“We thought it might fall into a legal gray zone,” said the former Cigna official, who helped conceive the program. “We sent the idea to legal, and they sent it back saying it was OK.”
Finally pre-approved on 3rd appeal after 8 months and 150pages of documentation of every piece of every single communication (who, when, response, expected next contact) only weeks before surgery scheduled >6 months before. First rejection was automatic, second was revealed to be a dermatologist, third was a gynecologist. (They really hated that we figured out who the person was, their specialty, the state they worked in, and pending disciplinary actions).
Standard answer is we can't tell you why you were rejected (code only) because the criteria are from a third party and their review document is proprietary. When you find an online leaked document with the same code it says "unnecessary cosmetic surgery". Wrong contact numbers are provided, people go on vacation and do not respond for weeks, "that person doesn't work here".
If you're not a professional in the field with time on your hands and a detail oriented A-hole, you will be denied anything expensive that isn't considered immediately lifesaving at a trauma ICU recommended by the attending.
After pre-approved surgery with excessive blood loss and an extra 12 hours in recovery... Overcharge/All-claims-denied. Multiple appeals until involving Hospital CFO who agrees to split the extra (self-insured) cost of the insurer and get the final insurance reimbursement check... it is $3k less than promised (hospital paid the correct amount). Surgeon was going to start charging late fees and interest or send it to collection after 4 months.
Is it worth fighting any more? No.
How did you find out about the automatic rejection/identity of the reviewers?
From the doctor's name and the Midwest area code for review center we were able to filter down the doctor's name to a single individual and then do a search in the state medical board system (I'm not sure if this is readily available to non-medical personnel). That popped up his med school, residency, work history (ended more than a year before) and some pending issues with his performance. When we replied by registered mail we made an obvious CC to a local lawyer.
Speaking to the surgeon we were also able to makes some guesses as to the rough name/title of a justification document they would use and that along with the citation number in a google search popped up a downloadable pdf which was 5-6 years old, but seemed about right. And when we looked up the paragraph and rejection it was pretty clearly related to roughly the right kind of surgery. That let us make a more focused/documented appeal to the rejection. When they finally approved we got a bit more documentation about the prior rejections and who reviewed them. I assume ass covering.
In the end the thing that really pissed me off is that they didn't even pay what they promised to and we knew it would another 100hrs of work to get it.
Edit: we paid ~10% out of pocket on a $60k surgery + their shortchange. good news is 15y later totally successful and healthy! P.s. this is by memory but somewhere we’ve still got that notebook and all the paperwork filed that I’d rather forget.
Can someone explain to me why the model we choose to pay for the health for the populous of this country is through insurance and not straight up taxes??
https://www.bostonreview.net/articles/jonathan-m-metzl-dying...
> Even on death’s doorstep, Trevor was not angry. In fact, he staunchly supported the stance promoted by his elected officials. “Ain’t no way I would ever support Obamacare or sign up for it,” he told me. “I would rather die.” When I asked him why he felt this way even as he faced severe illness, he explained: “We don’t need any more government in our lives. And in any case, no way I want my tax dollars paying for Mexicans or welfare queens.”
America's health care system is shaped and maintained by those who benefit economically from its configuration. Configuration maintenance tools include lobbying, gerrymandering, targeted tax favors, and wide dissemination of misinformation.
It's a very small fraction of "we" that maintains this status quo.
All it takes is a last name. You dont even need a first name or state I believe, although you may need a lot of patience and some luck to find the right "smith" without a state. Once you have at least a last name, you could look up the doctors specialty even practice address in the public NPES system.
Good for you though! Never though non surgeons would review surgery claims. Seems insane to me and grounds for a professional liability suit
You do need access to the state board if you want to check out complaints. i dont think You will find much though. Doctors rarely get "written up"
So you paid for a service, and you don't get the service you paid for, and you will not be told why?
If I did this in my line of work, I would be in prison for fraud.
