#aetna medical insurance for

[starry-genome]

If you have ever wondered why health insurance in the US is so messed up, I highly recommend checking out Dr. Glaucomflecken’s 30 days of Healthcare series. Click here for the YouTube playlist or click here for the TikTok playlist.

Each video is about 1-3 minutes and goes through different aspects of the healthcare industry explaining how it works and especially how corrupt it is.

I spent 5 years working hospital finance watching the way health insurance directly affected my patients, and oftentimes seeing the ways lack of access to affordable healthcare resulted in chronic and emergent conditions, and even death. I cannot stress enough that I literally saw people die because their insurance denied them treatment. And on the billing side, the things people would complain about to me as something the doctors or hospital were doing wrong were usually a direct result of the way health insurance runs everything. It’s disgusting.

At the end of the series, he has a call to action - ways we (as regular people) can help work to improve healthcare (other than pushing for universal healthcare/Medicare for all). A lot of people talk about how ridiculous US Healthcare is but rarely do I see anyone talking about what we can do to change it. I think this is the most important video of all, so I’m including it here.

This video series is probably the most comprehensive, easiest to understand breakdown of the way healthcare fucks everyone over - patients, doctors, and hospitals alike. Please check it out!

[tj-crochets]

Hey y'all! I am once again in health insurance hell, and could really use some help. I have a specific US health insurance question, but it might get long so it's below a read more

My employer offers two health plan options, and they are both absolutely terrible. I want to get my own health insurance, but the insurance broker lady I used when I worked part time says I can't, because I can get health insurance through my employer, even if I opt out. I spoke to another health insurance person today, and she said if I get a letter on company letterhead saying I'll lose health insurance on [date], as long as it's 60 days or less from now, it counts as a qualifying event and I can buy my own health insurance. She said opting out counted as losing health insurance. Do you know anything about this? How do I get health insurance as an individual NOT through my employer even though my employer offers it? The plans my employer is offering are Aetna, and Aetna is the absolute worst and I despise them as a company so much one of my long term goals is to warn people against them. They suck! They refused to pay for my inhaler until I got my doctor to fill out a form like three times, and also I had to email them A LOT and fill out a LOT of surveys with an emphasis on how horrifying I found it that they as a company clearly valued profit over their customer's lives, and would in fact prefer their customers die before they could reach the ER in case of an emergency, as evidenced by their refusing to pay for my rescue inhaler, a necessary life-saving medication. They also require I fill that form out every year, just in case I magically stop being in the small minority of people who get severe adverse reactions to albuterol and levalbuterol

[technofeudalism]

let's recap what we've learned about the United States in the last few days.

things that are terrorism:

allegedly shooting a healthcare CEO whose company generated more pure profit (not revenue, profit) in a year than the GDP of 94 countries, exclusively by denying coverage to people who pay for it

a 42-year-old mother of 2 using the wrong combination of 7 words during a heated conversation with a call center employee at a health insurance company who was in the process of denying her health coverage.

things that are not terrorism:

mass shooting in a Black church to incite a race war

going to a BLM protest specifically to kill protestors

a neo-nazi running over a crowd of people, killing a woman

targeting and killing 23 latinos in an el paso, texas walmart

killing 12 people in a theatre, shooting 58 others, rigging your apartment with explosives

a QAnon groyper killing 7 and shooting ~50 at a 4th of July parade

killing 3 people and shooting several others at a Planned Parenthood in defense of the unborn

stalking someone relentlessly and then killing them and their child despite months of the victim making police reports

any one of the 1,200 murders committed by US police yearly, the vast majority being minorities

tightening your border while ~100 immigrants (including children) drown every year in the Rio Grande

United Healthcare killing an unnknowable number of elderly people by using faulty AI to deny medically necessary coverage

Aetna killing a woman by refusing to cover her cancer care

Blue Cross killing a 6-year-old by denying her appendicitis surgery

Cigna killing a 17-year-old child by denying her liver transplant

the pharmaceutical industry killing half a million people with opioids in the name of producing revenues in 2023 that rivaled the GDPs of countries like Spain, Mexico, and Australia.

the United States killing 45,000 people a year because they can't access health coverage

make sure you keep this guide handy the next time you find yourself interacting with your insurance company or any other millionaire, billionaire, or an individual who is part of a protected class such as a CEO or president of a corporation.

[fellthemarvelous]

Deny. Defend. Depose.

