Interview with Mark Chipps
Hedrick Smith: We're talking with Mark Chipps, Deputy in the Sheriff's office in Palm Beach County. Tell me about your daughter, Caitlyn, and her condition.
Mark Chipps: When Caitlyn was born in 1990, she was two and a half months premature and at that time we were told that there could be complications, but we would have to wait and see what developed. Approximately six months later the pediatrician said she wasn't progressing the way he would like to see her progress and told us to go see a neurologist which he recommended - Dr. Winner. Dr. Winner did an extensive examination and some testing and diagnosed her at that time with cerebral palsy.
When we were first told there was a lot of crying. A lot of blame, what did we do wrong, until the doctor actually sat down and explained to us what cerebral palsy was and that it wasn't really something that we did, its just something that because of the prematurity, the brain hadn't had the opportunity to grow and form the way it should, and that is why she developed the cerebral palsy.
Hedrick Smith: Did she begin treatments for that right away?
Mark Chipps: As a matter of fact she did. When Dr. Winner diagnosed her, he recommended a place in Palm Beach . . . and we have been going there since she was about seven months old. Initially she was going there for physical therapy, and that was just basic infant mobility. She couldn't crawl.
One of the tests they did was they held her face down over the floor, kneeling down, and they would slowly bring her down towards the floor so she was facing the floor. A normal baby would instinctively put their hands out to stop themselves or catch themselves, and she had to be taught to do that. They would take her all the way to the floor and she just wouldn't move, she would lock her arms up and make a fist.
The rehabilitation center has worked with us about 8 1/2 years. As she's gotten older, they've started with occupational therapy which dealt primarily with fine motor skills and as she learned to talk, she went into speech therapy.
Hedrick Smith: Let me go back to the moment when you discovered. You are healthy, your wife is healthy, your older son is all normal?
Mark Chipps: Yes, we're all fine.
Hedrick Smith: What is it like when something really big comes along? It could happen to anybody. When we are healthy, we never think about that. What was that like for you? How did life change before and after that?
Mark Chipps: When we were told, it was just devastating. We didn't know how to deal with it. My initial thing was how are we going to pay for this, how are we going to get her the medical treatment she needs, and that is when we made a promise to each other that no matter what it took, we were going to make sure she got medically whatever she needed so she could develop to her full potential.
Hedrick Smith: Had you ever had any serious medical problems in your family?
Mark Chipps: There has never been any history in my family of any major medical problems. My grandfather passed away from cancer and that is basically it. There has been no major medical problems. Then the cerebral palsy. It was like getting hit in the head with a sledge hammer.
Hedrick Smith: You were covered through your work for a lot of this with an insurance policy, right? As she was growing up you were talking about taking care of the expense, you wondered how it was going to be paid for.
Mark Chipps: Yes, when she was born we had [insurance] through the Sheriff's office and throughout that policy, they paid for whatever she needed. Medically, as far as braces, doctors, treatments, they got the bills and they paid it.
Hedrick Smith: Tell me, how did you pick Humana as your health insurer?
Mark Chipps: The Sheriff's office, every few years, reviews the insurance policies and puts out for bids. They chose Humana, so we really didn't have a choice at that point. If we wanted to work with the Sheriff's office through their insurance, we had to pick Humana.
They offered two different plans. They offered an HMO program and a PPO program. In addition to that, if I didn't like either one of those programs, I could have went to my wife's employer and been put on the family policy there. There was a conversion in the old plan, but to get the coverage that I needed that currently existed under that plan, since it was a group plan, for me to pay for it individually was thousands of dollars a month.
Hedrick Smith: So why did you pick Humana?
Mark Chipps: Because the sheriff's office is so large, they had group meetings with Humana representatives and they explained the two programs, the HMO and the PPO. When I went up to the representative, I wasn't sure which plan would be more beneficial for my daughter. They explained to me that under the two policies, the PPO policy would be the best because it afforded the speech, occupational and physical therapies that she needed.
In addition to that, they also said they had a program called medical case management which was something I had never heard before. They explained to me that it was a program they had under our contract plan for catastrophically ill children or anybody that was catastrophically ill. It would expand their plan benefits so they could get the treatments that they needed for that illness.
Hedrick Smith: How important was it to you in your selection of your health plan, what the Humana representative promised to you personally about your daughter's care?
