Thursday, July 17, 2008

Disturbing News: Update

[Welcome Industry Radar and Insurance Forums readers!]
Regular readers know that we're nobody's shill; we regularly skewer carriers, providers, even fellow agents. But we also know that the "regular" media often fail to report (or even try to determine) "the other side." We saw it last year, with the sad story of Nataline Sarkisyan and CIGNA. And we're seeing it again now, with the equally sorry tale of Caitlin Jackson.
As it turns out, there's quite a bit of misleading information in the original news account. How do I know this? Because I spent a great deal of time on the phone late yesterday afternoon, working my way through Aetna corporate communications in order to give our readers a more precise understanding of the issues.
As it happens, I connected with a very helpful young lady, who remembered our earlier posts on Aetna's transparency program, and our interview with Dr Campinha-Bacote. This helped to establish our bona fides (literally: Fido's bones), and we learned a bit more about this unfolding drama.
Full disclosure: due to HIPAA privacy regulations, there were quite a few questions I asked for which the spokeperson could provide no answers. This may change as the case develops, and we'll keep you posted.
In the original story, it was reported that the surgery was initally approved by Aetna "15 minutes too late." While this makes compelling reading, and certainly casts the carrier in an unfavorable light, it was simply untrue, and the reporter knew it.
Let me repeat that: The reporter knew for a fact that there was no such process, and yet reported it as true anyway. According to Aetna, "under the plan, Aetna does not require pre-authorization for surgery so we neither would have pre-authorized or denied the surgery as portrayed in the Tampa TV news story." [ed: from email] Not only that, but Aetna "explained to the Tampa reporter that the scenario she was portraying of us "approving" surgery is not accurate because we don't pre-auth [pre-authorize], but she ran it anyway."
I also learned that "(m)edical necessity is not relevant to this conversation;" that is, there was no issue regarding the appropriateness of the treatment. As an aside, I think that's a mistake: as we've discussed before, "medical necessity" is a key component of health insurance, and would be relevant in ascertaining whether the surgery was even called for. Nevertheless, it wasn't in this case, and one supposes that Aetna is entitled to its own procedures.
There are apparently "other inaccuracies in the story as well," but my contact declined to identity them. Hopefully, that will change.
One final point: if we're going to have a meaningful discussion about the merits and shortfalls of our current health care financing system (and I think we should), then it's in everyone's best interest to do so in an honest, fact-based manner.
Well, maybe not everyone's.
UPDATE (7/18/08): Just received this email from my contact at Aetna:
"While I cannot share details, I thought you would want to know we have resolved this matter together with the hospital. We advised the member yesterday."
Good news!
CowPatty Alert: This is just self-serving; there is zero indication (or likelihood) that Ms Brooks' "efforts" resulted in anything other than sensationalism:
I need to take a shower after that.
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