How To Fight Back
In Real Life - Andrew Zellers-Frederick

From the publishers of the New England Journal of Medicine


       Even suffering from cardiac myopathy — heart-muscle damage caused by a viral infection — Andrew Zellers-Frederick mustered the stamina to fight through his health plan's appeal system and win.
       Zellers-Frederick, of Warminster, Penn., was in his energetic mid-30s when his condition was diagnosed in 1992. As executive director of a historical site he had the detail-orientation and verbal ability to make his case effectively.
       Even so, it took six months and three rejections before Keystone Health Plan East was persuaded to approve the $7,000 worth of cardiac rehabilitation two cardiologists had agreed would prevent or at least delay the need for a heart transplant.
       When he was first diagnosed, Zellers-Frederick says, his doctor ordered him hospitalized for cardiac catherization. But in a dither of confusion about whether his doctor was covered — "they reversed themselves three times in an hour" — Zellers-Frederick says the plan essentially had him kicked out of the hospital without the procedure. (When asked for a response, a spokesman for Keystone Health Plan East says he can't comment on an individual case.)
       "I wrote a letter of complaint about that, and an executive responded with a sincere letter of apology and said to call her if we had any future problems," he says. So when the health plan denied a $7,000 course of therapy intended to forestall a risky heart transplant costing untold thousands, Zellers-Frederick tried to contact his new friend in the health plan and found she'd left the company.
       With his primary-care physician and two eminent cardiologists vigorously behind him, Zellers-Frederick appealed the denial of care in writing. Keystone rejected the appeal. He appealed again in writing. Keystone rejected the appeal. Zellers-Frederick and his wife went to the next step in the internal procedure, a hearing in person before Keystone arbiters.

"It was almost like a court, except that one of their own employees was representing me to Keystone," he recalls. Keystone rejected the appeal. This time Zellers-Frederick appealed to the state Department of Health, which in Pennsylvania regulates HMOs. The regulators ordered Keystone to cover the treatment.
       Once it was under orders, Keystone "moved mountains" to get the therapy going, Zellers-Frederick says, and covered follow-up care with no problem. Tests now show significant improvement in his heart.
       "It was hard," Zellers-Frederick says of his struggle to get the procedure he needed. "You have to document, take names, record everything — and don't be afraid of them."


C. Grannan

HMOs Return
HMOs Return