7 ms·

“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

“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.” Reading this article is just maddening. I've been dealing with different insurers for the past 7 years or so, and it's my experience they must all do something similar. Anyone with any kind of serious health condition is regularly driven CRAZY dealing with insurance. It's just an insane and broken system.

kurthr 4y ago
Wife is a nurse. Required surgery for lifesaving/severe disability (inherited congenital, killed her father). Insurance was Aetna and Hospital Self Insured. Surgery recommended by world class surgeon she worked with. 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.
- anigbrowl 4y ago
  Standard answer is we can't tell you why you were rejected How did you find out about the automatic rejection/identity of the reviewers?
  - kurthr 4y ago
    That is a good question. The first appeal was "free" so we didn't have to justify it with anything other than, "no really the surgery is necessary". They only gave us a rejection number on the second and third rejections and we had to request the written forms by mail, which took weeks. The written form didn't have much more, mostly boiler plate, but it did have the number (and maybe a chapter/paragraph number citation?) and on the second one it had a signature by the reviewing doctor along with his typed name, which was luckily relatively uncommon. We had to provide statements from our doctors and surgeon (who also didn't get a reason for the refusal) justifying the surgery's need and effectiveness. 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.
    - anigbrowl 4y ago
geerlingguy 4y ago
I have Crohn's disease, and I'm fairly certain dealing with health insurance's ineptitude directly led to multiple hospitalizations and a major surgery last year. 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!
- magila 4y ago
  I also have Crohn's and am going through this right now. Months of delays and denials for a new drug lead to two hospitalizations. I'm currently on TPN (IV nutrition) while I taper my Prednisone dose as low as possible prior to surgery. 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.
  - geerlingguy 4y ago
    Exactly my thoughts. I can't believe the calculus here.
    - dreamcompiler 4y ago
      It's simple. Some executive gets a bonus soon if he saves the company money right now. Nobody gets a bonus for saving the company money over a 5-year period, and nobody gets punished for costing the company money over a long period either. The incentives are all about the next quarter.
      - magila 4y ago
        It still doesn't make sense. This whole ordeal has taken place over about 6 months. If anything, forcing me down the surgery route has pulled their costs forward in time, not pushed them back.
indymike 4y ago
When someone in my family does not get pre-approved for care, I write a letter and and ask my physician to sign, and ask the other doctors at his practice to sign a letter that goes like this: "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.
- firstlink 4y ago
  This must have been before insurers adopted the mantra "we aren't denying care, only paying for the care!" With that legal magic wand, there is no risk to the insurer.
  - indymike 4y ago
    That was in full effect at the time. They would like for this to be the case, but reality is very different.
- ridgeguy 4y ago
  Noted and saved for future use. Thanks for this.
stouset 4y ago
Counterpoint. 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.
- Centigonal 4y ago
  I'm glad you had such a good experience. Not a counterpoint, though. 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.
  - stouset 4y ago
    I’m not defending the current system at all. 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.
  - 4y ago
IG_Semmelweiss 4y ago
As long as insurance is subsidized by our tax dollars and is regulated to include (forcefully) everything, then theres no way out. 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/ICD10_FAQ.pdf https://eohhs.ri.gov/sites/g/files/xkgbur226/files/2021-03/I... [2] https://collectivemedical.com/resources/payers/ https://collectivemedical.com/resources/payers/
bushbaba 4y ago
Yep happened to me. Worst is when you have two insurance providers and they both claim to be secondary and refuse to pay the bill.

kurthr 4y ago

Wife is a nurse. Required surgery for lifesaving/severe disability (inherited congenital, killed her father). Insurance was Aetna and Hospital Self Insured. Surgery recommended by world class surgeon she worked with. 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.

anigbrowl 4y ago
Standard answer is we can't tell you why you were rejected How did you find out about the automatic rejection/identity of the reviewers?
- kurthr 4y ago
  That is a good question. The first appeal was "free" so we didn't have to justify it with anything other than, "no really the surgery is necessary". They only gave us a rejection number on the second and third rejections and we had to request the written forms by mail, which took weeks. The written form didn't have much more, mostly boiler plate, but it did have the number (and maybe a chapter/paragraph number citation?) and on the second one it had a signature by the reviewing doctor along with his typed name, which was luckily relatively uncommon. We had to provide statements from our doctors and surgeon (who also didn't get a reason for the refusal) justifying the surgery's need and effectiveness. 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.
  - anigbrowl 4y ago

geerlingguy 4y ago

I have Crohn's disease, and I'm fairly certain dealing with health insurance's ineptitude directly led to multiple hospitalizations and a major surgery last year. 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!

magila 4y ago
I also have Crohn's and am going through this right now. Months of delays and denials for a new drug lead to two hospitalizations. I'm currently on TPN (IV nutrition) while I taper my Prednisone dose as low as possible prior to surgery. 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.
- geerlingguy 4y ago
  Exactly my thoughts. I can't believe the calculus here.
  - dreamcompiler 4y ago
    It's simple. Some executive gets a bonus soon if he saves the company money right now. Nobody gets a bonus for saving the company money over a 5-year period, and nobody gets punished for costing the company money over a long period either. The incentives are all about the next quarter.
    - magila 4y ago
      It still doesn't make sense. This whole ordeal has taken place over about 6 months. If anything, forcing me down the surgery route has pulled their costs forward in time, not pushed them back.

indymike 4y ago

When someone in my family does not get pre-approved for care, I write a letter and and ask my physician to sign, and ask the other doctors at his practice to sign a letter that goes like this: "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.

firstlink 4y ago
This must have been before insurers adopted the mantra "we aren't denying care, only paying for the care!" With that legal magic wand, there is no risk to the insurer.
- indymike 4y ago
  That was in full effect at the time. They would like for this to be the case, but reality is very different.
ridgeguy 4y ago
Noted and saved for future use. Thanks for this.

stouset 4y ago

Counterpoint. 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.

Centigonal 4y ago
I'm glad you had such a good experience. Not a counterpoint, though. 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.
- stouset 4y ago
  I’m not defending the current system at all. 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.
- 4y ago

IG_Semmelweiss 4y ago

As long as insurance is subsidized by our tax dollars and is regulated to include (forcefully) everything, then theres no way out. 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/ICD10_FAQ.pdf https://eohhs.ri.gov/sites/g/files/xkgbur226/files/2021-03/I... [2] https://collectivemedical.com/resources/payers/ https://collectivemedical.com/resources/payers/

bushbaba 4y ago

Yep happened to me. Worst is when you have two insurance providers and they both claim to be secondary and refuse to pay the bill.