Mark Chipps: What they promised me about the health care was extremely important, because she is my child, I had to make sure she was taken care of. I explained to the Humana representatives exactly what she was getting now, the physical therapy, the occupational therapy, the speech therapy, the doctor she was seeing, the leg braces she needed every eight months because she was growing. I explained this all to them and they said, you go with us and you are not going to lose any of your benefits and that is when they said, we have this program called medical case management and we are going to put her in there and we are going to make sure that she gets what she needs.
Hedrick Smith: Then what happened? Was she under this plan a long time?
Mark Chipps: The Humana plan started in January of 1994 and February of 1994 I received a letter from the Humana case management department explaining that my daughter was placed in case management and there was a form I had to sign, a consent form, explaining to me what case management was, what it was going to do for us and there was a number of a case manager to call.
I called her up and explained to her who I was and she said she was expecting my call, and that she had already had it approved for the therapy she was getting, that she had already talked with the rehabilitation center and her doctors and that she was going to make sure that care was continued and coordinated through her to make sure the benefits were paid for and she would continue to get that care.
That pretty much continued on and we were very happy with the program. If there was a problem with the bills, if there was a problem with the doctor as far as getting paid or having to change appointments or whatever, or an increase or decrease in the therapies, I would just call her up. She was my lifeline with the insurance company. She was taking care of all this stuff for us to make sure she got what she needed. I thought it was great.
Hendrick Smith: When did that all change and how?
Mark Chipps: Caitlyn was going to the preschool program at the Cripple Children's Society where she was getting these therapies. I went to pick her up after school and I was told by the preschool teacher to go see a lady by the name of Judy Butterworth who does their billing or did their billing at that time. I went and saw her and she said I have some bad news for you. She said I was just faxed a letter from Humana stating that they were taking your daughter off of case management and that they were no longer going to pay for her therapies. I couldn't believe it.
There was an 800 number there to call, I called that and I got the case management department in Miramar, Florida. I asked them if my daughter was being dropped from medical case management. The case manager just seemed to be flustered and she said hold on a minute, I'll have to get you my supervisor. The supervisor was a lady by the name of Susan Jacques who was in charge of the case management, the case, the nurses. I spoke to her and I said, “Is it true my daughter was taken out of your program?” and she said, “Hold on a second,” and she checked, she said yeah, she's being dropped from the program. She says you should be getting a letter shortly. I hadn't even been notified yet, I found out through their billing department where my daughter was getting treatment.
That is initially how I found out about it. What is interesting about Susan Jacques is that I called her back several times to find out who took her out of case management so I could speak to them. She gave me the name of two doctors with Humana. I called them repeatedly, never got a call back. I called her a third time and said what am I supposed to do? What can I do to get my daughter these treatments? That is when she told me that no way, shape or form are we putting her back in our program. If you want any help for your daughter, than I suggest you contact Easter Seals or United Way.
I went to my on-site rep at the sheriff's office. It's so large of a contract, that Humana had someone there full time to deal with our problems. I went there with my policy in my hand and explained to him what happened and he said, “Well, let me make some calls to find out what's going on.”
So, the first call he made confirmed that she was taken out of medical case management program. The second call he made he spoke with someone for quite some time on the phone. He said, “I've got some really bad news for you.” He said, “Not only have they taken her out of medical case management, but under the terms of your contract, she is not covered for speech, physical or occupational therapy.” Basically she had no coverage at all at that point. I said, what can I do to appeal this?
He said, “We'll try to get you,” - this is a term I'd never heard before “market exception.” He explained to me that was something that you needed above and beyond your plan, supposedly plan benefits. So, I applied for that immediately and that was denied within a matter of days. I went back to the on-site rep a third time, and I said, help me out with the appeals process because I have to do something. He said, “We have to get letters from the doctors saying she needs these treatments, letters from the therapist.”
I asked where does it go. He said the person who ultimately has the final say is Susan Jacques at Miramar. I said, this isn't going to [do] me any good because she told me to go to Easter Seals or United Way three weeks ago. At that point, I was dead in the water. I didn't know what to do.
Hedrick Smith: Did anyone from Humana ever explain to you in writing or in detail why they dropped your daughter from this plan?
