In November of last year, Doug’s employer offered a choice of insurance plans. I did an extensive review of our medical expensive, going on the assumption that I would continue receiving my cancer treatments every month and getting the bone and CT scans every four months. I also took into account my impeding eye surgery and our prescription costs. I confirmed that UNC HealthCare and our primary doctor were in-network providers. Doug’s cardiologist visits were down to about every six months, so his doctor being out of network didn’t seem to be a huge problem. After doing all the calculations, we choose the Aetna plan that would save us several thousands of dollars by my calculations. After our deductible and a certain amount of out of pocket costs, paid partly by a contribution made by Doug’s company, insurance will pay 90% of in network costs, 70% of out of network. After paying $2250 out of pocket in network and $4500 out of network, then they cover 100% (but in the out of network it would only be what they consider appropriate, we would still be responsible for any charges above that). We hit our deductible at my January cancer treatment and would probably meet our out-of- pocket maximum with the eye surgery. Sweet!
On February 1st I called to confirm my surgery date as directed. The nurse unfortunately has to inform me that starting the 5th, UNC would no longer be an in-network provider for Aetna. She explained that contract negotiations between Aetna and UNC just broke down and it didn’t look like they were going to get back to the bargaining table. I was stunned. Very apologetically she said that I’d be responsible for paying the entire costs upfront and would have to wait for Aetna to reimburse me at 70% of what they feel is acceptable compensation. She asked if I wanted to postpone the surgery until I can work things out or find another hospital and eye surgeon. I held it together long enough to say, no, I didn’t want to postpone. After I hung up I just about flooded my basement again with tears of frustration.
Then, I got angry. I called Aetna and was told that yes, the contract with UNC has been canceled due to UNC demanding higher compensation for their services. UNC is a state hospital, so I decided to reach out to my elected representatives. I called up Kay Hagan’s senate office in Washington and asked to speak to her aid involved in the healthcare debate. I was transferred to a wonderful young man, Jason Lindsay. He was very sympathetic and told me he would look into the situation and get back to me. Early the next morning he called and asked if he could gave my phone number to someone who would know more about the situation than he did. A short time later, Miles Lacky, the director of UNC’s Office of Federal Affairs called me. He also was quite sympathetic and promised to look into it and get back to me.
I expected I’d hear in a few days, but instead a few hours later he called and explained it like this: UNC asked Aetna to raise its reimbursement rate to be in line with the rate reimbursed by other insurance companies AND equal to the rate Aetna reimburses other, similar healthcare systems in our area. Aetna refused. There was some hope that they would come to an agreement before the Feb. 5th deadline and he gave me the name and number of the vice president of Public Affairs & Marketing for the UNC HealthCare system who was involved in the negotiations. He asked me to keep him up to date with my situation and offered any help he could provide. He also told me look up on-line for an Aetna request form that would allow UNC to treat me as in-network for a period of time until things get settled.I found the forms, filled them out and sent them to the cancer clinic and the eye clinic for them to fill out their parts and then fax them to Aetna. While I waited, I also wrote an open letter to the chairman of Aetna which I sent to several local and big city news papers. I mean, who wouldn’t want to publish a scathing letter to the head of an insurance company? Of course, it rejected by all of the papers, but a few were very sympathetic and a reporter for a Raleigh Newspaper did call up to interview me. Here is a link to that article: Aetna's fee fight adds to cancer patient's stress (Unfortunately she interviewed me a day after my eye surgery and I was still a bit dopey on pain meds.)
As my cancer treatment and surgery date got closer, and I had not heard anything about my request, I called Aetna. When you call the Aetna member services number, you first get a computer voice that asks you to “describe why you are calling today.” If you ask to speak to a representative she cheerfully agrees to connect you but first she needs to “ask you a few questions to better direct your call.” She doesn’t give up. Yelling and cursing at her does nothing to get you a real person, I know that from experience. So I begrudgingly answer her questions. When I finally get to a person, they will ask me the exact same questions again. So I explained to the live person that I was calling to see if I had been approved for a Transition of Coverage for my upcoming treatment and surgery. After asking some more questions, he looked up on the computer and found no record of my applications. I asked to be transferred to the department in charged with receiving those applications and I was told it was a fax machine and no one would have that information until it was inputted into the system. Wasn’t there anyone I could speak to who could look through the incoming fax papers and tell me if mine was there? “No.” Isn’t there anyone in charge of logging in those faxes? “No.” Can I speak to someone in the department who makes the decisions about approving the applications for Transition of Coverage? “They wouldn’t know anything until it is in the system, and yours isn’t in the system.”