It is clear to those of us that live in America, the only people we truly have on our side are ourselves. The ruling class has made it clear we don't matter to them.

Luigi Mangione was arrested and happened to have every single piece of evidence on him that law enforcement was looking for, including the parts for the ghost gun, inside his backpack (that he also got rid of in Central Park containing the Monopoly money???). Either he was trying to get caught or that evidence was planted. And when he was being forcefully pushed into the jail, he hollered back to the press about "injustice" and "being an insult to the intelligence of American citizens and our lived experiences."

The people have now turned against corporate America and the CEOs and billionaires are fucking terrified. Nothing the news stations are saying to us are changing our minds. The American people have finally united over this issue and there is no going back for us. Whoever did kill Brian Thompson (and theories abound on the game The Adjuster is playing because no one plays Monopoly alone) exposed the very real divide that exists between every day citizens and the extremely wealthy. Things were easier for them to control when they were able to divide us, but now that we are aware of how uncertain our future is in America and seeing just how little we matter to the people who take our money, we have realized that we have more in common with each other than the people who control every aspect of our lives. We are waking up.

There isn't one person in this country who hasn't been a victim to the predatory scam that is private health insurance. Medical debt is the leading cause of bankruptcy in America, and many of us are one ambulance ride or hospital stay away from homelessness. We all know people who have died because the insurance company denied them the treatment they needed or waited until it was too late for an approval of a medical claim to matter anymore.

Recently, I decided to be tested for autism and ADHD. Not life-threatening or anything, but my life is still in shambles and I want to know if I'm going untreated for something else. Before being tested though, I was informed that the insurance company (Aetna) has said that they were going to cover the full cost of the testing I was having (which was six hours of testing by the way). She even made sure several times that they were, in fact, going to cover it in full and they said yes.

The same day that Brian Thompson, CEO of another horrible healthcare company, was murdered in broad daylight, I received a call from that doctor's office with the woman telling me that Aetna was now telling her they never agreed to cover my testing and that they are going to bill me for $1600 (where the hell am I supposed to get that?) and she is fighting them, but considering our lives don't matter to the people who tell us what healthcare we are and are not allowed to receive, I don't think they will feel compelled to change their minds because they are bloodsucking parasites who only care about lining their pockets while I don't even have $6 lying around, let alone $1600!!

Corporate America leeches off our taxes. They take and take and take and we see nothing in return. They raise prices on insurance coverage and then deny us the very coverage that we pay for. They poison our food, price gouge our poisoned food, and then force us to pay for the treatment we get when the food makes us sick. Corporate America profits off of our hard work, our taxes, our health, our lives, our deaths.

I don't know if this will reach a larger audience or not, but I wanted to talk about it on Tumblr because this platform seems to be a crossroads for every type of creative soul. I initially brought up this idea on TikTok earlier, but I want to see if it can get traction in other places as well since I have fewer than 3,000 followers on TikTok (and I have seen a small few express interest in my idea in the hours since I posted the video.)

We're busy being lectured by politicians and the news media because while they are clutching their pearls at what happened to Brian Thompson, the rest of us do not give one single flying fuck about what happened to him. As CEO of a for-profit health insurance company, he signed off on denied claims and death for those of us who struggle to make it from one day to the next. The sicker you are, the poorer you are, the more they force you to struggle and pay. The love to deny coverage because regardless of whether we live or die, they already have the money we are forced to pay them.

I don't condone murder at all, but I also don't care that he was murdered because he was guilty of murdering so many more people in this country through legal means because it's profitable. The CEOs are scared and there are wanted posters with their names and faces popping up in places. Every CEO of every healthcare company is guilty of murdering Americans and they continue to go unpunished for it because "it's just business".

So (if you've read this far) all of this previous rambling is to say that I keep thinking about how I want to make an impression. I want to continue upsetting the billionaires and the CEOs because corporate America is full of murderers who are legally allowed to decide whether we live or die based on which outcome will give them more money.

I have thought about the idea of creating a wall/constructing a wall somewhere as an art piece or something (making a statement) that will somehow honor the memory of people who died because insurance denied them care.

I know I definitely want it to say something along the lines of "In memory of those murdered by for-profit healthcare systems in corporate America". Something blatant. Loud. Something they are forced to look at every single day. Somehow. The wall could have images of those who are gone, or names of the person who died with the name of the insurance company responsible for their death underneath. Just something to make it clear that we see them for what they are. Something to avenge those who were sacrificed so billionaires and CEOS and shareholders could brag about record profits. Something that shows the whole world that American citizens are waking up to who the real monsters are.