Mark Chipps: In my conversations with Susan Jox I asked her why my daughter was dropped from the plan because the letter said that she was just dropped, she no longer met the criteria for case management. I asked her what is the criteria for case management? She couldn't tell me.
I said, could you send me something in writing, a pamphlet, a brochure, something about medical case management that explains what the criteria is that she doesn't meet. She refused, she just outright refused to send me anything. I said, can you send me my daughter's medical records that you used to determine that she no longer meets this program, and she refused to send me my daughter's own records.
No one ever explained it to me other than this form letter that was unsigned saying that she no longer met the criteria. Period. No one ever explained to me what the criteria was, what magic pills she took that she no longer had cerebral palsy and no longer needed this medical treatment.
This was the whole month of December of 1995, I was doing all this because I didn't know if my daughter was going to be able to be treated anymore. At that point my wife and I had returned our Christmas gifts for each other to get more money into the house because everything was falling on me at this point to get her the treatment she needed. I had exhausted all my remedies. I had no place else to turn other than to go talk to an attorney because I had jumped through Humana's hoops. I tried to play by the rules and I just kept meeting obstacle after obstacle.
Hedrick Smith: When Humana cut your daughter off, did that mean you had to cut back the treatments or could you afford to pay for treatments yourself?
Mark Chipps: Initially, the bill fell to me because I had to pay for this myself. Obviously, it is quite expensive. She was going for physical therapy and occupational therapy three times a week. She was going for speech therapy twice a week. The school board, since she was in the preschool program, was paying the bigger part of the physical therapy and occupational therapy in the school setting.
It was about $18,000 a year of treatment that she needed. At that point, we were talking about second mortgages. I was in the Air Force Reserves so I was constantly calling them up to find out if I could do extra days there to get extra money in the house. I cashed in my vacation leave, to get paid for that so I could have that money to pay providers so my daughter could be seen.
I had to cut back the amount of care she was getting because I couldn't financially make the payments. The rehabilitation center was not breathing down my neck for money, they understood the circumstances, but the outstanding bill was still my responsibility and I knew that sooner or later, I was going to have to come up with a large sum of money to pay these folks for seeing my daughter.
Hedrick Smith: Did this cut back in your daughter's benefits have any impact on her health?
Mark Chipps: The cut back in benefits had a lot to do with my daughter's health. We had to cut back on the speech therapy and we had to cut back on the occupational therapy.
When we reduced the occupational therapy and speech therapy, my wife and I both noticed that she became very frustrated on the computer, she started deteriorating in her hand/eye coordination, she would get so frustrated, she would just sit at the computer and cry. Then she would get up and go in her room and close the door, didn't want to be bothered with anybody. She just said that I can't do this anymore, I can't do that, what's wrong with me?
She started regressing in her ability to walk. Initially she was in leg braces from her knees all the way down to the bottom of her feet. She had progressed to a point where all she needed was the ankle support, she did not need the full leg brace.
When the therapies were cut back, she had to go back into the full leg braces; she was having a lot of problems walking as normal as she could before; she was constantly holding onto things for balance; she was constantly losing her balance, falling into walls, falling down. We noticed her starting to crawl a lot more. It was like she almost gave up walking -- reverted back to crawling.
Hedrick Smith: Humana takes the position that there was no harm done to your daughter because of the cutback of the benefits. What is your reaction to that?
Mark Chipps: Well, at this point, it is hard to believe anything Humana tells me, because they have just been so dishonest with me. We've had their doctors say that yes, she regressed, she didn't progress as she should have. She did regress. Children, when they are developing, have certain windows of opportunity for progression as they grow and if they miss those windows they can never get them again. She has missed that and for a handicapped child, that's devastating.
Hedrick Smith: When you got to the lawyer and you decided to file a lawsuit, did you learn anything about other people having similar problems, did you find out you were alone or that there were others in the same kind of situation?
Mark Chipps: The case has gone on for several years. During the course of this whole discovery, we found out that this was done to hundreds of kids. That they basically say that any child that has what they call static, that had cerebral palsy, they just dumped from the program.
There was a case manager who was in charge of a market here in Florida and she was told by [the] corporate office in Louisville that they were going to initiate other programs, and in order to be cost-effective and have the personnel to monitor these other programs, they had to weed out the pediatric patients in case management. The kids with catastrophic illnesses.