My sister was the manager of a coffee franchise named after a certain character from classic literature. Her location was doing extremely well, she was a competent type-A who commanded a great deal of respect in her entire district, and was generally assumed to on the fast-track for promotion.
One day, $200 was missing from her daily cash. She was fired the next day. Not for the missing money; they came showed her a list of very minor issue (clerical errors, an unwashed countertop on a random inspection, a couple unhappy customer feedbacks) that had come up in her eight-year career, and said she was fired for general incompetence.
Two weeks later, one of her ex-employees called up, crying; she was doing her laundry, and found $200 in one of her pockets. She had gone to the safe to make change for the register and screwed up.
The point here is: corporations understand that you can't fire someone or deny coverage based on reasons that can be contested. It's not fraud if you fire them for some other reason. It's not fraud if you don't even know why you denied coverage. You're only in trouble if you play fair.
We’re Americans and we love this sht and it's no wonder the CEO of that coffee company thought he deserved to be President.
Like in US insurance is at will, okay, fine.
But insurance is surely under a legal obligation to fullfill their end if the bargain?
> [...]you can't fire someone or deny coverage based on reasons that can be contested. It's not fraud if you fire them for some other reason. It's not fraud if you don't even know why you denied coverage.
Corporate counsel for insurance companies comprise one of the very few spots on the brontosaurus with low-latency innervation from the brain. Poke it, you'll usually get a response that will arrive faster than the usual appeals processes.
What can be done?
That change doesn't have to be 100% or perfect. The ACA ensured that a lot more people got covered, even if it was not perfect.
Also, it's about far more than voting. Voting is done every once in awhile. Citizenship is every day. Powers-that-be are watching and investing enormous energy in manipulating public opinion - for a reason. It's powerful. Today is the day to act.
There definitely aren’t any healthcare systems inside of my mirror, not even the bathroom one with a cabinet behind it.
The media also loved to bring on people who “adored their current insurance plan and would hate to lose it”. I’ve never met someone like that in real life, but the MSM would have you believing you were the only one in all of America who had any ill thoughts about their insurance company.
If voting could change anything it’d be illegal.
The absolute best way to ensure that nothing changes is to get cynical and try and demotivate anyone else from trying.
The "We need to raise taxes to have universal coverage" argument doesn't hold water.
> Health care is financed through a mix of financing arrangements including government spending and compulsory health insurance (“Government/compulsory”)
Digging into the source report[0], we see the following footnote exclusive to the US:
> All spending by private health insurance companies reported under compulsory health insurance. Category “Other” refers to financing by NGOs, employers, non-resident schemes and unknown schemes.
[0]: https://www.oecd-ilibrary.org/sites/ae3016b9-en/1/3/7/4/inde...
Yet things do change, dramatically.
What have the “far right” changed? And was it through voting or other means? In a sibling I admit violent revolution as a plausible change causer, and claim it is unique in that regard.
This is one of the more annoying failure modes of socialised medicine; when things go wrong the consumer has no control over the waste because they aren't in control of the money being spent.
Absolutely pick a different phrase, but it'll still have applied before the ACA and it'll apply after except for people with preexisting conditions, eliminating lifetime caps, and maximum out of pocket limits.
I'd really like to hear one, cause the violence option isn't really very appealing.
Or we could just bring back bribing....
Oh you sweet summer child...
You don't want to get shot? Don't try to cheat people out of their money, especially when it is about their healthcare. It isn't complicated.
Going all philosophical here is, what, you making excuses for being a monster? Because what you're saying is that ruining other people's lives for your own profit is fine.
And yeah, violence is an extreme and distasteful solution, as I said. But if the only other option is to suck it up and let the exploiters win, then that's on them. You don't get to have a hypocritical morality system where it is ok for you to inflict harm on others for your own profit and not ok for them to inflict harm back in self defense.