The Adjuster (whoever he is or is not) has fanned the flames of revolution in America. He managed to unite us in a way I can't even recall before. It's not over. We know what happened to Brian Thompson was just the beginning, and corporate America only just now realized how much we actually hate them. A single shooter has sparked an awakening in America that is starting to snowball into something much bigger.

So if there is anyone out there who might be interested in collaborating on something like this, please let me know. I know we are all tired and demoralized and we have no money. I want to make a statement though, and I love doing that through art or writing. Collaborating with other people who have been through this same shit will also probably help us unite even more.

This is a watershed moment in American history.

In the words of Kanan Jarrus, Jedi Knight,

"There is a future for us. One where we're all free. But it's up to us to make it happen."

[theonion]

Paying tribute to the brave men and women on the frontlines, Aetna president and CEO Larry Merlo released a statement Tuesday honoring his courageous employees who continue to seek and collect insurance debt from customers “proudly and by any means necessary” in this difficult time. “Our nation owes a great deal of respect and gratitude to these medical debt workers who have stepped up and remained fully committed to collecting every penny owed to our close-knit community of executives, investors, and brokers during this span of unprecedented emotional and financial difficulty and distress,” said the comfortably sequestered multimillionaire in charge of not only Aetna but also its parent company, CVS Health, saluting the “red-blooded American heroes” working day and night to shake down valued Aetna family members until they cough up their payments. Full Story

[thebiscuiteternal]

EviCore has several ways to cut costs for insurers. Chief among them is the dial, the proprietary algorithm that’s the first stop in evaluating a prior authorization. Based on data entered by a doctor’s office, it can automatically approve a request. The algorithm cannot say no, however. If it finds problems, it sends the request for review to a team of in-house nurses and doctors who consult company medical guidelines. Only doctors can issue a final denial. This is where tweaking the dial comes in. EviCore can adjust the algorithm to increase the number of requests sent for review, according to five former employees. The more reviews, the higher the chance of denials. Here’s how it works, the former employees said: The algorithm reviews a request and gives it a score. For example, it may judge one request to have a 75% chance of approval, while another to have a 95% chance. If EviCore wants more denials, it can send on for review anything that scores lower than a 95%. If it wants fewer, it can set the threshold for reviews at scores lower than 75%. “We could control that,” said one former EviCore executive involved in technology issues. “That’s the game we would play.” Over the years, medical groups have repeatedly complained that EviCore’s guidelines were outdated and rigid, resulting in inappropriate denials or delays in care. Frustration with the rules has led some doctors to refer to the company as EvilCore. There is even a parody account on X. The guidelines are also used as a tool to cut costs, the investigation found. Company executives “would say, ‘Keep a closer eye on the guidelines for reviews for a particular company because we’re not showing savings,’” said a former EviCore employee involved in the radiation oncology program.

[oysters-aint-for-me]

i’m so upset bc my antidepressant that works really well and basically saved my life, well, the prior authorization expired after a year and so my doctor had to send it in again. stupid, but no real big problem. aetna approved the medication pretty quick and sent my doctor a fax saying so and also sent me a letter saying so and also the CVS website says my insurance has approved the medication. however when i go to the pharmacy it still has “needs prior authorization” stuck to it and we can’t seem to get rid of it so i can’t get my antidepressants and it’s starting to really affect me and i’m getting really depressed again and im scared and i just want my stupid meds for my stupid brain but some fucking computer somewhere has some stupid fucking wire crossed and no one seems to be able to take responsibility for it or fix it so i’m stuck without the meds and i don’t know what to do anymore at this point. no one knows what the problem is. also now you can’t just call CVS, wait on hold for 20 min, and talk to someone, oh no, nothing that simple, now you have to leave a stupid fucking voicemail and wait for them to call you back which they WONT DO because i’ve talked to them plenty of times in the past where they’ve said “we’ll call you back with that info.” AND THEY NEVER HAVE, THEY NEVER DO, THEY NEVER WILL. which means i have to go there AGAIN tomorrow and wait for half an hour while the pharmacist tries to get a human representative on the phone only to find out “we have no record of a prior authorization” like please just kill me now

[feminist-space]

"EviCore markets itself to insurance companies by promising a 3-to-1 return on investment — that is, for every $1 spent on EviCore, the insurer would pay out $3 less on medical care and other costs. EviCore salespeople have boasted of a 15% increase in denials, according to the investigation, which is based on internal documents, corporate data and dozens of interviews with former employees, doctors, industry experts, health care regulators and insurance executives. Almost everybody interviewed spoke on condition of anonymity because they continue to work in the industry.

