NOEL KING, HOST:
Sometimes it takes an unusual occurrence to uncover a weakness in your health insurance plan. Once a month, NPR and Kaiser Health News take a close look at medical bills that you send us. Today we hear from a Los Angeles family that had a strange experience. Days apart, father and son suffered nearly identical injuries. Stephanie O'Neill reports on this medical double whammy. And just a warning - some of the descriptions can be fairly graphic.
STEPHANIE O'NEILL, BYLINE: Angel Dean Lopez is a Hollywood television writer and father who enjoys doing projects with his three kids. Every fall, in fact, he helps them transform 7-inch-long blocks of wood into whimsical race cars for the neighborhood's annual pinewood derby.
ANGEL DEAN LOPEZ: So you have to take your block of wood, shape it, sand it, paint it. Use your imagination. You see I have an ice cream cone, penguin, Altoids box.
O'NEILL: But the derby project that will live in infamy, a Pellegrino bottle on wheels. His 11-year-old son Theo came up with the idea in the fall of 2016. Lopez recalls he was slammed with work at that time.
A. LOPEZ: I had to do three of them in 12 hours. I was in a hurry, and I did a horrible thing. I turned the router over the wrong way.
(SOUNDBITE OF ROUTER WHIRRING)
O'NEILL: A router is a handheld power tool with a fast-spinning, interchangeable blade that shaves and shapes wood. Lopez figured he could work faster if he flipped it over, held the wood in his hand and carefully guided it across the router's blade. But that didn't work.
A. LOPEZ: My hand slipped and got caught in the router. And I looked down. And if you imagine, the bone is a hot dog, and your skin is the bun. It just looked so horrible.
O'NEILL: After a two-day hospital stay and surgery, Lopez returned home with his pinky finger sewn together, the tip at an odd angle and his right hand immobilized in a cast. Then, nine days later, it was deja vu for the Lopez family. While carving a Halloween pumpkin at a friend's house, Theo, then 9 years old, seriously injured his right hand.
THEO LOPEZ: My knife got stuck, and my fingers slipped down the blade. And then it got cut about a third of the way through. And I cut my tendon.
O'NEILL: Did it hurt?
THEO: Actually, surprisingly not. It was just so fast.
O'NEILL: Still, Theo, like Dad, required complex surgery to repair the injury. And then both father and son underwent numerous rounds of doctor-ordered occupational therapy to help them regain use of their hands. The healing went well, and Lopez was pleased - until the bills started rolling in. That's when he discovered that his normally robust insurance policy, which he gets through the Writers Guild of America, requires him to pay for the bulk of each therapy visit.
A. LOPEZ: You know, carrying the load for two of these expensive rehabs was a lot.
O'NEILL: So he appealed the decision. The Writers Guild health policy denied the appeal and refused to speak with NPR. Lopez says he's looking for other ways to continue the fight and is hoping to at least encourage his health plan to change its policy because, he says, it seems unfair that necessary treatment isn't well-covered.
A. LOPEZ: I owe a ton of money, and I'm still on the hook.
O'NEILL: His out-of-pocket share - more than $8,500. Theo got his care from Children's Hospital Los Angeles. Lopez got his from Cedars-Sinai Medical Center, also in LA. Each facility billed Lopez's insurance about $325 an hour after discounts. Lopez did some digging and discovered the financial disconnect. The union health plan classifies occupational therapy as an alternative treatment on par with acupuncture and chiropractic care. And because of that, it limits payments to $60 a visit, less than half of what Medicare pays for such service. Randall Steward is vice president of payor relations at Children's Hospital LA.
RANDALL STEWARD: That is lower than any private insurer we've seen.
O'NEILL: And how the care was classified is unusual, he says.
STEWARD: I've worked for payors and hospitals now for close to 25 years. And I've never seen an insurance plan categorize occupational and physical therapy, as this plan does, as an alternative treatment.
KING: We reached out to the American Occupational Therapy Association and spoke to Sharmila Sandhu, the group's director of regulatory affairs. She says among the biggest challenges her group faces is educating the public, insurers included, about the profession. Broadly speaking, she says, occupational therapists help people who've suffered injuries and a host of other conditions, including stroke, regain the ability to function.
SHARMILA SANDHU: Occupational therapists work on what we call occupations, which is another way of talking about their daily activities.
KING: For some people, that means the ability to groom, bathe and feed themselves. For Angel Dean Lopez, it means being able to once again type out his television scripts. And for young Theo Lopez, occupational therapy ensures he can hold a pen in school, throw a ball and continue playing bluegrass music on his fiddle.
THEO: So this is one of my favorites.
O'NEILL: For NPR News, I'm Stephanie O'Neill in Los Angeles.
KING: If you have an interesting medical bill, we would love to see it. Go to NPR's Shots blog to share your bill with us and with Kaiser Health News.
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