"I'm a healthy 22-year old male with no family history to worry about, go ahead and ravage the program to save me a nickel on taxes."
or, from the other side,
"I might need an ingrown toenail treated and how dare that go into a triage list and I have to come back in six months because there are more seriously ill people-- don't they know I'm rich and important?"
An insurance provider for a specific industry has teams of skilled attorneys that are expert in that specific domain. Cigna might self insure if they consider medical malpractice a core part of their business. In that case, your attorney sends the letter to their corporate counsel.
Often times, day to day business people just ignore liability risks because it's not in their core mandate. But the corporate counsel is in charge of managing legal risk, and they will see such a situation as unacceptable. Corporate counsels also hold a lot of sway within a businesses structure.
Does this mean that the hospital self-insured and provided the surgery? As in why have Aetna involved at all then?
Instead of paying monthly insurance premiums, the company directly funds the claim payments as they come in. They outsource the work of adjudicating claims, negotiating with providers/facilities, cutting checks, setting approval criteria and first level appeals to another company, called a Third Party Administrator.
Now, who happens to have all the skills and expertise to do the job of a TPA? The big health insurers. These are giant companies with many lines of business. One of those lines is selling insurance to individuals and small businesses, another is selling administrative services to larger ones.
Note that even with a self-insured plan, there’s often insurance involved too: the company will buy a separate “stop-loss” policy that kicks in and starts paying after the employer has paid out a certain amount in total over a year. This protects them from the risk of covering a plan member with a particularly expensive condition.
"I beleive this procedure _____________ is medically necessary for __________. Time is of the essence, and this procedure should be performed as close to immediately as possible."
In the signature block, I include the degree, specialty and medical school of the doctor. I then fax the letter in, and within 30-40 minutes, I have a phone call apologizing for rejecting and giving me pre-approval for the care. I learned about this when my (at the time) 15 year old was rejected for a cardiac procedure and the billing person pulled out a pre-printed deck of letters that was pre-signed by every department head at the hospital. The one thing the insurance people fear most is risk.
Had it not been for their constant denials of a drug I had been on for over two years prior, I might still be taking that medication instead of having developed antibodies for the 6 months they denied.
My doctors office gave me free samples as long as they were able, but in 2022 they were wiped out as all patients that were on that drug were being denied coverage.
Worse still, insurance recommended "use drug X, which is similar"... but I couldn't because I was on drug X—until I had anaphylaxis from it!
The funny/sad thing is: between my hospitalizations, TPN and related home health care, and surgery, this is all going to cost my insurance far more than the drug they were denying would have. One would hope this provides them with motivation to better judge the necessity of treatments, but I'm not holding my breath.
I have UC that's well-controlled with mesalamine, and I've had a few scares (my insurance rolls out a new prior auth every year, and I have to call my provider to have them sign it for some reason, or the new insurance only covers the name brand (not generics) because of PBM antics). The thought of having to come off of mesalamine for even a week is terrifying. I really feel for you because your condition seems much more severe/hard to control.
Why do I need a new prior auth every year? My medication hasn't changed, and neither has my condition. It's a bureaucratic hoop, and if I don't jump through it I get to spend my whole day on top of a toilet. That's a terrible way to treat a human being.
Even from a purely amoral capitalist perspective, I know the cost of my medication is a small fraction of the dollar value that doesn't get generated if I can't take it. I don't benefit and society doesn't benefit if I'm sick - the only group who benefits is the insurance company who gets to pocket my premiums and avoid paying out. It makes me furious.
Even a moment's thought about the power disparity between an insurer and an individual facing medical problems leads me to conclude your "simple solution" has little to recommend it.
If a patient breaks a leg and a doctor recommends not experiencing gravity for a while, do we fly them to space?
I am using hyperbole to demonstrate a point: there are meaningful economic limits that must be created by some entity and enforced.
What is the value of a human life? The GDP of a nation is a hard upper limit. The total money a particular person in question has access to is the lower limit.
If you run an insurance company (or you run government run healthcare) you can't avoid answering that question with an actual real dollar amount.
