[Welcome Industry Radar readers!]
Thank goodness for the Tampa Tribune, which brought Aetna to its (proverbial) knees.
Oops, I mean: Thank goodness for Fox News, which brought Aetna to its (proverbial) knees.
Oops again! I mean: Thank goodness for Florida Governor Charlie Crist, who brought Aetna, well, you know.
Of course, not all of them (or indeed any of them) can claim credit. For one thing, as we reported earlier, the procedure was never authorized, or not authorized, because there was no pre-authorization necessary in this case.
But hey, let's not let any facts get in the way of a good story, shall we?
I spoke late yesterday with our aforementioned Aetna rep, who was able to confirm several key facts, deferred on a couple others, and will try to help me with a few more. Here's what we know for sure:
■ There was no issue of scheduling or pre-authorization regarding the surgery. So reports that the surgery was cancelled at the last minute because of pre-certification issues was simply untrue, and the Tampa reporter knew this.
Here's what Aetna cannot confirm or refute because of HIPAA restrictions:
■ While I don't understand how this is covered by HIPAA, Aetna isn't allowed to confirm or deny that the coverage was cancelled, or that benefits had "run out."
And here's what we hope to find out:
■ Whether this was an ERISA (self-funded) or fully insured plan, and whether it was group or individual medical. My contact was unsure whether or not she could divulge this and, as a favor, agreed to ask her HIPAA compliance guru for guidance.
All of these questions, by the way, should have been asked by the various news folks, but there's no indication that such was the case. As we noted before, it is frustrating that the media just won't do its job, settling instead for the sensational over the informative.
Now, there are some who would claim that the Aetna rep would lie (or at least mislead) about the nature of the problem. And it would be fair to at least regard such information with a dose of (ahem) healthy skepticism. The problem with the "he said, she said" scenario in this case is that, because of stringent HIPAA privacy regs, Aetna is proscribed from offering policy details that might confirm (or refute) their position. There's an easy solution to that, of course: Caitlin's family has only to waive those privacy rights, and allow the carrier to answer completely, including documentation to support its claim. We're waiting...
And while we're waiting, let's discuss why this is such a crucial case. If, and it's a big if, Aetna "caved" in the face of media and political pressure, then we can effectively kiss health insurance as a risk management tool goodbye.
That's a bit overwrought, isn't it?
Sadly, no: if a carrier folds based solely on PR, then the next step is buying insurance in the ambulance. After all, if the carrier balks at the claim, one has only to threaten with Fox and Friends to have the claim paid. It would set a dangerous precedent, and literally change the face and nature of health insurance. This is not tinfoil hat time; it is simply the logical end result of such an action.
Interesting times, indeed.