An analysis of the company’s own data shows that, since 2021, EviCore turned down prior authorization requests, in full or in part, almost 20% of the time in Arkansas, which requires the publication of denial rates. By comparison, the equivalent figure for federal Medicare Advantage plans was about 7% in 2022.

...

EviCore is not alone in engaging in the denials-for-dollars business. The second-biggest player is Carelon Medical Benefits Management, a subsidiary of Elevance Health, the health insurer formerly known as Anthem. It has been accused in court of wrongfully denying legitimate requests for coverage. The company has denied all charges. Several smaller companies do the same kind of work.

...

Insurers do not make explicit demands for more denials, a former EviCore sales executive said, Instead, they asked about “controlling the spend” — the amount of money paid out on certain procedures, he said. Nor would EviCore always use the word “denials” — they employed circumlocutions like “inappropriate determinations.”

Aetna and Cigna are two of the companies that have requested “high touch” plans — those that would send more cases to clinical review and thus generate more denials, according to the former employee involved in data issues.

...

Holding the companies legally responsible for their decisions is also difficult. In 2022, Carelon settled a lawsuit for $13 million that alleged the company, then called AIM, had used a variety of techniques to avoid approving coverage requests. Among them: The company set its fax machines to receive only 5 to 10 pages. When doctors faxed prior authorization requests longer than the limit, company representatives would deny them for failing to have enough documentation. Carelon denied the allegations in court and admitted no fault. A spokesperson declined to comment on the lawsuit."

Read the full article here: https://www.propublica.org/article/evicore-health-insurance-denials-cigna-unitedhealthcare-aetna-prior-authorizations

[allthegeopolitics]

A major US health insurance company is making artificial insemination available on all its eligible plans – regardless of sexual orientation or partner status. Aetna, a subsidiary of CVS Health, announced the landmark change its intrauterine insemination (IUI) policy on Tuesday (27 August). Members can access the benefit as a test of fertility and, in some cases, to increase the chances of pregnancy.

Continue Reading

[justinspoliticalcorner]

Andrew Perez at Rolling Stone:

EARLIER THIS WEEK, two Democratic senators announced they have requested a criminal investigation into Supreme Court Justice Clarence Thomas — regarding, in part, a loan for a luxury RV provided by a longtime executive at UnitedHealth Group, one of America’s largest health insurers. Thomas apparently recused himself in at least two cases involving UnitedHealth when the loan was active, according to a Rolling Stone review. Yet, he separately chose to participate in another health insurance case and authored the court’s unanimous opinion in 2004. The ruling broadly benefited the industry — shielding employer-sponsored health insurers from damages if they refuse to cover certain services and patients are harmed. Thomas’ advice to patients facing such denials? Pull out your checkbook.

While UnitedHealth was not a party to the case, the company belonged to two trade associations that filed a brief urging the Supreme Court to side with the insurers.  “As we saw so starkly this term, Supreme Court decisions can have sweeping collateral implications: If the court rules in favor of one insurance giant, for instance, it tends to be a boon for all the other insurance giants, too,” says Alex Aronson, executive director at the judicial reform group Court Accountability. “That was the case here, and it’s a perfect example of why justices shouldn’t accept gifts — especially secret ones — from industry titans whose interests are implicated, whether directly or indirectly, by their rulings.” The public had no way of knowing about Thomas’ RV loan at the time of the decision: The loan was only exposed by The New York Times last year. Senate Democrats investigating Thomas believe that much or all of the loan, for a $267,230 motor coach, was ultimately forgiven. Sens. Sheldon Whitehouse (D-R.I.) and Ron Wyden (D-Ore.) recently requested the Justice Department investigate whether Thomas reported the forgiven portion of the loan on his tax filings, after he failed to disclose it in ethics forms.