At some point spending money on a person with a particular condition does mean that someone else with a different condition can't have money spent on them.
That's why it's important to spend money on research; to develop new technologies and techniques, and improve existing technologies and techniques; that can make cost of care lower.
That's why it's important to have standards of care and treatment, for all medical providers to follow.
I have an Aetna PPO and experienced a stroke last year. $100,000+ hospital stay and insurance just… covered it. I paid $1,100 out of pocket.
I had a $100,000+ surgery a few weeks ago to repair a heart issue that may have led to it. They just covered it. No fuss, no hassle. I paid $3,300, which was the remainder of my total annual out-of-pocket, and now I will pay $0 for healthcare for the rest of the year.
For the surgery, I called in advance to double check that it was covered and after five minutes on the phone with a concierge they confirmed that it would be covered.
Obviously I am only a single data point and I can’t speak towards other conditions or procedures. But Aetna has done right by me, at least from within the perspective of our insane for-profit healthcare system.
Healthcare is like running water, bridges, or banking systems - a high-volume system with extremely high stakes. We need many nines of consistency as protection against preventable harm.
There are around ~35M hospital admissions in the US every year. Even if 9/10 patient experiences are like yours, that means more than 3.5 million people had a sub-par experience that year - that's the entire population of LA. We need to strive for a much higher bar of quality and consistency.
I was simply trying to say that, within the confines of the current system, this particular actor has not gone out of their way to fuck me over in the same way that I hear about so many other actors.
I have no idea if my experience with Aetna is common or an outlier. My hope was that by posting this, it would provide a data point for people forced to choose a private health insurance provider in the future. I also hoped to hear from others who had experiences either mirroring or opposite my own.
If I could, I would dismantle our current system in a heartbeat and replace it with some form of single-payer. I can’t, so I tried to provide information about one player within the incredibly fucked up system Americans are forced to operate within.
So with insurance you paid more than a European without insurance would, and you call that a counterpoint?
I don’t and neither do the hundreds of millions of others who remain in the US. So for those people, I wanted to provide a data point that might help them when they, like me, are forced to make decisions about their healthcare in this system.
Also this is anecdotal. I too have an Aetna PPO and can tell you of horrid stories and countless hours on repeated phone calls with them.
Not saying you just did this (you obv did not) but as a whole in this country we need to start dropping the “it didn’t happen to me so something must be wrong with you” mentality. It is pervasive in the healthcare topic and unfortunately in many other facets of American life.
Germans in WWII that enjoyed the fruits of the regime have sang its praises - that didn’t mean the war machine on the whole wasn’t decimating the people and their country. We shouldn’t lose focus of how our country is being decimated by our collective ineptitude.
Please do!
My point was simply to say that this option is one that has done right by me so far. If there is significant evidence this is an outlier experience, I (and I’m sure others) would benefit from knowing so.
For the record, to comprehend what this means from the doctors side, this means that Doctors (and billers) must be aware of every possible permutation that is "allowed" for billing by every insurer, for every CPT (procedure code).
I did some quick math to measure:
A) There are ~12000 valid CPT codes. (I could not google the exact number but CPT codes go from 0xxxx to 99xxx, plus therr are also S codes (Sxxxx), J codes (Jxxxx) etc.)
B) There are 155,000 ICD-10 diagnosis codes [1].
There are roughly 900 payors in USA. [2]
This means there are 1.67 x 10^12 rules a doctor billing insurance must know.
Even if you consider the narrow view that a doctor of X specialty may bill only top 100 cpt codes, for maybe 50 payors, thats still a huge number (25M!!!) because diagnosis DX (I.e. ICD-10) is not narrow and requires knowledge of related conditions - billing z11 is different result vs billing z11.26 and you must know that.
Its insane to think anyone will memorize 25 million combinations to know what to bill or not bill. And this calc does not consider modifiers OR primary DX....
[1] https://eohhs.ri.gov/sites/g/files/xkgbur226/files/2021-03/I...