contracts with facilities they consider to be 'In-Network'. Let's say that Approved Place #1 charges 15K for a Butt Scan. Well, if Detroit charges 23K for the same Butt Scan, then the insurance company, after we have met the new co-pay amount of the $14.00 or however much it is, can say 'Mr. Lilly, hmmm, yes, let's see now...we will only cover the 15K for what we consider to be the approved cost of a Butt Scan, so you will be responsible for the remaining 8K of this particular Butt Scan. Thank you very much, hmmm.'
And they can do that ON EVERY SINGLE ITEM ON THE BILL. From the actual brain surgery itself to the Tylenol he gets on his last day in the hospital. If they do not agree to the cost, there is no discussion, we are responsible for the remaining amount owed.
Do we have bad insurance? I don't know. I've had better, I've also had worse or none. I am grateful that we HAVE insurance. I am grateful that we do have some options.
But my feelings of gratitude and my opinion about our insurance is not relevant to this writing. What is relevant is one simple fact.
We have a decision to make about Bennett's care, and it is a difficult one. Do we go back to Detroit, and risk owing tens of thousands of dollars we do not have, or do we decide to stay in our network and have Bennett seen and treated at the Cleveland Clinic? CC has a fantastic reputation, but it does not have Dr. Chugani. That does NOT mean CC can't treat Bennett as well. No one can answer that.
But it is a heavy thing to sit and think about, a decision like this. On the one hand you want to be sure you make the right choice for Bennett short term, but I also have to protect my entire family long term.
So we have some thinking to do...we won't actually make THE decision until after we see if the Vigabatrin can help Bennett. Then we will see. I can only hope that we are able to sort through the emotion and make a SOUND, REASONED decision.
Can't ask for much more than that.
Well, I could ask myself why this particular blog is so Butt-centric? Maybe cause I feel like I have my head up my ass.
Be honest...you were NOT expecting that one, were ya?