or, Why Does Aetna Hate Ruth Kaufman's Toe?
There are two strands here: denial of care, and lack of transparency.
My health insurance, for which I pay $395 per month, will not cover the foot surgery my doctor says I need: a toe joint replacement that is supposed to last 20 years and which will restore mobility and reduce pain.
Aetna won't cover this; according to them the procedure is experimental, though it has been FDA approved. Aetna will, however, apparently approve two other procedures: fusing my toe to my foot so it would never bend again, or removing the joint so the toe sort of flops around. Yuck. But both options are supposed to eliminate pain.
Apparently "experimental" means "Aetna doesn't like it."
Our intrepid health care "consumer" then considers the cost cutters' preferred approach: pay for it yerself.
Just how much does foot surgery cost, per foot? Despite numerous phone calls, calculating the exact total remains an unsolved challenge, because so many entities and individuals are involved...
Can you imagine a cost conscious consumer going into a department store and buying a dress without knowing precisely how much she'll pay? How can you dispute a charge after the fact, if you've been given and then used a product or service?
No matter how many times critics of the current system say it, it always seems to need saying again: treating health care like a classic market doesn't make sense. The imbalance between the buyer and seller's knowledge and need is huge, far too great for the buyer to have meaningful bargaining power. And without bargaining power on both sides, all those Econ 101 supply/demand graphs simply don't apply.
Even here, where the surgery is elective in the sense that it's not an emergency, the would-be buyer can't even determine the price she is being offered!
All this would be moot if Congress would pass H.R. 676.
Adopt your very own corporate parasite today!
(Edit: try L's kludge)
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Senior Correntians, how do I get rid of inappropriate glosses?
That gloss on "hate" is not adding anything to my point....
Policy not party!
Use this trick
If you can't lowercase Hate
, defeat the pattern recognizer by throwing some markup up: Hate. Copy that to see what I did.
[ ] Very tepidly voting for Obama [ ] ?????. [ ] Any mullah-sucking billionaire-teabagging torture-loving pus-encrusted spawn of Cthulhu, bless his (R) heart.
Tx for the kludge n/t
Policy not party!
Can she get her docs to write/call Aetna and explain that it is
FDA approved, etc.?
Other types of appeals?
Go to her local TV consumer complaints reporter? Or radio?
I've noticed that when things like this get publicized on TV here (NYC metro area), especially TV, the insurance companies tend to rethink their denials.
Also, the first action is to deny. But, after listening to some people in my head and neck cancer group, tenacity can change that. I was quite amazed by one young woman who'd had tongue cancer, who at the time could barely speak, but she managed to get the treatment she needed at the hospital which could provide it. And now she can speak normally--which wouldn't have happened with the first course of treatment they were going to force on her. Impressive young woman.
Tenacity is not easy when one is in pain, btw, or sick. So, boy, do we need better healthcare coverage in this nation.
This story is infuriating--and it's the company I have. Grrrrrrr. I can't change--until I can get Medicare. Yowl, as well.
well done
this is great work you are doing on Aetna. I think one thing that could be done by a politically ambitious prosecutor is charge Aetna with practicing medicine without a license. If they are over ruling doctors, what is the basis for their judgment? They are an insurance company.
Captive docs
The ins. cos are a step ahead of you on this. They have legions of desk-bound docs on the payroll to scrutinize claims and come up with good "medical" reasons to deny them.
Had a friend in a small group practice who used to spend half her day arguing with these captive docs about how she wanted to diagnose and treat her patients.
Upshot was she gave up medicine altogether because she felt like she was being required to commit malpractice on her mostly elderly and lower-income patients.
and captive nurses
I had a dog-walking acquaintance who got so fed up with the working conditions she was subjected to as a hospital nurse that she took a job with an insurance company analyzing claims to see what they could squeeze out. Didn't seem to bother her either. Ugh. Just part of the game of life I guess.
Not that most nurses are like that, I hasten to add.
Policy not party!
malicious wounding
they could also be charged with malicious wounding. One thing for an individual patient to take them on, another thing for an ambitious Attorney General.