Posted on 12/11/2017 12:40:06 PM PST by nickcarraway
Cara Pressman sobbed in the big red chair in her living room. The 15-year-old tried to absorb the devastating news relayed by her parents: that their insurance company, Aetna, denied her for a minimally invasive brain surgery that could end the seizures that have haunted her since she was 9 years old.
When my parents told me, I went kind of blank and started crying, she said. I cried for like an hour.
Her friends had been lined up to visit her in the hospital for the surgery three days away, on Monday, October 23. Between tears, she texted them that the whole thing was off.
(Excerpt) Read more at kfor.com ...
They could also see if this procedure is done overseas someplace. The amount of money overseas would be a fraction of what it is here and affordable.
The base salary for Aetna’s CEO is $31,000,000. And money is biggest motive for denial. Even if surgery experimental no reason to deny. That should be decisions of patient.
That bastxxd could pay for it out of his pocket and never feel it.
No. Not experimental. Read article.
“Common sense is so dead in this country, isn’t it?”
I’ve seen a number of things that make me think an organization loses the ability to act rationally when it reaches a certain size.
“Big Medicine shouldnt really be doing experiments on people and expecting Big full payment. Why even bring up the existence of unproven procedures to folks and planting false hopes?”
Doesn’t that depend on the prognosis? If you’re going to die otherwise, might as well go for a low-odds experimental procedure, no?
I did read the article. I did not say it was experimental.
TangledUpInBlue wrote:
“Crap like this has been going on for 30 years. When my son was an infant, he could not tolerate any formula because he was induced at 39 weeks. His intestines werent mature.
The answer was a pre-digested formula powder that was made in England. It wasnt available here in the US. So his pediatrician recommended we get it. It was Dr. prescribed treatment. My son was 2-3 months old at the time.
Aetna rejected paying for the formula because they said they didnt cover supplemental nutrition. At the time, I think this stuff was $300 for 4 cans and each can lasted about 5 days. So roughly $500 per month. I wasnt making much then and it would have been extremely difficult.
They make decisions in a vacuum without understanding the facts. Even after long phone calls with them and my arguing that my sons only food couldnt possibly be supplemental they wouldnt budge.”
What did y’all end up doing?
My wife spent one afternoon and overnight in the emergency room of our local hospital. She had what is referred to as a TIA or a mini stroke. The gave her all sorts of tests, blood tests, heart monitor, scans Etc. The bill came to $25,601. Insurance company paid and the hospital accepted $2,355.
Our cost was $75 for a visit to the emergency room.
I only recently finally realized why my own employer keeps me around at 55 in the I.T. Sector within financial services: Commmon Sense and Critical Thinking Skills.
Both of which are in short, short supply everywhere these days.
It's not like it's brain surgery.
.
Oh, wait, it IS brain surgery. And experimental, unproven, brain surgery at that. Maybe she can ask the local general surgeon that doesn't speak English to give it a shot.
Sounds like Aetna is worried about also having to pay to fix a potential bad outcome if the experimental procedure she wants to try goes badly.
“Reading the article, Aetna did not deny her care, they just disapproved the particular treatment (laser surgery) as experimental. They would cover regular surgery.”
***
It seems that if she has had seizures since she was 9 then whatever Aetna covered so far HASN’T WORKED. Maybe a small ‘experimental’ approach would not be so experimental after all . . . I would not side with the insurer on this one. The insurance industry sometimes forgets that life isn’t always numbers, it’s also supposed to be about helping your PREMIUM PAYERS to get healthy.
A relative had to undergo surgery a year ago. The bill was $250K. The insurance company brought them down to $79K. If you do not have the kind of bargaining position which an insurance company can wield, then you are screwed.
Plus, the hospital has to get the money to cover the care given to non-paying "customers" from somewhere. If the hospital was allowed to let shot gang-bangers bleed out without treatment, society would probably be improved.
“Both of which are in short, short supply everywhere these days.”
Yes, they are, especially in HR departments. It’s a wonder that your employer even knows those things when he sees them.
Was that formula Pregestimil? My daughter had to have it 35 years ago. Couldn’t afford it on an E4’s pay. Thankfully the Air Force provided us with it. Had to have a prescription from the pediatrician and go to the hospital nursery twice a month to pick it up.
They didn’t deny treatment - just experimental treatment.
Sorry, I cut it short.
He’s fine now, a healthy 17 year old. What happened was, I was complaining to a co-worker who had been there longer than I had and she told me that the Head of our department was on the Corporate Benefits Committee and things like this were really important to him and that I should talk to him.
So here I was, the 24 year old newbie going to see a Global VP. He treated me like his equal in listening to me. I’ll never forget him for that. I told him the story just as I posted it here and he said let me make a few phone calls and see what I could do. I thanked him and left.
By the time I walked back to my cubicle, my phone was ringing. It was the company’s benefit coordinator at Aetna. At the time, our medical and Rx insurance were two different plans. She advised me that all I had to do, was have the Pediatrician write a Prescription for the formula and they would cover it fully. So we ended up getting a 90 day supply, for I think $30 - our Rx co-pay at the time.
Can you believe that? So again, bureaucracy, but clearly, it’s how hard you shake the tree and it helps to know people.
I answered to another person below. Should be a current post at the bottom of this thread. Thanks!
I am almost certain that’s exactly what it was. It sounds familiar. It was 17 years ago, but that sounds familiar.
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