Acting on medical necessity

Rita Hart

Caring for children

Children needing dialysis

Acting on medical necessity

An abrupt change in scenario

Rita Hart was 12 when the abdominal pain and frequent bouts of diarrhea began. Her pediatrician referred her to Emory-Children’s Center (ECC), where specialists diagnosed Crohn’s disease.

Once a month, Rita went to the infusion center at ECC, where a watchful nurse joked with her and other children while medicines dripped into needles in their arms or hands. Rita’s infusion of Remicade kept the inflammation and symptoms under control.

Then her father lost his job. As his boss was apologizing, Joe Hart kept thinking of Rita’s medical costs. The Remicade alone cost almost $4,000 monthly. When he called ECC to confess that the family no longer had insurance, pediatric gastroenterologist Bess Schoen seemed concerned only about Rita: “Don’t even think about not showing up for your daughter’s next infusion. She needs this treatment. Emory will figure it out.”

And Emory did. Kathy Thornton, director of patient accounts, started by helping the family apply for Medicaid. In the meantime, Schoen and the infusion nurses not only provided care but also persuaded the pharmaceutical company to provide the costly drug without charge. Rita’s father got another job, only to have the new insurer refuse to cover Rita’s care, since her Crohn’s was a pre-existing condition. Thornton and Schoen filed a medical necessity appeal: without this treatment Rita would have a terrible quality of life and could even face death. The insurer agreed to pay half of the cost of the treatment, after an $8,000 deductible.

Now 20, Rita is doing well. Since taking on her care, Emory has written off more than $40,000 in charges. Next year, she will say goodbye to her Emory pediatric specialist and hello to an Emory gastroenterologist. As an adult patient, she will receive the same kind of care, whether it is fully reimbursed or not.

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