Meanwhile, Thomas’ health insurance opinion has had wide-ranging, long-lasting ramifications, according to Mark DeBofsky, an employee benefits lawyer and former law professor.  “It hasn’t been rectified. The repercussions continue,” DeBofsky tells Rolling Stone. “People who are in dire need of specific medical care, and [their] insurance company turns around and says, ‘That care is not medically necessary,’ and there’s an adverse outcome as a result of the denial of the treatment, or hospitalization, or service — there’s no recompense for what could have been an unnecessary death or serious injury.” Since last year, the Supreme Court has faced an unprecedented ethics crisis, with much of the focus aimed squarely at Thomas. ProPublica reported that Thomas received and failed to disclose two decades worth of luxury gifts from a conservative billionaire, Harlan Crow, who allegedly provided free private jet and superyacht trips to Thomas and his wife; bought a house from Thomas and allowed the justice’s elderly mother to live there for free; and paid for at least two years of boarding school tuition for Thomas’ grandnephew.

[...] Federal law requires Supreme Court justices to recuse themselves in any case where their “impartiality might reasonably be questioned.” The justices decide for themselves when such a move is necessary — and when they do withdraw from a case, they rarely say why. Thomas does not appear to have explained his decision to withdraw from the two matters that directly involved UnitedHealth. Thomas did not take similar steps in Aetna Health Inc. v. Davila, a case that broadly affected the health insurance industry. He instead authored the court’s opinion, which expanded insurers’ favorite tool for limiting liability: ERISA. Congress passed the Employee Retirement Income Security Act, commonly known as ERISA, in 1974 to protect employee benefits. The law is relatively vague when it comes to “welfare benefits,” and contains a broad preemption clause. The courts have filled in the blanks — including in the Aetna Health case — with distressing results for patients. Half of Americans have employer-sponsored health insurance coverage; nearly all of these plans are governed by ERISA.

Rolling Stone exposes how SCOTUS Justice Clarence Thomas received a $267K RV from a health insurance executive.

[tj-crochets]

Hey y’all! Aetna (the worst health insurance company I’ve dealt with) denied my doctor’s Prior Authorization Requests for my inhalers, so I could use some help.  What do you know about appealing health insurance coverage decisions in the US? I think there’s something about asking who made the determination and if there were doctors involved, but I can’t remember the details.  Additionally, do you know how to determine when your open enrollment period is? I am at this point wanting to get away from Aetna as quickly as possible, but apparently even if I am paying the premiums myself out of pocket I can’t get blue shield until it’s an open enrollment period??? I don’t really understand that because I know I’ve seen forms asking like “which of your multiple health insurances are you using for this” so I thought you could have multiple forms of health insurance if you wanted. Health insurance makes no sense and I deeply resent everything about this. Especially Aetna. Resenting the fuck out of Aetna tbh

[partisan-by-default]

Aetna, a subsidiary of CVS Health, announced the landmark change its intrauterine insemination (IUI) policy on Tuesday (27 August). Members can access the benefit as a test of fertility and, in some cases, to increase the chances of pregnancy.

“Expanding IUI coverage is yet another demonstration of Aetna’s commitment to women’s health across all communities, including LGBTQ+ and unpartnered people,” the company’s chief medical officer, Cathy Moffitt, said.

“This industry-leading policy change is a stake in the ground, reflecting Aetna’s support of all who need to use this benefit as a preliminary step in building their family.”

Aetna is one of the United States’ largest medical insurance providers, serving over 35 million people and when combined with the rest of CVS Health, makes up 11 per cent of the market share.

[fenrislorsrai]

Healthcare denied

This happened a few years ago, to my father, who had managed Medicare. (Aetna, I'm naming names)

We got hit with a hurricane. All power is out for miles around. Note: no evacuation warning. Was not expected to do that kind of damage. We had no power for 10 days.

This man in OXYGEN DEPENDENT. He uses an electrically powered oxygen concentrator and has some back up bottled oxygen. But oxygen place would never give us more than a 24 hour supply. Because insurance.

He's also got COPD and needs nebulizer treatments several times a day. That also requires power.

Hurricane had finally cleared out enough we can get out of the house. All the hotels in safe travel distance: either NO POWER or fully booked. We managed to find ONE with power. "we have one out of service room with no working shower, if that fine"

We'll take it.

Throw elderly man in the car, his oxygen, his oxygen concentrator, the nebulizer, everything, in car and get him checked in at hotel. It is STILL not enough. His oxygen is crashing, he can't breathe.

The ambulance arrives to take him to the hospital. The fire department and ambulance corp are all running off generator power because there is nothing with power.

