So, as my dear readers know, Ez is having surgery at the end of this week. The surgery has been a long time coming (see more about the surgery on this post). Since our Children’s Hospital is in another state and the surgery was only scheduled a week ago, I have been sort of wrapped up in packing for her to be inpatient for awhile, trying to organize where to stay, and so on.

When I spoke with our surgeon last week he explained that Ez would need to be inpatient for 5-7 days and spend 1-2 days in the surgical intensive care unit. I knew the hospital would be arranging everything with insurance and not to worry unless I heard something.

SO, yesterday I heard something. We have a dedicated customer service person as well as a dedicated nurse at our insurance company who both follow our case (and are both wonderful, BTW). First the nurse called to warn me that Esmé’s hospital stay was likely to be denied. Her surgery has been approved, but the hospital stay was not. Funny, right? Wait for it…according to the coding of her surgery, the insurance believes Esmé’s surgery should be ambulatory.


From two days of ICU to ambulatory in 60 seconds.

Whatever, the notion that this surgery could be ambulatory for a child like Ez is so ridiculous that our nurse explained (very quickly, because she is aware of my “advocating”) that it, essentially doesn’t matter. If the doctors don’t feel that Ez meets the “minimum requirements for discharge”she will not be discharged, and our insurance has to cover the stay. Obviously Ez will not meet these minimums post-op. She will likely be keeping low oxygen levels, not tolerating food, and having any number of other issues. Which is why the surgeon was planning for a longer stay! Right, because he knows her history and is, therefore, a better predictor of her needs than some coding protocol put together by an intern and a dartboard.

Meanwhile, the hospital is appealing the case (so they won’t have to battle down the line about “minimum requirements for discharge”) and this means that our surgeon now has to spend time (that would be better suited, I dunno, saving lives?) on the phone doing a “peer-to-peer” conversation with the insurance’s doctor…explaining why a medically-fragile, epileptic, severely hypotonic, failure-to-thrive toddler with a neurogenetic/neuromuscular disorder shouldn’t be discharged ten minutes after a series of major abdominal (albeit likely laproscopic) surgeries.

Perhaps I should offer to make the call?

One Comment

  • I feel like banging my head against a brick wall on your behalf. I should have expected as much. After all, everyone knows that "fun" and "insurance" don't belong in the same phrase/paragraph/continent.

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