From the Austin American-Statesman, May 14^th, 2004:

A 22-year-old woman injured in an auto accident had to wear a plastic helmet because of a standoff with Medicaid and the hospital over who would cover the surgery.

By Alexandria Sage

ASSOCIATED PRESS

Friday, May 14, 2004

MIDVALE, Utah -- After months of waiting, Briana Lane has her skull back in one piece.

The 22-year-old woman was injured in an auto accident in January, and doctors temporarily removed nearly half her skull to save her life.

But for nearly four months afterward, the piece of bone lay in a hospital freezer across town -- and Lane had to wear a plastic street hockey helmet -- because of a standoff between Medicaid and the hospital over who would cover the surgery to make her whole again.

The surgery finally came through after an excruciating wait, during which she suffered extreme pain just bending down and would wake up in the morning to find that her brain had shifted to one side during the night.

“When you think of weird things happening to people you don’t think of that,” Lane said. “It’s like taking out someone’s heart -- you need that!”

Sonya Schwartz, a health policy analyst for Families USA, a consumer health care group, said insurance horror stories happen every day. But “this particular story is outlandish.”

On Jan. 10, Lane’s car rolled over on an icy Utah road. Lane, who was not wearing a seat belt, was thrown through the windshield. (She was later charged with driving under the influence and not having a driver’s license.)

Doctors at the University of Utah Health Sciences Center in Salt Lake City removed the left side of her skull to treat bleeding on her brain.

Lane’s doctor originally scheduled the replacement surgery for mid-March, a month after her release from the hospital, said her mother, Margaret McKinney, a nurse who works in another division of the medical center.

But the operation was canceled the night before because the hospital was waiting to see whether Medicaid would cover it -- a process that can take at least 90 days.

Lane, a waitress with no insurance, was sent home from the hospital with a dent in her head where the bone had been removed but the scalp had been sewn back into place. She stayed at home, able to walk around but not go to work, and had to wear the helmet during the day.

During the wait for a decision from Medicaid, the hospital could have declared an emergency, moved ahead with the surgery and figured out afterward who would pay -- the hospital, Medicaid, or the patient. But the hospital did not do so.

After months of delay, Lane contacted a local TV station, a move she believes hastened the surgery. “All of a sudden -- top of the list!” she said. The operation took place April 30.

Exactly what broke the impasse is unclear.

The operation took place after Lane’s mother’s insurance company decided to cover the surgery, as well as the nearly $200,000 in medical bills.

But hospital spokeswoman Anne Brillinger, while refusing to comment on specifics of Lane’s case because of federal privacy rules, said the medical center decided to perform the surgery before it learned the insurance would pay.

Utah’s Medicaid program has yet to decide whether Lane qualifies.

Robert Knudson, director of eligibility services at the Utah Health Department, which oversees Medicaid, said the agency has not yet seen enough evidence to decide whether her injuries entitle her to benefits under the law.

He would not comment on whether her four-month wait was unreasonable.

But he said the decision over how fast Lane got treatment was up to the doctors, not Medicaid. “We only pay the bills,” he said.