Guaranteed Healthcare

My Wife and I are both RN’s living in Metro Boston. On 12/18/07 she fell back off a ladder rupturing her Achilles tendon. An ED visit led to an MRI that showed a complete rupture. We get our primary care through a large group practice (It is almost impossible to find a primary care MD in the area).

They have certain referral policies in the group and of course our health insurer requires referrals before they will pay for specialty care. The first Orthopedic Surgeon, in the primary care referral group, she was sent to did not do these types of procedures. I used my contacts to find someone in one of the hospitals in the city to get some recommendations. When my wife contacted the primary care office she was told that this was outside of their referral pattern and they would not do the paperwork.

This would mean that Blue Cross would not pay for the visit or the surgery. When my wife told them she couldn’t work and her leave time was rapidly being consumed she was informed “that this was a business” and they would not change their policies. She made an appointment with the second Orthopedic Surgeon recommend by the primary care group, This surgeon said he didn’t do these procedures and referred her to the another group (The group that my sources recommended she see in the first place).

The first appointment she could obtain was on 2/5. Then she will need to get on the OR schedule. While this was going on she was notified by the hospital she worked for that if she did not return 11 weeks after the accident she would be terminated. The projected post op rehab from this procedure is 10 weeks. Thanks to corporate medicine and the health insurance industry my wife will lose a job she loves. I always hear insurance industry spokesman ridicule the Canadian system because “you have to wait for care” and you don’t in the US.