August 1, 2014
Christoph Hitz
The Haggler
By DAVID SEGAL
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.
man and a health insurer.
Typically, these stories end with the same score:
Health Insurer 1, Patient 0.
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.)
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.
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.
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.)
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.
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.
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.
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.
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.”
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.
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.
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.)
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.
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.
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 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.”
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.
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.
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?”
“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.
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.
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: [email protected].
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.
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.
the New York edition with the headline: Dogged Persistence Pays Off, With
Interest.
=============================================
Keep CURRENT and up to date, with MS News and Information
Keep CURRENT and up to date, with MS News and Information
Sign-up for emails
.
WATCH OUR MS EDUCATIONAL VIDEOS by Topic,
found here: www.youtube.com/msviewsandnews
.
Visit our MS Learning Channel on YouTube: http://www.youtube.com/msviewsandnews