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HOUSE CALL WITH DR. SANJAY GUPTA

Getting Results With Your Health Insurance Company; TB Patient Andrew Speaker Undergoes Surgery; Healthy Video Games?

Aired July 21, 2007 - 08:30   ET

THIS IS A RUSH TRANSCRIPT. THIS COPY MAY NOT BE IN ITS FINAL FORM AND MAY BE UPDATED.


SUSAN ROESGEN, CNN ANCHOR: ...home of the University of Texas longhorns, of course. He came up with this novel way of tricking out a bicycle. And he says he might even add a cowbell to complete the look and the sound of it. That's pretty cool.
T.J. HOLMES, CNN ANCHOR: And of course, Betty is a University of Texas grad. And we are going to put our money together and have a bike ready for her when she gets back.

ROESGEN: She can tool around the studio on it.

HOLMES: Yes.

ROESGEN: Yes.

HOLMES: Well, your next check of headlines, folks, coming up at the top of the hour.

ROESGEN: Right now, we've got HOUSECALL with medical correspondent Elizabeth Cohen starting right now.

ELIZABETH COHEN, GUEST HOST: Good morning. This is HOUSECALL, and I'm Elizabeth Cohen. Dr. Sanjay Gupta is on assignment. We've got an exciting show on tap this morning. There's news that everyone who's watching can use.

First up, we're helping you get results from your health insurance company.

Then, if your claim has been denied, learn what steps you can take now to help you get that reversed.

And later, an exclusive look inside the OR as TB patient Andrew Speaker undergoes surgery.

Finally, healthy video games? Seems like a contradiction in terms, but we'll explain.

We'll start with health insurance. There's a lot of talk about the millions of people without it, but this morning we're talking about the millions with insurance who are fighting the system to try and get paid.

(BEGIN VIDEOTAPE)

COHEN (voice-over): Karin Perry and her son Andrew have faced so much together. Andrew was born with a severe birth defect. He's had 21 surgeries. But Perry says she's now facing one of her biggest challenges yet. 13-year-old Andrew was born without adult teeth buds. He'll soon have no teeth in his lower jaw.

When Andrew loses that bottom row of teeth, how is he going to eat?

KARIN PERRY, PARENT: I'm not sure. I'm really not sure.

COHEN: Perry's a kindergarten teacher and doesn't have the $60,000 for teeth for her son. But wait. Perry has health insurance. Won't that pay for it? She says they told her no, that it's a dental expense. Her dental insurance has a $500 cap.

PERRY: It makes me want to scream. Why can't you just see that this is medically necessary?

COHEN: Karin Perry isn't alone, far from it. One out of four Americans says they've had what they consider a legitimate health insurance claim denied, according to PNC Financial Services Group. The insurance industry says that survey is wrong and that only a tiny percentage of claims are denied.

MOHIT GHOSE, AMERICA'S HEALTH INSURANCE PLANS: This industry pays billions of dollars in healthcare services, routinely covers millions of claims every month, and makes sure that people are getting the care they need.

COHEN: Perry says insurance has paid for a lot.

PERRY: All of his surgeries have been covered by insurance. For that, I'm very grateful because we're looking at, you know, probably a $1 million kid at this point.

COHEN: But she says she had to pay $10,000 for medical expenses insurance wouldn't pay for. Her friends held a fundraiser.

PERRY: I'm a school teacher, and I'm a single mom. And so $10,000 is a lot of money for me. It's a real lot of money for me.

COHEN: Mohit Ghose, who represents an insurance industry trade group, says people like Perry should appeal insurance decisions if they think they're wrong.

GHOSE: It's important to note that consumers do have options.

COHEN: Perry says she did appeal once and failed. And she's never tried again.

PERRY: I'm probably the exact kind of person they're hoping comes into the insurance appeals process, because it's exhausting. And it's time consuming. That's what they count on. They want you to give up.

COHEN: Ghose says that's not true. And they try to make the process as easy as possible. Perry says she's thankful for the insurance she has, but she wishes it were easier.

(END VIDEOTAPE)

COHEN: Now we called Ms. Perry's insurance company, HMO Blue, for comment. And they immediately called Ms. Perry to say they would pay for Andrew's new teeth. Their spokesman told me, "Typically, we don't cover dental implants. But if there's a unique clinical circumstance, that's considered in making medical coverage decisions."

Now Perry used to have a different insurance, Harvard Pilgrim Healthcare. They declined to talk to us because of privacy issues.

Now Karin Perry's situation ended well because of our story, but what about other people? What do they do when they get denied? A group called the Patient Advocate Foundation helps people with insurance problems. And they've agreed to specially staff their phones this morning just for our viewers. The founder and CEO of this foundation is Nancy Davenport-Ennis. And she's here with us this morning. Welcome, Nancy.

