Kevin Leininger: Cancer patient’s story raises questions about insurance networks — and the need for improved diagnosis in Fort Wayne

Oct. 25--The way Scott Mentzer sees it, he's arbitrarily being forced to choose between risking either his health or his wealth.

But to officials at Fort Wayne-based Physicians Health Plan -- and, probably, the entire insurance industry -- Mentzer's response to an initially misdiagnosed and potentially life-threatening illness is a symptom of his personal choices and corporate cost-control measures designed to benefit the most customers most of the time.

For Mentzer, a 53-year-old Bluffton resident and a vice president at Phoenix America a Fort Wayne company specializing in magnetic encoders and sensors, it all started two years ago when he noticed a lump in his neck while shaving. Mentzer consulted not one but two local doctors, both of whom recommended surgery for the removal of what they considered a cyst, which was drained.

He was told the cyst would refill, "but there was no reason to be concerned. I went on with the rest of my life."

By late 2017, the lump had refilled. So Mentzer returned to one of the doctors, only to be told the "cyst" could not be drained because it had solidified. Six weeks later a biopsy revealed the shocking truth: the presence of squamous cell carcinoma, the second-most common form of skin cancer.

"I was told (by the doctor), 'I have never seen this in 30 years. You're lucky you decided to come back to have it drained. From now on, my follow-up protocols for men with lumps in their necks would change.' "

Because the doctors in his PHP network of providers had recommended surgery followed by radiation, Mentzer decided to seek additional medical opinions out of network "as my in-network care had failed me." A visit to the Cleveland Clinic was followed by a trip to the MD Anderson Cancer Clinic in Houston, which quickly located the source of the tumor and has been treating Mentzer -- apparently successfully, without surgery -- ever since.

Just one problem: MD Anderson is not in PHP's network, and Mentzer has failed to persuade PHP to consider the facility "in network" despite support from his local doctors. As a result, Mentzer could face additional out-of-pocket charges under his company's policy of up to $10,000. But it's even worse than that, Mentzer insists, because he could also be liable for expenses considered in excess of "reasonable and customary charges" -- and PHP won't say where it draws that line.

"How do Indiana residents make sound medical decisions, such as whether to choose in-network care or out-of-network care, when the insurance carrier refuses to provide its out-of-network compensation?" Mentzer asked. "I have no means to determine my financial risk. I am making a medical decision totally blind of the financial impact to myself and my family. How is this allowable?"

It's allowable because, according to the Indiana Department of Insurance, PHP and other companies are not legally required to specify which charges are "customary" for specific procedures -- at least in part to dissuade providers from increasing their bills accordingly. Nor can insurance companies be expected to ignore their own networks, since the entire point of networks is to control costs through pricing agreements with listed providers.

As PHP Chief Sales and Marketing Officer Nick Mehdikhan points out, PHP's network includes numerous cancer specialists, and Mentzer could have followed up his diagnosis by MD Anderson with local treat locally, saving thousands of dollars in travel and other non-medical and medical costs.

But to Mentzer, who clearly has little faith in local doctors, his health justifies the cost -- especially when, he says, some of his new doctors warned him to avoid treatment in Indiana.

Mehdikhan said PHP works with customers to control costs and ensure quality care and said problems and concerns can best be addressed when they are expressed early, not via after-the-fact appeals. "We want to arm members to make the best decisions, not always the cheapest care," he said. He also said PHP works with out-of-network providers to accept its level of payment, and said he believes MD Anderson has done.

Mentzer, however, said he has already committed to pay MD Anderson more than $12,000, with a balance pending insurance settlement of more than $28,000.

I'm not writing this column to side with either Mentzer or PHP on the insurance issue. I understand why Mentzer is seeking the best care possible, just as I know PHP's customers likely would see higher premiums if it routinely ignores its own network (which includes not only IU Health in Indianapolis but Northwestern Memorial Hospital in Chicago and the University of Michigan system). Fort Wayne is no different than anyplace else: Some of its doctors are better than others, and Mehdikhan said PHP works to ensure members of its network offer quality care.

In the end, my goal is Mentzer's: "I don't want to create any controversy," he said. "I just want to get well and I want to make sure the next gentleman who walks into (the doctor's office in Fort Wayne) with a similar lump gets diagnosed properly."

After all, not everyone has the resources to do what he has done. And, as Mentzer noted, not even corporate vice presidents can afford to write blank checks.

This column is the commentary of the writer and does not necessarily reflect the views or opinions of The News-Sentinel. Email Kevin Leininger at kleininger@news-sentinel.com or call him at 461-8355.

___

(c)2018 The News-Sentinel (Fort Wayne, Ind.)

Visit The News-Sentinel (Fort Wayne, Ind.) at www.news-sentinel.com

Distributed by Tribune Content Agency, LLC.