The only things WITH power are the things on this one circuit: a nursing facility, this hotel (where every lineman is staying, its filling with utility trucks as we stand there), and the Lebanese restaurant. This is suburb connected to NYC city by train. It is PITCH BLACK.

I and my mother go home, to the pitch black house while Dad goes to the hospital. (fortunately it was summer, so okay weather) Someone else with similar health problems immediately snagged the room with broken shower. I pray they had better outcome.

The power is STILL OUT days later. it is declared a federal disaster area.

Hospital: we're discharging him!

Us: the hell you are. there is no power here. there is no water. He will be back a few hours later. also every time he's had a crisis like this, he's gone to a step down rehab for a few days to make sure he doesn't immediately crash again.

Hospital: insurance says no . Come pick him up. they won't pay for more hospital care or rehab facility

We had enough money banked we could GET him to the rehab facility for a week that meant we finally had power again. We just had to pay for a full week. Up front. We talked to our congresswoman (Jahanna Hayes) who went to bat vs the healthcare company because it was managed Medicare. They eventually reimbursed us for that nursing care, which he really needed!

If we hadn't had that savings available...

TLDR: Aetna denied care to a medically fragile oxygen-dependent patient and tried to have him sent back to a federal disaster zone where his house had no power or water. Or bottled oxygen.

[meret118]

Dialing for Dollars: America’s largest insurers hire EviCore to make decisions on whether to pay for care for more than 100 million people.

“The Dial”: EviCore uses an algorithm that allows it to adjust the chances that company doctors will screen prior authorization requests, increasing the possibility of denials.

Lucrative Deals: Some EviCore contracts are based on how deeply the company can reduce spending on medical procedures. It tells insurers that it can provide a 3-to-1 return on investment.

. . .

EviCore markets itself to insurance companies by promising a 3-to-1 return on investment — that is, for every $1 spent on EviCore, the insurer would pay out $3 less on medical care and other costs. EviCore salespeople have boasted of a 15% increase in denials, according to the investigation, which is based on internal documents, corporate data and dozens of interviews with former employees, doctors, industry experts, health care regulators and insurance executives.

. . .

Over the years, medical groups have repeatedly complained that EviCore’s guidelines were outdated and rigid, resulting in inappropriate denials or delays in care. Frustration with the rules has led some doctors to refer to the company as EvilCore. There is even a parody account on X.

The guidelines are also used as a tool to cut costs, the investigation found. Company executives “would say, ‘Keep a closer eye on the guidelines for reviews for a particular company because we’re not showing savings,’” said a former EviCore employee involved in the radiation oncology program.

. . .

EviCore is not alone in engaging in the denials-for-dollars business. The second-biggest player is Carelon Medical Benefits Management, a subsidiary of Elevance Health, the health insurer formerly known as Anthem. It has been accused in court of wrongfully denying legitimate requests for coverage. The company has denied all charges. Several smaller companies do the same kind of work.

------

My brain literally read that as Evilcore every single time until the article mentioned the nickname, and I realized my mistake. I was shocked at the arrogance in the name before that.

[truthwithlight]

oh my god i can't take this shit anymore 😭 now my insurance is saying they won't approve my medication until they get "proof it's clinically necessary"??? my doctor already sent you the relevant records what more do you fucking need?

i've missed 3 doses now that's a month and a half without any sort of treatment. my knees and hips hurt so badly that i can't walk for more than like 10 minutes without getting exhausted and upset and needing to sit down. i went to the aquarium the other day and only saw less than half of it before leaving because walking for that long was beyond exhausting. i'm essentially confined to my house and painful trips to the store at this point. i'm fucking miserable

getting to the point where even sitting and lying down all day is uncomfortable because my hips are constantly stiff and sore. back to the "mom is concerned because i nap more than half the day and she doesn't even know how bad my mental health is" stage i was at before initially going on my medication

fuck insurance fuck aetna fuck my stupid baka life

[deadweight-at7am]

Are we in the French Revolution Season of America? Well, we should have been decades ago.

I have a migraine and can't sleep so let me yap about insurance for a bit.

Everyone's heard the UHC CEO was shot dead in NYC. And I'm sure most people are like "yeah, and?" Indeed. I have a unique perspective on this because I work in healthcare, specifically healthcare admin and my actual specialty is fighting claim denials on behalf of my company. I am unusually qualified to have opinions on this. I know quite a bit more about it than the average joe.