NANCY DAVENPORT-ENNIS, PATIENT ADVOCATE FOUNDATION: Welcome.

COHEN: Well, Nancy, we have been inundated with e-mails on this topic. So let's just jump into these questions.

DAVENPORT-ENNIS: Good.

COHEN: The first one is from Debbie in Virginia, who writes, "My son was born at 32 weeks and went straight into the NICU. The hospital was in network, but none of the doctors in the NICU were. Our insurance refuses to pay the doctor's bills, and he would have died without immediate care. What can we do? We have medical bills of $150,000."

Nancy, what do you recommend for this family?

DAVENPORT-ENNIS: Elizabeth, the first thing that I would say to the family is please understand that what is happening to you may the first time for you, but many other consumers have faced a very similar denial.

I think it's very important for them to understand that, when you have a child that is born and needs to go into a neonatal intensive care unit, that the child was actually delivered in an in network hospital that was part of their health plan and an approved provider. When the child needed to be moved into the intensive care unit and required physicians with specialty care backgrounds, certainly, the parents assumed that those were approved providers.

When finding out that they were not, we advise that she immediately let the insurance company know she will be filing an appeal, and go to the hospital and collaborate with the hospital in this appeal. Because ultimately, the parents were not asked to make a decision of who was going to provide care to this child. The decision was made by the hospital.

COHEN: Nancy, do you think this family can work this out?

DAVENPORT-ENNIS: I do. And I think this is happening more and more in the United States. And what we find is that you have to engage the hospital in getting the resolution. And you may have to actually engage a caseworker from the hospital or caseworker from the health plan.

COHEN: Now we should point out this claim sounds legitimate. But to be fair, some claims aren't legitimate. Some things just aren't a part of your healthcare coverage.

DAVENPORT-ENNIS: Indeed, that is true. And so, one of the things that any parent has to do, if they're looking at a denial of a benefit for a child, is to look at the language of your health plan and see indeed what it provides for. In the case of this child, the child was born in an in-network hospital. And certainly the benefits that that child needed, needed to accrue to the child. That family was not aware that the doctors providing the care were not in-network providers. And that information had not been provided to them.

COHEN: Nancy, that's good guidance for this family. Now we're going to take an e-mail from Loretta in Indiana. She wants to know, "I recently underwent gallbladder surgery. The insurance company refuses to pay, stating that it was a preexisting condition. We cannot afford the $20,000 plus in bills. What is your advice for us?" Nancy, you hear about this a lot. Preexisting conditions. Is that -- can you argue against that?

DAVENPORT-ENNIS: Yes, you can argue against that. And you do hear it a lot. But again, remember that the argument is initiated by your insurer. And you have the opportunity to appeal that.

In the case of Loretta, there are three or four concrete steps that she needs to take. Number one, she needs to get a copy of her health plan. Number two, she needs to ask the hospital for a copy of the medical records that were provided to the insurance company upon which they made the decision there was a pre-existing condition. She needs to go back to her files at home. And if she has a copy of her original application for health insurance, she needs to refer to that. If not, call the health plan. Ask for a copy of her application and ask for a copy of the health form that she filled out at the time she applied.

If in reviewing all of these forms she finds that there is no mention and no evidence of a pre-existing condition, she's ready to sit down and draft her letter appealing this decision. And again, we encourage her to have her doctor support her in this process and write a letter of his own identifying the medical necessity for this care, and as her treating physician, indeed, he did not have any evidence that this was a pre-existing condition.

COHEN: Nancy, I think talking to your doctor and getting them on board is so important for so many of these cases. Let's go to another one that a lot of people can relate to because it has to do with red tape. Shelly from Texas writes, "I have a $300 bill from a lab for some allergy tests. The insurance company won't pay because they say it's coded incorrectly. I called the lab. They say they can't recode it. The doctor's office has to do it. I've talked to the doctor's office, and according to their records, it was coded properly. So the lab says they can't do anything. The doctor's office says they didn't do anything wrong. And the insurance won't pay for the bill unless it's coded correctly."

Oh, boy, this just sounds like a mess. Is there any way out of this, Nancy?

DAVENPORT-ENNIS: There is. And Shelly in Texas has got a problem that a lot of us that have been in the health care delivery system have had to deal with. And it's pretty simple actually.

She can pick up her phone and call the physician that is involved, and ask the physician to identify to her what is the billing code number that was used for the procedure that was received and for the diagnosis that the lab work was ordered for.

As soon as she's written down those two code numbers, call the laboratory. Ask the laboratory. What are the coding numbers that you submitted to the insurer that I am trying to double check and be certain that the numbers are the same?

COHEN: So you can get the two sides on the phone?

DAVENPORT-ENNIS: You absolutely can.

COHEN: Get them coordinated. You've seen it work.

