July 05--TROY -- He could no longer stand the agony. So Anthony Piscitella made a decision that might lead to financial ruin.
The first thing you should know about Piscitella is that he has a horribly bad back, a source of grinding pain. It's been that way for about a decade, since the former occupational therapist's attempt to move an obese patient went horribly and ridiculously awry. (And, no, there isn't video.)
But in September, as Piscitella vacationed with his family on the Jersey Shore, the pain came with a new and stunning intensity. A month later, an orthopedic doctor delivered the verdict: Piscitella needed surgery.
The big -- and still unanswered -- question: Who would pay for it?
That, of course, is always the looming consideration with medical procedures.
Now, this wouldn't be Piscitella's first back surgery. And since he was injured on the job, the prior operation was funded by insurance carried by his then-employer, Northeast Health, through a workers' compensation claim. This second surgery was related to the first, so Piscitella filed another comp claim -- despite the elapsed time.
Northeast rejected the request, sending Piscitella's case to the legal quicksand of a system that is workers' compensation in New York. (Northeast's reason for doing so is not entirely clear; a company spokeswoman denied comment, citing the ongoing case.)
To be sure, a workers' comp case is no one's idea of fun -- not for an employee or employer. In fact, New York's workers' comp system is widely regarded as one of the nation's most glacial and dysfunctional.
Piscitella, a 43-year-old who lives in Troy, was in stunning pain, but still he waited for a resolution to his case. He was hospitalized four times, but still he waited. And waited. And waited.
Finally, in March, as his workers' comp claim dragged on with no end in sight, Piscitella decided to ask his private health insurer, Schenectady-based MVP Health Care, to pay for the surgery. It was a risky move. His attorney, in fact, warned that he was inviting trouble by asking an insurer to pay for a procedure under consideration by the workers' comp system.
But Piscitella didn't care.
"If you had seen the pain I was in, I had no choice," Piscitella said. "It was a gamble I had to take."
MVP quickly approved the surgery and Piscitella went under the knife five days later. To Piscitella, the quick approval and scheduling of the surgery proves it was urgently needed. And he's sure that if he hadn't made the request to MVP, which he receives through his wife's work, he'd still be waiting.
"I know I still wouldn't have had it," Piscitella told me this week, sitting at his kitchen table, surrounded by piles of paperwork related to his case. "I'd be lying on that bed and in and out of the hospital."
The most important thing is this: The surgery was successful and Piscitella is recovering well, with his pain greatly reduced.
But the big question remains: Who will pay for it?
"It was not an inexpensive surgery," Piscitella said.
Indeed, the bill is estimated at more than $100,000. In some places, you could buy a house for what Piscitella's surgery cost.
When MVP learned of the ongoing workers' compensation process, according to Piscitella, the company decided to let the case play out before paying the bill. That's understandable. Why should the company (and its clients) pay for a surgery that might be the purview of another insurer?
A spokesman for MVP, citing federal patient privacy laws, declined to talk about the case.
"But, in general, when a person is injured while on the job, their workers' compensation insurance pays the health claims," said company spokesman Michael Traphagan. "We understand that the workers' compensation system can be slow to resolve some cases and, in that situation, the injured person unfortunately can face uncertainty while the case is pending."
Adding to uncertainty, though, is this: The state Workers' Compensation Board seems unwilling to pay for surgery already performed, unless Piscitella proves it was an emergency procedure.
See, there's an order that's supposed to be followed with these things. And you're expected to follow that order -- no matter your crippling back pain or how long you've had to wait.
The workers' comp board concedes it has a problem with timeliness: For too long, waste, delay and abuse have infected New York's workers compensation system," said Jeffrey Fenster, the board's executive director, as he announced a modernization program in April.
Rachel Phelan, who is Piscitella's attorney, is asking the court to consider the surgery an emergency.
And she has support from his surgeon, Dr. John Herzog, who notes in a letter to the board that Piscitella was unable to move.
"This is a failure in the system that he had to wait this long to perform the surgery," Herzog said in the letter.
Piscitella's greatest fear is that he'll be stuck with the medical bill -- that his decision to go ahead with the surgery will keep both MVP and workers' comp from covering his bill.
That, of course, could bring on financial ruin for the married father of a daughter. And it would be a troubling end to a workplace injury that rendered him unable to work in 2005.
But who could blame Piscitella for taking the step he did? Anyone who has experienced back pain knows it's an especially difficult type of suffering. Wouldn't you do what Piscitella did, if you'd suffered for six months with no end in sight?
"To me, it's beyond an exorbitant amount of time to expect somebody to wait," Piscitella said.
Advocate@timesunion.com --518-454-5700 --@chris_churchill --Comment on this story online at http://blog.timesunion.com/advocate
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