United Health Group is a notorious ghoul in the healthcare world, specifically behavioral health (mental health). It surprises me how many people don't understand what I mean when I say "behavioral health". We're talking psych. UHC's vendor for behavioral health is called Optum. Not many people know this but you can have Blue Cross and Blue Shield insurance, but your behavioral health benefits can be taken care of by Optum. This is called a "carve out". Insurance companies do this for... God knows why (cost? savings? something to do with saving a buck I'm sure) but it surprises patients time and time again. It doesn't happen super often but it does happen. And what that means is that you have to find providers that take Optum/UHC even though your main insurance is BCBS/Cigna/Aetna/Whatever. Behavioral Health is it's own little special world in the insurance marketplace and it's... sometimes very poorly run and very mismanaged. I work in psych and this isn't my first job working in psychology - so I have a LOT of experience here. When I tell you that Optum is one of the WORST and most predatory behavioral health payors I've ever encountered, I kid you not. The only other tragic fucking mess I've seen that rivals UHC is Cigna's BH group called Evernorth. Oh my god, don't ever try to get any answers at Evernorth - no one there knows how a fucking thing works.

So anyway, what UHC likes to do with patients that get therapy is they will see that a patient is costing them a lot of money - you know, actually using the benefits they pay premiums for. They'll then decide that this can't continue and they'll stop paying for services until the provider that is doing them undergoes a "Medical Records Review". What that means politely is that they think you're over-using their benefit and they don't want to pay for this service, so you now have to prove that you need it. This is usually a taske the provider must do. Our providers must write an appeal and submit the patient's records for review to UHC. You might think "so what? submit the paperwork". Not so fast. The process is not cut and dry. You have to write the review, which is time the provider isn't being paid for. They must then give it to someone (me) or fax the paperwork themselves, while also compiling their medical records which usually means months worth of notes. This means in our practice that we must have a medical records person submit the documents to our boss, who then signs off on them after proofing them - this is so the records meet requirements medically. Then we have to compile, sort and fax the paperwork and then we get to track it. Meanwhile, the payments for the service stop. UHC does not continue to pay for services while a review is in process. You just have to assume it will work out. Our success rate with these reviews is low, something like 40%... so our providers often just opt not to do them. When I tell you it doesn't matter what the provider writes in the review or who does it, I mean it. We have a Harvard trained Psychologist who sees patients for talk therapy and knows all the specifics. She wrote one of these for a patient, gave it to me, I sent it, tracked it, etc. It was magically approved (one of the only successes I've personally seen) and then 6 months later they did it AGAIN and this time our Psych was like "I'm not doing this anymore, we've proven she needs the therapy, her situation hasn't magically changed in 6 months!" The patient had complex issues that definitely required therapy and pharmacological intervention. I also get calls from Optum, about 1-2 a month wherein a doctor will call us and say they're from Optum and they're stopping services because X, Y, Z. They'll say that the diagnosis doesn't require the amount of visits that the patient has had and I can't argue with them - I just note it and relay the message. Every single Psychologist in our practice hates UHC. Whenever the email I write contains the word "Optum" or "Denial" the providers tell me they don't even want to read them LOL I do not get the same kind of denials from any other insurer, JUST Optum. That tells you something. There is no insurance company I like, to be frank, but if you asked me who I hated the most it's Optum. And the funny thing is that our healthcare through my job is UHC (but I can't afford it). The benefits are outrageously expensive and have high deductibles. Count me out.

That was a lot of words to say that their processes are in place to make things hard on providers and on patients. They want it to be difficult, confusing and nearly impossible to navigate. They bank on you not knowing anything - so the best thing to do is know AS MUCH as you possibly can. What I described here is the main reason why I can not work for an insurance company or become a broker, I do not like or want to sell anyone any of it. I hate insurance and I think it's all a huge scam.

An insurance company's first priority is to keep profit margins high. It is not to help provide excellent care. It's not patient satisfaction. You give them money and they aim to keep it. That's it. So, a CEO is most definitely in charge of helping to keep that company profitable. Insurance companies make BILLIONS - yes, BILLIONS of dollars - a year. They're not "just scraping by".

My number one concern has ALWAYS been single payer healthcare in the US and I have never quite figured out why people are so against the idea. I know why greedy companies don't want it to happen and all I can assume is that the lobbying against it and spreading of misinformation and fear mongering is the reason it's gotten in to so many people's heads that it's "bad". Look around you, does it seem like anything is working well the way it is?