DAVENPORT-ENNIS: You absolutely can. And when you see that there is a disparity between the number that was submitted to the insurer and the number that the doctor thought they submitted, it is the doctor that needs to go back and reinitiate that claim to the insurer with the correct code.

COHEN: Well, it's good to know that that strategy works. We're taking your questions on battling health insurance red tape. After the show, make sure to click over to cnn.com/health. Find out the top three mistakes that people make when they're dealing with their insurance companies. Plus, check out cnn.com/housecall for links to a state by state insurance appeal guide, help for sick kids, and of course, free transcripts of any of our shows.

We're answering more of your questions coming up on HOUSECALL. A child in need of experimental treatment. The insurance company might not pay. What the parents can do now to get help.

Plus, is Vitamin C a good choice for fighting colds? A new study is out. We've got the details.

Then experts claim that some video games may actually help you burn calories. How that works? Well, we'll bring you the story when HOUSECALL returns. (COMMERCIAL BREAK)

COHEN: I'm Elizabeth Cohen. And we're talking about how you can get results when you've been denied health coverage. Nancy Davenport- Ennis is back with us. She's the founder and CEO of the Patient Advocate Foundation, a non-profit group helping people challenge their health insurance.

Nancy, we were just flooded with e-mails on this topic. Let's jump back in with a question from Linda in Boston. Linda writes this. "A close co-worker's toddler's daughter has a rare form of cancer. Fortunately, there are some encouraging experimental drugs which show promising impact. They are running into challenges securing coverage for this experimental treatment. What is the best approach?"

Nancy, what do you do in a situation like this?

DAVENPORT-ENNIS: Well, I think what you do is realize that if it's a child with a rare cancer, you simply get that child immediately to a pediatric oncologist and try to get care for that child in a community cancer center, where the child is likely to be enrolled in a clinical trial, where the drugs that are needed to treat the condition are going to be paid for within the context of the clinical trial. Additionally, that family is going to find a lot of help in solving insurance reimbursement and social service needs that they're going to have.

COHEN: And Nancy, in general, when your doctor says you need this treatment and you need it in the next week, but the insurance is going to take a month to work it out, what do you do?

DAVENPORT-ENNIS: Well, we can certainly assist patients in getting an immediate court injunction that allows for their admission into the hospital and for treatment to be initiated, while we continue to resolve the insurance reimbursement issues.

You cannot allow the disease to march ahead while you're trying to work out an appeal. I would say to your viewers this morning...

(AUDIO GAP)

...they're not the only person to have faced this. And there are ways to have solved these problems.

COHEN: Nancy, thanks so much for that encouragement. I think people need to hear that. And thank you so much for joining us this morning. We really appreciate it.

DAVENPORT-ENNIS: Thank you, Elizabeth. It's been a pleasure.

COHEN: Well, we are committed to helping our audience get answers. The Patient Advocate Foundation has agreed to answer all the e-mail questions that we were unable to get to this morning. And they've opened up their phone lines this weekend just for us.

Caseworkers will be ready to answer your questions from 9:00 a.m. 'till noon Eastern time at 1-800-532-5274. And of course, their Web site is always open with lots of great information for consumers. Patientadvocate.org.

Now, just ahead on HOUSECALL, an exclusive look inside the OR as TB patient Andrew Speaker undergoes lung surgery.

And later, food giants say they'll cut back on advertising to kids. The details when HOUSECALL returns.

(COMMERCIAL BREAK)

COHEN: Welcome back to HOUSECALL. Slapped with a $1 million lawsuit and still defending his decisions, this week was a step forward for TB patient Andrew Speaker. Speaker had lung surgery in hopes of curing his multi-drug resistant tuberculosis. CNN correspondent Dr. Sanjay Gupta has this exclusive look inside the OR.

(BEGIN VIDEOTAPE)

SANJAY GUPTA, HOST (voice-over): Thirty-one-year-old Andrew Speaker spent the eve of his surgery with his new wife Sarah at National Jewish Medical Center in Colorado. It's one of the country's few facilities equipped to deal with drug-resistant tuberculosis. His hope, getting cured and going home, months after being ordered into isolation. Why did you decide to have surgery?

ANDREW SPEAKER, TB PATIENT: With the amount of treatment I'm going to be on, the doctor said, if you go ahead and have the surgery, you don't have to worry 10 years from now or 20 years from now or 30 years from now if it's ever going to come back. And that's worth the peace of mind to me.

GUPTA: Of course, future peace of mind made for more worries now. Speaker is in the operating room under general anesthesia. Surgery is already underway. The goal is to try to remove a tennis ball sized infection from his right upper lobe.

Doctors are using a technique called video-assisted thorascopic surgery or VATS. It requires only three small incisions through which doctors remove diseased tissue.

