Hopefully John's insurance will pay

Wow.  Last night I had a big scare.  John told me that Dr. Claxton, the transplant specialist, had told him that his insurances may not cover the bone marrow transplant.  I have heard of cases like this where the families have had to go fundraise before being able to schedule the transplant.  Now THAT would be a nightmare, I am already going through enough stress.

So after John tells me this at about nine o'clock last night, I got on the internet and did a google search.  I typed in "Will Medicare pay for a bone marrow transplant?"  John has Medicare Part A and B as his primary payer, and Medicaid as his secondary payer.  Where the search led me to was a page that explained what kind of bone marrow transplants would be paid for under Medicare.  John's bone marrow cancer (MDS) was not listed among those that would be paid for.  My heart sunk.  But at the bottom of the page there was a note that said that the bmt would be paid for if the local area (I think they meant state) agreed to pay for it.  

Well, needless to say I had a hard time sleeping.  I determined that as soon as morning came I would call both Medicare and Hershey Medical Center to see it he was covered.  At the stroke of 8 am, I dialed Medicare.  I asked the woman on the other end of the line whether or not the BMT would be paid for and she began to read from a book the page that I had read on the internet the night before.  I told her I had already read that page, and that John did not fall under any of the categories that were paid for, and told her about the blurb at the end.  I asked her if his kind of BMT was covered in PA.  She promptly told me she didn't know.  Sheesh, who was I supposed to ask then?  I asked her that.  She said she didn't know.  Then she told me to assume it wasn't covered, as it wasn't listed at the top of the page under the transplants covered.  I told her I wasn't going to assume anything (in my sweetest voice, of course).  Then she told me to call the hospital where he was going to get the transplant at.  

I got ready to dial Hershey Medical Center.  I wondered if this too would be fruitless.  Often I get somebody at a hospital who has no idea what they are talking about.  I hadn't had much experience with the clerical staff at Hershey, so leerily I gave it a try.  I was pleasantly surprised!  Immediately the receptionist put me in touch with a woman whose sole job is to be financial counselor to those who are going to have a BMT!

She told me that Medicare did not pay for those who got BMTs for MDS in PA.  However, she believed that John could probably still get the BMT.  The way it is going to work will be like this.  This woman Christine is the one that recommends to the hospital who gets the BMT.  She said she will recommend that John get one.  The physicians on staff will have to concur with her, but she doesn't forsee a problem, as the BMT is a medical necessity or John will die.

This means that the Hershey Medical Center will pre-approve the BMT for John.  Medicare will not pre-approve, however.  Hershey will go ahead and do the transplant.  Then Christine will submit the paperwork to Medicare asking them to reimburse the hospital.  She said that in the past Medicare has always reimbursed because MDS turns into AML (MDS leukemia - which kills you even quicker than MDS).  But even if Medicare doesn't reimburse the hospital, she said the hospital would absorb the cost, because the hospital already pre-approved the procedure.  That means John and I would "not have to pay the hundreds of thousands of dollars that would be incurred as a result of the procedure".

This presumes that the physicians agree that the hospital will take John on as a special "Medically Necessary Case" and pre-approve him.  I said all of the above to ask each of you to pray that the hospital will pre-approve John for the BMT procedure.  Otherwise, it aint happenin'.  But at least he has a good shot. 

Thanks, Krissy :)