6 ms·

Wife is a nurse. Required surgery for lifesaving/severe disability (inherited congenital, killed her father). Insurance was Aetna and Hospital Self Insured. Sur

• 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
      Good grief. I'm sorry you had to go through that, the bureaucratic trauma involved in health billing/insurance increasingly seems as bad as or worse than the medical issue itself.
      • kurthr 4y ago
        It was definitely a learning experience. If you're in the hospital under a doctor's care it's a lot easier, but if you have major (expensive) preventative care, then the insurers want to discourage or delay that as long as possible.
    • Jcowell 4y ago
      How on earth can some one read this and think that the American Health System isn’t fucked up? 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??
      • tstrimple 4y ago
        Because it works well enough for them now, and they seem to have no capacity to either understand or care that others are suffering under the same system. For some, the demand for maintaining the status quo is far more cruel. https://www.bostonreview.net/articles/jonathan-m-metzl-dying-whiteness/ 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.”
        • anakaine 4y ago
          If that isn't the best summary of what I feel the conservative American psyche is at large, then I don't know what is.
• ClumsyPilot 4y ago
  > 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 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.
  • prh8 4y ago
    This is literally how it works in the US, this is not the exception
  • Eric_WVGG 4y ago
    Here’s an example of something that happened to my sister that isn’t exactly the same, but is the same sort of philosophy in action. 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.
    • ClumsyPilot 4y ago
      I understand that, but how is it legal to refuse to fullfil your insurance obligations without revealing the reasons? Like in US insurance is at will, okay, fine. But insurance is surely under a legal obligation to fullfill their end if the bargain?
• anonuser123456 4y ago
  The sneaky thing to do is have your attorney send a letter to the insurance carrier's liability insurance provider, detailing everything you uncover and that they will be on the hook for the malpractice claim. That will get you an highly aggressive advocate with teeth.
  • djbusby 4y ago
    Lawyers, the best way to get reasonable healthcare in USA. What can be done?
    • davidw 4y ago
      Elect people, starting at the local level, who want to change the system? 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.
      • dahfizz 4y ago
        The ACA just gave more power and money to these same scummy insurance companies.
        • davidw 4y ago
          So, no, definitely not perfect. Also, some people are alive today because of it, and many are healthier. I'll take that over a better reform that doesn't get passed, and keep working to elect the people necessary for better reforms in the future. This stuff just doesn't happen overnight, sadly.
        • bee_rider 4y ago
          Yeah, we should have done some single payer system, medicare for all or whatever, but unfortunately we don’t have a very strong left wing in the US.
          • wolverine876 4y ago
• theGnuMe 4y ago
  >Insurance was Aetna and Hospital Self Insured Does this mean that the hospital self-insured and provided the surgery? As in why have Aetna involved at all then?
  • sveiss 4y ago
    This is common for medium or larger companies. 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.
    • theGnuMe 4y ago
      Right but here the self insurer is the hospital doing the procedure. So you’d think it would just take the loss.