(on camera): So there's a lot of things that sort of go into this. Right now, they've got to take down all these blood vessels and all these airways that connect to the right upper lobe, so they can remove that part of the lung. It's the trickiest part of the whole operation.

(voice-over): After two hours, finally the moment they were waiting for. The diseased lobe is removed. TB in a plastic bag. That bag keeps the infected lung from spreading in his chest. There are no guarantees for Speaker that he will be cured, but Dr. Mitchell is optimistic about his recovery.

If he wanted to run a marathon or something, could he do that again in his life?

DR. MITCHELL: Well, hopefully he'll be able to.

GUPTA: For now, Andrew Speaker may be rid of an infected piece of lung, but he's left to deal with the aftermath of his disease.

Dr. Sanjay Gupta, CNN, Aurora, Colorado.

(END VIDEOTAPE)

COHEN: Sanjay reports that Speaker will remain in Colorado for at least the next couple of weeks continuing drug therapy.

For more of this week's medical headlines, let's check in with Judy Fortin. Judy?

JUDY FORTIN: Hi, Elizabeth. Here's what's happening in the headlines.

The benefits don't apparently outweigh the costs for one popular cold remedy. Australian researchers analyzing 30 studies on Vitamin C found it does little to reduce the length or severity of the common cold for the average person. But marathon runners and skiers exposed to periods of high stress while taking 200 milligrams of Vitamin C reduced their chances of catching a cold by 50 percent.

Living near high traffic areas may be hazardous to your health. That's according to a new study published in the Journal of the American Heart Association. A look at more than 4,000 people found those within walking distance from the air pollution of major freeways and other congested roads were 63 percent more likely to develop blocked arteries, increasing their risk of heart disease and stroke.

And fasting may not be the best way to monitor cholesterol levels, new research shows. Patients are typically asked not to eat for up to 14 hours before testing, but new research finds elevated lipid levels following a meal are a much stronger predictor of heart problems and even death in some cases.

Elizabeth, back to you.

COHEN: Judy, that last one, that is indeed a surprising finding. Thank you.

FORTIN: Sure.

COHEN: When HOUSECALL returns, once pointed to as the contributor of childhood obesity, experts now say some videogames may not be so bad. We'll explain after the break.

(COMMERCIAL BREAK)

COHEN: Welcome back to HOUSECALL. Under pressure to help curb childhood obesity, several major food companies say they're changing the way they advertise to kids. Some say they won't use popular characters in ads unless they're for healthier products. Others don't advertise at all to children under the age of 12. Now we all know that it's tough for parents to get kids off the couch these days. Video games are all the rage. Some experts now are saying that they're getting healthier. Dr. Sanjay Gupta explains with today's "Fit Nation."

(BEGIN VIDEOTAPE)

SANJAY GUPTA, HOST (voice-over): Fourteen-year-old Caroline Davenport is indoors, playing a video game but not slumped on the couch. She's rockin' to the beat as she competes in her neighborhood Dance Dance Revolution tournament.

CAROLINE DAVENPORT, TOURNAMENT PLAYER: It's active, and it's something to do on the long hours of the summer where you have nothing else to do.

GUPTA: It's the latest craze in video gaming -- videoactive games that require kids to get up and get moving. Tournament organizers say they're helping kids stay fit.

CHRISTOPHER BORAWSKI, WHEATON, MD. LIBRARY: It helps them. It keeps them moving. They have to move very fast. It gives them quite a workout.

GUPTA: Dancing is obviously better exercise than playing a stationary video game on a sofa, but we wanted to know just how much better. Researchers at the Mayo Clinic in Minnesota are finding that kids playing these type of active video games burn twice, sometimes three times the amount of calories of kids playing traditional games.

LORRAINE LANNINGHAM-FOSTER, MAYO CLINIC: When we did allow a few children to play the game at higher settings, they could actually burn maybe five or six times the number of calories they would while they were playing the traditional handheld game systems.

GUPTA: The study uses Sony I-toy and X-Box's Dance Dance Revolution. And researchers are planning further studies on the newest in the video craze, like Nintendo's Wii, popular with children and their parents. As for Caroline, she's lost ten pounds since she started playing in tournaments. And she's having fun as well. It's a perfect combination, experts say, for successfully fighting childhood obesity.

Dr. Sanjay Gupta, CNN, reporting.

(END VIDEOTAPE)

COHEN: Thanks, Sanjay.

Now just ahead, a new program hoping to break an old stigma.

(COMMERCIAL BREAK)

COHEN: Welcome back. The Army is starting a program, hope to go get quicker treatment for those returning from Afghanistan and Iraq with brain injuries. Over the next three months, the Army is hoping to educate more than one million soldiers to recognize the symptoms of brain injury and stress disorders, certainly a big undertaking.

Well, we're out of time for today. Thanks for watching. I'm Elizabeth Cohen. Stay tuned for more news on CNN.

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