Wednesday, July 16, 2008

Disturbing Carrier News

[Welcome Industry Radar readers!]
On the one hand, this is news because it's the exception, not the rule. On the other, one wonders why "journalists" don't seem to ask a lot of relevant questions, particularly since they could help us understand what really happened here:
19 year old Caitlin was scheduled for surgery to, well, something; the "journalist" doesn't seem to think it's important enough to tell us exactly what (was it experimental, for example). And we're also not told how effective this procedure's been in the past, which could indicate its value.
It would be nice to know why the family scheduled this surgery, which doesn't seem to be an emergency, before Aetna approved it (or not). The story says only that "Caitlin needs immediate surgery," but doesn't explain why. It may well be that her condition had deteriorated quickly, adding urgency to the situation, but the story doesn't tell us. It is sensationalism at its worst.
We are told that the hospital pegs the surgery's cost "at a staggering $113,000," and requires a substantial "deposit" before it would be done. Why's that? Where's the hospital's compassion? The surgeon's? It's only the nasty old insurance company that's dragging its (metaphorical) feet here?
Uh hunh.
This is why stories like this are so counter-productive. We're asked to feel compassion, perhaps pity, for Caitlin, and we're left with the distinct impression that the insurance company is the only player in this game which lacks compassion. Maybe it's just me, but I also infer from it a sort of "hey, that could be me, or my child" feeling. And indeed it could be. But what we don't know is why Aetna apparently declined to authorize the treatment. All we're told is: "her benefits ran out." Again, why is that? Was this a group plan with a limited annual benefit? Was it an individual plan with a limited lifetime maximum? Who chose this plan in the first place?
All of these questions are relevant, but will most likely be lost in the maelstrom of publicity about the "evil insurance company." If Aetna made a mistake here, then they need to own up to it, and make it right. And certainly we all feel for Caitlin and her parents. But we also need to know that there's at least the possibility that the carrier isn't the bad guy here, only the fall guy.
UPDATE 1: Aetna's National Medical Excellence Program seems like it would have rendered much of this moot. According to them:
"If you have a complex illness or injury, your doctor can request authorization from Aetna to use our National Medical Excellence Program. If authorized, the program gives you access to our national network of respected doctors and facilities. This means your care (less any applicable copays or coinsurance) and your related travel costs (for you and a companion when traveling more than 100 miles) will be covered. And program nurses, who specialize in complex care, will work with you every step of the way to help you get the services you need."
So, was this available to Caitlin and her family and, if so, did they access it? And if they did, why would the surgery have been denied?
This took me all of 3 minutes to find, begging the question: where's the "journalist" on this?
UPDATE 2: Available here.
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