Eureka! I think I figured out how employers or at least my former employer, Adventist Health (that religious hospital/healthcare corporation), saves money on the treatment of my work-related injury – they pawn it off on my private insurance. I think it’s the Workers’ Compensation (WC) version of a patient dumping scheme.

Over the past several years, through the use of utilization review and the claims adjuster simply ignoring the pleas of my WC physician they, Adventist Health (that religious hospital/healthcare corporation), have managed to pawn of the cost of nearly a year and a half of medications and numerous labs and medical exams onto my private insurance. This is a version similar to the patient dumping that numerous hospitals in the Los Angeles area have been accused of doing. On 2014, Glendale Adventist Medical Center (my former employer and where I suffered my work-related injuries) paid out $700,000 in settlements from patient dumping claims stemming back several years.

So here’s how, I think the WC patient dumping scheme works. They simply stop providing care, hiding behind utilization review (UR), even though the injured worker hasn’t been returned to pre-injury condition and may still be living with debilitating pain. Or because the process of getting care takes so long the injured worker then suffers additional injury/sequelae from the initial injury and from the failure of the employer to address the work-related injury in a timely manner. Then if the patient is provided care or finds a way to pay for the care/medications the employer sees this as an “out” for them from providing additional care, and each time the injured worker finds a way to pay for care for their work-related injury the employer see this as a “savings” and the process continues with the employer using UR to continue to deny any care or medication requested until the injured worker learns that the only way they’ll receive much needed care for their work-related injury is pay for it out-of-pocket and/or with their private insurance.

I find it interesting that UR review will deny let’s say pain medication for a work-related injury being handled through WC, but your private physician and insurance will cover the same pain medication. How is it that the private insurance company that everyone rails against seems to believe that its medically necessary and acceptable, but your WC claims adjuster and their UR agent comes to a different conclusion?

I guess its because your private physician really believes in his/her Hippocratic Oath. Meanwhile the WC claims adjuster has no such oath and the UR agent is someone who will never see you, the injured worker, and maybe hasn’t seen a patient in years. He/she just scans “the literature” so he/she can find a way to deny or at least reduce the care the injured worker receives all in the name of saving a buck at the expense of the injured worker – sounds like a patient dumping scheme to me!

More to follow . . .

As I ended in my last post, I left my internal medicine consult with the need to get a cardiac clearance before I could be cleared for right shoulder surgery. Once again, Adventist Health (that religious hospital/healthcare corporation) left it to me, the injured worker, to make all the necessary arrangements to secure the needed cardiac clearance.

Normally, this is something that’s paid for by the employer; but, oh no not in my case since it would appear that Adventist Health (that religious hospital/healthcare corporation) had decided to simply abandon their responsibility and pawn it off on my private insurance and personal physician. Or perhaps Adventist Health (that religious hospital/healthcare corporation) decided that if they refused to pay for the necessary medical clearances and thus delaying this surgery long enough as they did with my spinal stimulator permanent implantation that I’d give up on my right shoulder surgery, as well. You see after Adventist Health (that religious hospital/healthcare corporation) delayed for almost a total of two years the approval of the spinal stimulator surgery I agreed to forgo the spinal stimulator surgery all together if Adventist Health (that religious hospital/healthcare corporation) agreed to approve my right shoulder surgery. I suggested this since the medical literature showed that the effectiveness of a spinal stimulator lessened with time; and by agreeing to forgo this surgery I saved Adventist Health (that religious hospital/healthcare corporation) at least $100,000 or even more in associated care.

So, while I thought I was being reasonable I would latter learn from the attorney representing Adventist Health (that religious hospital/healthcare corporation) that he believed my cardiac issue was my own fault for having waited “so long” after my last surgical clearance. I guess he was unaware that like many things in life a surgical clearance has a “life expectancy”, and the generally medical acceptable practice is that a surgical clearance has a life span and that span is dependent on the surgeon and hospital. So the likelihood of a competent and ethical surgeon accepting a surgical clearance that was approximately 2 years old was almost nil and as such I had to start the surgical clearance process all over again.

Once again with no help from Adventist Health (that religious hospital/healthcare corporation), but with expert help from my private insurance and personal physician they referred me to a cardiologist four days after seeing the internal medicine physician. Unfortunately, Adventist Health (that religious hospital/healthcare corporation) was displeased at the pace set by my cardiologist and filed to have me removed from total temporary disability to permanent and stable – their logic seemed to be that I was refusing surgery – the very surgery I couldn’t undergo until I was cleared to have – I guess that’s the logic Adventist Health (that religious hospital/healthcare corporation) uses to save themselves some greenbacks.

More to follow . . .

As you all may know; and in case you didn’t; clearances (not the kind you get at Nordie’s) but the medical kind are as much a part of the surgical process as are the nurses, surgeons and anesthesiologist. So in short you can’t have one without the other, at least for the planned surgical procedures, trauma and emergency situations are another matter entirely. So to deny access to medical clearances is to deny a patient the ability to proceed more safely with surgery.

So with no help or support from Adventist Health (you know that religious, hospital/healthcare corporation); but thanks to my private insurance, patient advocate and doctor, I was able to keep my hematology appointment and ultimately my hematology clearance.

I dutifully submitted a copy of my clearance to my surgeon so he could schedule the internal medicine clearance necessary for my right shoulder surgery. Twelve days after getting the green light from my hematologist my surgeon’s office scheduled my internal medicine clearance. I attended the scheduled February 22, 2016 appointment with the expectation that I would leave with the necessary and mandatory medical “go-ahead” required to schedule my surgery – but that wouldn’t be the case. At that appointment the physician discovered that I had a left branch bundle block, something that would require a cardiology clearance before internal medicine would sign off on the surgery.

