Carlsbad family gets $25000 refund

From: San Diego Union Tribune, CA - Apr 8, 2007

Biller at hospital was persistent with insurer

By Elizabeth Fitzsimons
UNION-TRIBUNE STAFF WRITER
April 8, 2007

The day they turned on her cochlear implant, Elizabeth's eyes went wide, her eyebrows jumped and her 7-year-old face was alight.

“I hear that!” she said.

Elizabeth's mother, Laura, tells this story. And though nearly two years have passed, she still gets chills when she remembers that moment.

How Elizabeth Shaw has changed since that day in August 2005. The second-grader now reads at her grade level, scores 90 and 100 percent on her spelling tests, and hears what her sisters and parents are saying. Elizabeth, 9, has blossomed.

That the implant, not covered by insurance, cost her parents $40,000 wasn't easy to swallow. But Jon and Laura Shaw had been through so much. Since the premature birth of Elizabeth and her sisters, triplets who each have their own special needs, the Carlsbad couple have battled insurance companies, health care providers and school administrators.

This time, they saw no chance of winning. So the couple – he's 53; she's 49 – wrote a check to Rady Children's Hospital for $30,000 and another for $10,000 to pay the anesthesiologist and surgeon. And then they moved on.

They didn't know someone had taken up the fight for them until Jon Shaw answered the phone in January. It was Jamie Cha calling from the billing department at Children's Hospital.

Cha had a refund check from the insurance company for $25,000, she told him. Would he like to pick it up?

Cha, the Shaws learned, had been working on their case for nearly 18 months, gradually proving to the insurance company, Pacificare, that the cochlear implant, an electronic device that improves the hearing of a person who is deaf or hearing-impaired, was indeed covered under the Shaws' policy.

“I never expected to see any of that again,” Laura Shaw said.

It was simply a matter of how the billing was coded. From her cubicle in Kearny Mesa, where her children's photos share space with Post-it notes and inspirational messages from fortune cookies taped to her computer, Cha called one Pacificare employee after another. She pored over the policy. She filed an appeal over the phone, then appealed again in writing.

“I felt, honestly, that it would probably be worthless in the end,” Cha said.

But she kept at it. A mistake had been made, and Cha, herself a mother of three, was going to fix it. She didn't know much about Elizabeth Shaw. She didn't know Elizabeth was one of triplets, or that she had hearing loss and was very nearsighted, or that sister Olivia was a Braille reader and sister Katy had a prosthetic eye and poor vision in the other eye.

“Every day I always think, 'Gosh, if one of my kids gets sick, where am I going to come up with this money?' ” said Cha, 25, who lives with her children and husband in south San Diego.

“It makes you realize how lucky you are.”

Upon receiving the case in September 2005, Cha saw the hospital had been paid, and that the money had come from the family because the procedure wasn't covered.

“I was like: 'What in the world? What did the patient have done, and why is it so expensive?'”

She'd worked on large amounts before, but it had always been the hospital seeking the money. The most she'd seen a family pay was a $500 co-pay on a surgery.

“I reviewed all the procedure codes and looked at the contract with Pacificare, and it says right here it would be covered if we billed with the code,” Cha said.

How good it felt to give the family the news, Cha said. The hospital in turn congratulated Cha. And then it was back to work on all the other cases on her plate.

Roger Roux, the hospital's chief financial officer, was pleased with Cha's success, but said the hospital expects these kinds of wins.

“What Jamie did here for this family is, believe or not, not unusual for us,” Roux said. “What is unusual for us is the dollar magnitude.

“Billing to insurance companies in this day and age is very, very complex, and it involves lots of codes and prior authorizations. And insurance companies, as you can appreciate, scrutinize the bills very carefully.”

Once the Shaws had the check in hand, Laura Shaw was nervous about asking too many questions. But she was delighted to have the money back, especially now, as the family prepares to move to Templeton, a small town near Paso Robles.

On Friday afternoon, the girls returned from school and dived into a bowl of popcorn. Olivia tapped away at her Braille laptop on a couch off the kitchen, and Katy and Elizabeth hovered over another laptop, where they took turns at a game that lets players design SeaWorld.

Since the cochlear implant, Elizabeth has jumped three grade levels. Still, there are gaps. She has difficulty with similar-sounding words, like “continent” and “consonant.” And she has trouble with words that have more than one meaning.

When Laura Shaw asked Elizabeth what grade she gets on spelling tests, Elizabeth answered that she was in the second grade.

No, Laura Shaw said. What percentage?

“One hundred percent,” Elizabeth said, smiling.

Cha and the Shaws haven't met. It was just too far for the Shaws to drive. So Cha dropped the check in the mail.

And then she returned to her work.

Elizabeth Fitzsimons: (619) 542-4577; elizabeth.fitzsimons@uniontrib.com

© Copyright 2007 Union-Tribune Publishing Co.