Frmr Aetna Med Director admits to not reviewing files before

[debatethis]

Mar 2, 2019 22:36:09 GMT -5 aprilsails said:

debatethis I’m so sorry. I hope you find a way to get it covered soon. My Mom is a virologist (here in Canada) and is furious about the way the provinces are dragging their heels about Hep C treatment coverage. I have a friend who also had a bad transfusion as a kid and he should really have the treatment but can’t afford it yet. It’s covered in some provinces but is waitlisted and you have to meet certain criteria to qualify.

I feel like I’m so so lucky to be where I am. There are definitely some big issues with health care in Canada still but I can’t even imagine having to go through the insurance battles that I hear about every day on this forum.

My company at the time luckily put their weight into it and finally were able to get it covered. He's considered cured now, thank goodness. The lengths people are having to go to get something that is CLEARLY the cheapest treatment option (vs transplant) is blowing my mind.

[claudiajean]

It’s such a joke. While you fight through an appeals process, you get bills and statements from treatments, letters from bill collectors for thugs you think were already paid, and requesting documentation is confusing and often ineffective.

[capscapscaps]

Having worked at Aetna, with a family member that still does, this does not surprise me one bit. Aetna fucking sucks.

[vanillacourage]

My insurance company has been amazing through all my bullshit which has been such a blessing, but if we’re trading stories: 
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we were hanging with some neighbors last night whose kid has been getting injections of growth hormones for years after falling off the charts as a baby. They think now he’s outgrown the issue but their doctor’s advice is to continue getting the injections filled at the pharmacy and discarding them for the next 6 months to a year when they can be sure, because once he comes off the shots it will be a nightmare to convince the insurance company to ever cover them again. OMG. 

[cherryvalance]

Mar 2, 2019 19:38:45 GMT -5 bronxgirl said:

When I was going through IF treatments they would regularly deny random stuff. When I called they always had random excuses or tell me my plan didn't cover basic stuff that I know it did. I was always able to get it taken care of in one or two phone calls, but they were hoping I wouldn't realize and just pay myself. Fuckers.

Mine was the same with certain things and I fought them on who makes the final decision. Like, I don't want some customer service rep or random practioner telling me I can't have something my actual reproductive endocrinologist says I need. It's awful.

[StrawberryBlondie]

I just assumed this was SOP.

[aurora]

Mar 2, 2019 18:57:33 GMT -5 GilliC said:

I know someone who worked on the billing software for a major health group, and for a certain insurer, they actually set up the system to automatically bill that insurance company twice, because its regular practice was to deny everything the first time it came in!

Yeah, I'm still angry almost 20 years later when my insurance denied a claim, and then when I called to ask why the agent said "oh, we deny every claim the first time, assuming some people won't bother to fight."

I have great insurance now (for the US) and I still think we'd be better off if we just cut off all for-profit insurance and restarted everything. In my dream the regular workers would get new, better jobs (with far fewer angry calls!) and the executives would be dumped on an island somewhere they couldn't hurt people when they were most vulnerable.

[gibbinator]

(some @@@)

This doesn't surprise. When DS1 was a year old he had to have a surgery on his hand to separate fingers which then required us to buy 2 $500 gloves to ensure his skin didn't creep back up and cancel out the whole surgery. The hospital told us our insurance would cover it. So after buying the things we submitted a reimbursement claim... which was denied. So DH called them up and basically insisted "you do cover this", and the rep was all "oh yeah, seems we do..."
The policymakers are a bunch of crooks.

[zaneyzoo]

Not surprised. It happens in the mental health field as well. I ha dale the billing for dh ‘s practice and fight frequently with the insurance companies to pay. It’s ridiculous.


My mom is on a name brand mood stabilizer. She’s been on it for years. She’s tried other meds but they don’t work for her. Last month, the insurance company denied her coverage for it and said she needed to do generic or try another new. I’m like, THATS NOT HOW THESE MEDS WORK!!! You can’t just take people off these medications! . No warning of the denial, just denied it at the refill. It took an act of Congress and her doctor to convince them that yes, indeed, she needed the name brand.

It’s becoming such a joke to even have insurance but you wouldn’t want to go without.....

[cherryvalance]

Mar 3, 2019 18:50:26 GMT -5 aurora said:

Mar 2, 2019 18:57:33 GMT -5 GilliC said:

I know someone who worked on the billing software for a major health group, and for a certain insurer, they actually set up the system to automatically bill that insurance company twice, because its regular practice was to deny everything the first time it came in!

Yeah, I'm still angry almost 20 years later when my insurance denied a claim, and then when I called to ask why the agent said "oh, we deny every claim the first time, assuming some people won't bother to fight."

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It infuriates me because at least I have the capability and wherewithal to call and fight claims like this. DS had a breathing issue when he was 2 weeks old and we brought him to the ER at his pedi's advice. Long story short, we're still getting bills for it because they incorrectly coded it as a routine visit (but coded the facility and another charge as emergency). What would happen if I wasn't able to fight this or freaked out and paid the bill when it came in? Rhetorical, obviously, but it disgusts me that they prey on people.

[ohgillian]

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On my second-level appeal for a claim for my daughter, the BCBS person made her case, we made ours, and the outside reviewing geneticist didn't ask a single question. Then he recommended it be approved. DH and I liked to think that after the call he was like, "WTH was BCBS thinking??" I was pissed that I had to go thru 2 levels of appeals, but I put together a kick-ass appeal package, something that not all patients would have the time or ability to do. It's frustrating that we had to do it.