Now you’d think that Adventist Health (you know that religious, hospital/healthcare corporation) would take the lead on getting this clearly critical clearance scheduled so their injured worker could get the care they’d need – but again you’d be wrong.

More to follow. . .

Mission and value statements can be very helpful in defining what drives corporate culture, but they can also shed a light on a corporation’s weaknesses. While gathering information on Adventist Health I stumbled on their corporate website (https://www.adventisthealth.org/pages/about-us/mission-vision-and-values.aspx).

After reading their published values I found I couldn’t help but adding my “two cents” to reflect my personal experiences as they relate to Adventist Health values and my journey as an injured worker covered thorough their workers’ compensation insurance – they are self-insured. What follows is taken directly from their website:

Our Values

At Adventist Health, we value:

• Compassion- The compassionate, healing ministry of Jesus – NOT!
• Respect- Human dignity and individuality – NOT!
• Integrity- Absolute integrity in all relationships and dealings – NOT! NOT! NOT!
• Quality- Excellence in clinical and service quality – NOT!
• Stewardship- Responsible resource management in serving our communities – NOT!
• Wholeness- The health care heritage of the Seventh-day Adventist Church – NOT! NOT!
• Family- Each other as members of a caring family  – NOT! NOT!

You’d think that Adventist Health, you know that religious, hospital/healthcare corporation would do everything in their power to ensure that their employees who suffered a work-related injury would get care in a timely fashion. Unfortunately, that’s not been my experience, especially with what should’ve been my final surgery.

As I posted yesterday, I suffered a full respiratory/cardiac arrest just as the anesthesiologist gave me a nerve block. More than four months later, I’m still waiting for the follow-up care required after such a life-threatening event; but this delay shouldn’t come as a surprise since Adventist Health did nothing to get the medical clearances needed for my shoulder surgery.

After having to go to court to get the Adventist Health to approve my right shoulder surgery, I discovered that Ms. CA decided that before giving the surgeon the go ahead she had to run it by utilization review (UR), in case UR paper-pushers could find a “way-out” of having to provide the very surgery that Adventist Health had agreed in court to provide, I guess. UR, however, green lighted the surgery, including the hematology consult requested by the surgeon. So after this unseen delay, it fell to my daughter and I to make all the necessary appointments to get the requisite medical clearances.

Medical clearances are part in parcel prior to surgery and this is a generally accepted medical practice and standard of care Ah, but not so with Adventist Health. After scheduling the same hematologist that Adventist Health had used for an earlier clearance, I learned one day before my appointment that Ms. CA had denied the clearance. Not only did she deny the approval she told the hematologist’s assistant that my right shoulders wasn’t part of my Workers’ Compensation claim. So with the clock ticking and thanks to the help of Keck-USC where the hematologist practiced we were able to get my private healthcare insurance to cover the consult. Of course the whole point behind Workers’ Compensation is that your employer’s workers’ compensation insurance pays for all the care, direct and related, of the injured worker. Perhaps this isn’t the case with Adventist Health?

To be continued . . .

You’d think that if you surfer a life threatening emergency while undergoing a surgical procedure you’d think that your employer’s Workers’ Compensation insurer carrier wouldn’t question your surgeon’s medical decision – but that didn’t happen in my life-threatening moment. Here’s what happened.

After several years of going back and forth with Adventist Health (who’s self-insured) to get them to approve surgery on my right shoulder I finally got the green light. This process had been very contentious and time consuming, but on August 17^th, I arrived at the “hospital” to have my surgery. All was going along as planned until just after the anesthesiologist performed a nerve block. I almost immediately began to experience problems breathing and informed the operating team that I was having severe chest pains and couldn’t breathe. And as they say “all hell broke loose”. I remember the anesthesiologist screaming “I need help over here” and I asked God to please let me live.

I awoke sometime later in the ICU, hooked up to a BPAP and other various monitors and medical personnel. It was then that I learned that not only had I suffered respiratory arrest but a cardiac arrest as well – in short I “died” on the table. After a little more than a day in the ICU, I was discharged home. Not long afterwards I received a letter from Excel Utilization Review (UR), the UR company that my Adventist Health claims adjuster, who shall remain “nameless to protect the guilty” so I’ll just call her Ms. CA. Apparently she thought that my surgeon’s decision to have me admitted to ICU after such a serious medical event required a review and approval of Excel, you know just in case it was an inappropriate and costly decision to admit a patient who’d suffered a full respiratory and cardiac event to ICU. Yeah, you read that right, Adventist Health, a hospital/healthcare corporation, was unsure that my surgeon had made a medically sound and financially correct decision!

Excel denied my admission to ICU! However, in their defense one of the reasons was the failure of my surgeon to send them “appropriate” information, but as a medical professional myself I was rather incredulous that they (Adventist Health and Excel) even questioned the need to admit a patient to ICU – most surgeons don’t just do this on a whim. But this is Workers’ Compensation after all so logic goes out the window and often doesn’t seem to apply.

Sometime later I received another letter from Excel that approved my ICU stay – whew! The irony was that Excel actually commented that the average ICU stays in a case such as mine was just less than 5 days, while I stayed just over 1 day. So while Ms. CA thought my stay was possibly inappropriate and costing Adventist Health unnecessary money that turned out not to be the case.

In the meantime, Ms. CA refused to return me to “total temporary disability” (TTD) status as order by my surgeon and have taken no action to discover what might have happened to cause this serious medical event.

Stay tunned for more . . . .