Cliff Faraci sustained first-, second- and third-degree burns after trying to save a teen girl after a car accident in March 2013. He stayed in a hospital burn unit for a week to get treatment for his injuries. Days later, Aetna told him it wouldn’t cover the stay.(Photo: Garrett Wichmann/12News)
The accident happened in an instant. One second, traffic was moving steadily. The next, metal debris was flying past Cliff Faraci’s windshield as cars skidded across Loop 101 near Scottsdale Road.
Faraci jammed on his brakes. In front of him, a battered red car was stopped sideways and steaming. Inside, a teenage girl, covered in blood, slumped in the driver’s seat. Faraci ran to the car and tried to help her out. The driver and passenger doors were jammed. He talked to the girl, told her everything was going to be OK.
“I noticed smoke coming from under the hood,” Faraci said, describing the March 2013 accident as if it were still unfolding in front of him, the way it will play out inside his head for the rest of his life.
“I reached in through the driver’s window to turn off the ignition … but I could not reach it … I reached further into the car with both arms and upper body. … I was halfway through the driver’s window.”
The engine ignited. Faraci, standing in a puddle of gasoline, was enveloped by searing heat and yellow flames. He jerked away, trying to stop the burning. The ruptured gas tank exploded and Faraci watched the girl inside the car die.
The rest was half-remembered blur. Though severely injured, Faraci said he helped other motorists involved in the wreck get out of their cars. A second car exploded. He talked to a police officer. He called his wife and tried to explain what happened as pain radiated from his arms in excruciating waves. Then he began to shake uncontrollably.
A team of paramedics loaded Faraci onto a gurney and into an ambulance. They cut off his shirt. An IV was inserted into his foot because of the burns on his arms. He was taken to the burn unit at Maricopa County Medical Center, where he was treated for first-, second- and third-degree burns.
“I remember praying constantly,” he said. “Not only for me, but for the girl in the car.”
After a week of intense treatment, Faraci was discharged from the hospital. But he hadn’t been home two full days when he received a letter from his insurance company informing him that he wasn’t covered for the hospital stay.
Aetna claimed Faraci’s injuries were not sufficient to warrant a weeklong stay in the hospital’s burn unit, which was deemed an out-of-network facility. Maricopa County Medical Center had billed him about $165,000. He filed an appeal with Aetna. It was denied in August.
Almost overnight, the freeway Good Samaritan had become a victim of a health-care nightmare. His case is an example of what can happen when an insurance company decides to question the administration of care provided by doctors and other medical experts directly involved in the patient’s treatment.
The out-of-network designation and a determination that a patient didn’t need hospitalization can cost tens of thousands of dollars. This week, in a series of stories, The Republic, 12 News and azcentral.com examine the cases of several people that highlight the larger financial problems in a fragmented health-care system.
Faraci, 44, of north Phoenix, is the father of two teenage boys and owner of Metal Masters Mechanical, a family business. He said he was shocked when he was denied coverage. He said he is insured through his business and assumed that because he pays his premiums, he would be protected in the event of a medical emergency.
In interviews and a letter to Call 12 for Action written in November, Faraci talked about the accident, his time in the hospital and the aftermath of being denied coverage.
“They said my injuries were not that severe and I should not have been kept there,” he said. “How can the (insurer) go back and tell the doctor, you don’t know what you’re talking about? It’s not like I was at Club Med and enjoying a sauna.”
Faraci remembered his stay at the burn unit in terms of pain. He said his wife, Bonnie, described watching nurses scraping chunks of skin from his palms and wrists. He said it hurt so bad he nearly passed out, even though he was on pain medicine.
They coated his arms with silver sulfadiazine cream and wrapped them with gauze. Over the next few days he would undergo debriding procedures twice a day, in which the wounds were cleaned. Faraci said his wife told him his skin peeled from his arms as the wrapping was removed and that nurses scraped the burns with a tool that resembled a butter knife.
Initially, doctors told Faraci he might have to go undergo a skin-graft procedure. But he said his recovery made it unnecessary. He was released from the hospital after about a week.
Faraci said he tried to talk with Aetna and got nowhere. He said he provided doctors’ letters and statements, to no avail. In an August denial letter, Aetna officials told him his coverage extends only to services and supplies Aetna deems medically necessary.
“The member had no signs of respiratory burn and was otherwise stable,” the insurer wrote. “Ongoing wound care, including medications, does not require acute hospitalizations. Further treatment of this member could be provided at a less intensive level of care, or in another setting, e.g. non-acute facility, other outpatient setting or home.”
Faraci kept fighting the claim denial. He hired a lawyer and contacted Call 12 for Action.
“It was not my choice to stay in the burn center for seven days,” he said. “This was a decision made by medical professionals who treated me on a daily basis. To have the doctors’ judgment questioned and overruled by an insurance company who did not treat me or see the extent of my injuries is unthinkable.”
Faraci’s lawyer appealed Aetna’s initial denial of the claim; the company denied a second appeal. The lawyer, Gregory Gillis of Scottsdale, appealed again and asked for an outside review of the case by an independent examiner.
The independent examiner determined that Aetna should pay for half of Faraci’s hospitalization, leaving him with a remaining bill of $82,500.
In February, Aetna told Call 12 for Action that Maricopa Medical Center was going to waive bills for any of Faraci’s hospitalization not covered by Aetna.
“I don’t believe they are going to bill him for the three days that the external medical review confirmed were not appropriate as inpatient,” Aetna spokeswoman Cynthia Michener wrote in an e-mail. “I believe he is only responsible for his deductible and co-insurance.”
Michener said Wednesday that the company is “pleased the matter is resolved.”
Faraci credited Call 12 with getting Aetna to work out a resolution with the medical center. He said he tried for months, with no success, to negotiate a similar outcome. His total cost will be around $5,000 for a co-pay.
That is about $77,500 in savings.
“It’s wonderful,” he said. “It’s a tremendous thing that you guys do to get out there in the community and help people.”
Shelby Dwyer, 19, a graduate of Pinnacle High School, died in the March 14, 2013, crash. Her family and friends reached out to Faraci and thanked him for trying to help her.
“I met her parents, her grandparents and her boyfriend. They were glad she wasn’t alone in her final moments,” Faraci said. “That has kind of given me some peace of mind.”
Faraci, a former scoutmaster for the Boy Scouts of America, said he doesn’t regret trying to help Dwyer. He said he wouldn’t hesitate if circumstances repeated themselves tomorrow.
“I would do it again. I would do it again in a heartbeat,” he said. “That’s what we are supposed to do.”