Mark Chipps: I didn't have a chance to talk with other parents, but I listened to their testimony in court. They brought in several other parents in situations similar to mine to show …the court and the jury that it wasn't just my child that was affected by this, that it was just a sweeping motion by Humana to get rid of these kids.
Hedrick Smith: When you filed suit, you asked for 100 million dollars in damages. Were you trying to send a message?
Mark Chipps: When we filed suit, we didn't say anything about damages. There was no dollar figure that we put on there. Initially, I just wanted Humana to wake up and say, wait a minute, maybe this guy means business. Maybe we need to provide him with what we promised him and what we've contracted with these folks to do. What's interesting is once they were put on notice that I had an attorney, Humana wrote back saying that they were going to reevaluate the denials for her therapies and that they were in fact [going to] pay for her speech therapy. That never happened.
Months, months later, on the advice of Humana's attorneys, she was put back into medical case management. However, they still didn't pay any bills. They put her in the program, they authorized the treatments, she got the treatments and they still didn't pay. So, the bill just kept mounting and mounting and mounting.
Right now, the Rehabilitation Center for Children put the bills in limbo. They, out of the goodness of their heart, continue to see her and give her the treatments she need[s], but the bill still needs to be paid. There is an outstanding balance there of over $18,000 that these people promised they were going to pay and they still haven't paid.
Hedrick Smith: There are obviously several issues here that are of concern to you. Primary, of course, is your daughter's health. You are also concerned about legal contract, what they promised you, so forth. What is it that you feel was wrong here?
Mark Chipps: What I feel was wrong with my whole dealings with Humana was I was lied to; I was lured into their program, I was promised certain things. They delivered those things for a while. When they saw it wasn't going to be cost-effective, they dropped her from the program. Not only did they drop her from the program, they said, guess what, we're not going to cover [her] under your plan benefits either.
Hedrick Smith: You said before, Humana never really explained to you why they dropped your daughter. Why do you think Humana dropped your daughter?
Mark Chipps: I can state with certainty now, especially after the trial, as to why she was dropped from the program. They had these other programs they were starting that fell under case management and utilization management, and they didn't want to hire extra people, so they got rid of the kids so they could take those nurses that were taking care of these kids and focus on the cardiac patients and cardiac heart failures and that type of thing; I think those programs are great and I think they should have them and I hope it works.
They are saving money on both ends because they are reducing their hospital days, and at the same time they are denying all [this] coverage for these kids. It's a save-save for Humana.
Hedrick Smith: Is there a lesson in your experience for other parents of kids with chronic, deeply serious illnesses?
Mark Chipps: There is a lesson for other parents: I think that if they have an insurance policy and they are denied benefits they should hound, hound, and hound. They should do whatever it takes to get what they are promised. It just seems the more you yell and scream and the more you kick and fuss, the more apt they are to listen to you, that you're not going to go away.
These corporations are so big that they play percentage. They'll deny a thousand people nationwide and maybe only five percent will appeal it and out of that they can finagle their way around it and maybe only pay a couple hundred claims, so it’s still a win-win for them. The whole thing is a business. It has nothing to do with "quality of care." The whole thing is making money for the CEOs and the higher-ups and the supervisors. That is why they have their salary incentive plans, for denying benefits, for denying hospital days.
We had check stubs from Humana employees -- from case managers, from supervisors of case managers where it said right on the check stub, $250 bonus. We produced documents from Humana saying $250 bonuses will be awarded for the following: It spelled out reduced hospital days, reduced coverage, cut down the costs in this area, cut down the costs in that area. If you meet your goals this month, your employees will be receiving a $250 bonus. Humana swore up and down that there was no bonus incentive program for their folks.
One lady who was an ex-employee of Humana, which incidentally happened to be Susan Jacques, testified that when she was there, she was instructed by her supervisors all the way up to corporate in Louisville to deny claims, lose the claims, to say there was a wrong code number on it, send it back, just so that it would be reprocessed.
I had claims that weren't paid for over a year. [It] took a year for some of my bills to be paid, for the doctor bills to be paid. To this date, some of them still aren't paid. You have to stay on top of the insurance plan; you have to make sure that they are paying what they are supposed to be paying, and you have to make sure that your family is getting the coverage that they need - that they are contracted to get, that they are supposed to get, that you are paying to get.
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