Patient 1, Health Insurer 0 – an MS Patient’s victory and a model of consumer advocacy, for his case.

Stuart SchlossmanAlternative therapies and devices for Multiple Sclerosis (MS), An MS Patients Story, Inspirational, Stem Cell Related

August 1, 2014

    Photo

    Credit

     Christoph Hitz
    The Haggler

    This NY Times article is found here
    In this episode, the story of an epic, four-year battle between a
    man and a health insurer. 

    Typically, these stories end with the same score:
    Health Insurer 1, Patient 0.

    This story is different.


    It started in 2006, when at
    the age of 37, Dave Bexfield of Albuquerque learned that he had multiple sclerosis, or M.S. Three years later,
    the disease ramped up and he was forced to quit his job as managing editor of a
    car magazine, in part because he could not type. He qualified for a clinical
    trial, sponsored by the National Institutes of Health and conducted
    by the University of Texas MD Anderson Cancer Center in Houston. He spent three
    months there getting a stem cell transplant. His total bill was
    just under $200,000. (Yes, though sponsored by the N.I.H., the treatment came
    with a price tag.)
    Mr. Bexfield tapped his savings account and hit up his parents for
    the cash. Happily, the treatment worked. On one of the 
    YouTube
    videos
     
    he’s made documenting this ordeal, he snowboards, albeit with
    more than a few tumbles along the way.

    “I’m better,” he said last week. “I can drive, do all sorts of stuff again.”
    The disease has not progressed, and he is not on any M.S. medications.



    His health insurer, Presbyterian Health Plan, declined to cover the treatment
    because at the time, officials said, it was not a covered benefit under the
    terms of the plan Mr. Bexfield is enrolled in, namely the Federal Employees
    Health Benefits program. (Mr. Bexfield’s wife works for the Department of the
    Interior, and he received coverage through her.)



    A few months after Mr. Bexfield completed treatment in 2010, Presbyterian added
    M.S.-related stem cell transplant trials sponsored by the N.I.H. to its
    benefits for those in the Federal Employees program. A medical officer at
    Presbyterian later described this timing in a letter to Mr. Bexfield as
    “unfortunate” for him, demonstrating a fantastic gift for understatement.



    Mr. Bexfield spent much of the next few years campaigning to overturn the
    denial-of-coverage decision, writing emails, making phone calls and asking for
    meetings with Presbyterian executives. Eventually he lined the walls of his
    garage with letters from Presbyterian, all of them bearing bad news — 116 pages
    in all.



    Mr. Bexfield also enlisted anyone he could to the cause. This included the
    Haggler, who in March 2013 contacted Presbyterian on Mr. Bexfield’s behalf. It
    didn’t help. The Haggler received an email from Nicole Allcorn, then a
    Presbyterian spokeswoman, explaining that Mr. Bexfield was simply not eligible
    for reimbursement at the time he was treated, though he would have been had he
    been treated just a little later.



    Mr. Bexfield kept at it. Last year, he submitted a Freedom of Information Act
    request, to determine exactly what the federal government had said about stem cell
    treatment, and when.



    “What I found out is that there was never any mandate from the feds to change
    its policy regarding stem cell transplants,” he said recently. “P.H.P. had lots
    of leeway in extending coverage, and when it added these transplants, it did so
    itself.”



    To Mr. Bexfield, that meant that Presbyterian had lied to him. Specifically,
    the company had stated that the federal government had required the addition of
    stem cell transplants for M.S. as a covered benefit, when Presbyterian appears
    to have made that decision on its own, apparently after deciding there was
    sufficient evidence the treatment was effective. Mr. Bexfield wrote to
    Presbyterian, outlining what he’d learned through the Freedom of Information
    request. The emails, and a subsequent meeting with the company medical
    director, yielded nothing.



    On June 24, his claim was turned down yet again.



    A few weeks later, on July 7, he emailed the Haggler, describing his Freedom of
    Information findings. He used the word “lie” a lot. The Haggler forwarded that
    email to Presbyterian’s spokeswoman.



    The next day, everything changed. The president of Presbyterian, Lisa Farrell
    Lujan, called Mr. Bexfield and offered what amounted to an unconditional
    surrender. She agreed to cover not just the original expense of the treatment
    but four years of accumulated interest that the money might have earned Mr.
    Bexfield and his family, at 18 percent. (The insurer agreed to pay that much in
    interest because that’s the rate it uses when it is late paying a medical
    provider, like a physician.)



    Presbyterian has since wired Mr. Bexfield $402,000 — that’s $198,000 for the
    treatment and $204,000 in interest. (It adds up.) Ms. Lujan also agreed to meet
    with Mr. Bexfield, along with the chief executive of Presbyterian Healthcare
    Services, Jim Hinton. The two committed, in writing, to changing the company’s
    claims process, to make it more responsive.



    What provoked this change of heart at Presbyterian? In a phone interview, Ms.
    Lujan — who took her job in April 2013 — explained that she re-examined Mr.
    Bexfield’s case a few weeks ago, mostly because he’d been such a persistent
    advocate for both himself and other M.S. sufferers through his website, 
    ActiveMSers.org.



    “I feel as though the individual decisions we made were correct,” she said on
    the phone. “But I have the ability to take a step back and look at the whole
    case. When I looked at the forest, I came to a different conclusion than those
    who had looked at each individual tree.”



    The need for consistent policies, she went on, had to be balanced against a
    basic test of fairness. “We’re not processing widgets,” she said. “These are
    people’s lives, in some cases their financial solvency.”



    As for the Freedom of Information evidence, there was “never any intent to
    deceive,” she said. At most, there was some confusion about the use of the word
    “mandated” when Mr. Bexfield was denied coverage.



    Was Ms. Lujan aware that the Haggler had written the day before the company’s
    about-face? Nope, she said. News to her.



    Informed of this on Monday, Mr. Bexfield actually burst out laughing.



    “You think it’s possible that this was a coincidence?” he asked, rhetorically.
    “And that I would then get a meeting with the president and C.E.O. and demand
    interest, were it not for your email?”



    The Haggler has no idea. What’s beyond dispute is that Mr. Bexfield was a model
    of consumer advocacy, a savvy and tireless campaigner for his case. He nudged
    the right people, rallied others to his side and wrote emails that were
    measured and reasoned and that stuck to the facts.



    And he’s not done yet. At the moment, he is waiting to learn whether the money
    Presbyterian has already sent is taxable. Presbyterian has indicated that it
    thinks it is unlikely Mr. Bexfield will be taxed but has agreed to make him
    whole if it should happen — which could cost about $190,000.




    EMAIL: haggler@nytimes.com. 


    Keep it brief and family-friendly, include your
    hometown, and go easy on the caps-lock key. Letters may be edited for clarity
    and length.

    A version of this article appears in print on August 3, 2014, on page BU3 of
    the New York edition with the headline: Dogged Persistence Pays Off, With
    Interest. 


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