By the time I got off the phone, I had no more information and no one to scream at. I called up my doctor’s assistant to see if she had actually faxed it in. I’m not a religious person, and I may not believe in miracles and supernatural beings, but I do believe in angles on earth, and Jeanne G., my doctor’s assistant, is one of them. When she told me that she had faxed it the same day she received it and even had a confirmation that the fax had gone through, my resolve crumbled. Through my tears I told her all that was going on and that my treatment and scans were that week and I didn’t know if they would be covered and my surgery was in a couple of weeks and I’d have to pay upfront and that I was so stressed out about the surgery and my upcoming scans and no one at the insurance company cares and I hated that stupid computer person who won’t let me talk to a real person and that the real people there don’t know anything and it all really sucks… Jeanne calmly told me that after we hang up I should go get myself a cup of tea, put my feet up and just relax. She said not to even think about this, she will call the insurance company and get things all straightened out!
She called before she left work that day to say she had spoken to a nurse at Aetna who was one of the people who made the decisions about the transition of coverage and that she would call me as soon as she heard back from her. The next morning she called to say that a TOC was approved for TOC for Dr. Carey and the Cancer Hospital until May. I made a note to myself to take her a present when I go in for my appointments. After I hung up I realized that I still didn’t know about my eye surgery coverage. Enter now my second angle, Juan.
Juan is the financial counselor at the eye clinic. I called him and explained the situation, on the most part without tears. I gave him Jeanne’s phone number so he can get the name of the person she had spoken. It took a bit more time, and faxing some more papers to him, but I also got approved for the eye clinic and the surgery. For the first time in weeks I was feeling like things were looking up.
Then I got my first EOBs (Explanation of Benefits) from Aetna. They were all wrong, they were covering it at the out of network rate, not the in network my TOC allowed. Although a few phone called go that straightened out, for the next few months, every EOB came in wrong and I’d have to call up (and yes, go thought the whole rigmarole with Ms. Computer and again with a person) and get the bills resubmitted. With all the appointments I was having, it was an almost daily routine.
At the follow up eye appointment where I needed a consultation with one of the other doctor’s there, I had to get it approved by the insurance before I could see him. Mind you, back in the fall, when we had other insurance, the eye doctor had simply pulled his college into the room to consult. So another TOC request was sent in and an appointment was made. I didn’t even bother to wait for the acceptance; I wanted to see this doctor as soon as possible. However, when they wanted to do the tear duct procedure, I had to go into the financial counselor’s office to see if the insurance would cover it. Juan came through for me once again, not only getting it approved, but also getting them (he said it was their idea) to extend my coverage until August. It would have been a great relief, but I went straight from his office into the procedure room to have the punctoplasty on my blocked tear duct while worrying about Doug and his heart issues.
My next installment will deal with the good, the bad and the in-between of the Holsteins, but I do have to add some good news. As my August treatments were coming up, I decided to ask for one more extension of my TOC. I figured all they could say was no, but I decided to ask them to extend the coverage until the end of the year. Here is part of what I attached to my request:
On February 1st I called to confirm my surgery date as directed. The nurse unfortunately has to inform me that starting the 5th, UNC would no longer be an in-network provider for Aetna. She explained that contract negotiations between Aetna and UNC just broke down and it didn’t look like they were going to get back to the bargaining table. I was stunned. Very apologetically she said that I’d be responsible for paying the entire costs upfront and would have to wait for Aetna to reimburse me at 70% of what they feel is acceptable compensation. She asked if I wanted to postpone the surgery until I can work things out or find another hospital and eye surgeon. I held it together long enough to say, no, I didn’t want to postpone. After I hung up I just about flooded my basement again with tears of frustration.
Then, I got angry. I called Aetna and was told that yes, the contract with UNC has been canceled due to UNC demanding higher compensation for their services. UNC is a state hospital, so I decided to reach out to my elected representatives. I called up Kay Hagan’s senate office in Washington and asked to speak to her aid involved in the healthcare debate. I was transferred to a wonderful young man, Jason Lindsay. He was very sympathetic and told me he would look into the situation and get back to me. Early the next morning he called and asked if he could gave my phone number to someone who would know more about the situation than he did. A short time later, Miles Lacky, the director of UNC’s Office of Federal Affairs called me. He also was quite sympathetic and promised to look into it and get back to me.
I expected I’d hear in a few days, but instead a few hours later he called and explained it like this: UNC asked Aetna to raise its reimbursement rate to be in line with the rate reimbursed by other insurance companies AND equal to the rate Aetna reimburses other, similar healthcare systems in our area. Aetna refused. There was some hope that they would come to an agreement before the Feb. 5th deadline and he gave me the name and number of the vice president of Public Affairs & Marketing for the UNC HealthCare system who was involved in the negotiations. He asked me to keep him up to date with my situation and offered any help he could provide. He also told me look up on-line for an Aetna request form that would allow UNC to treat me as in-network for a period of time until things get settled.I found the forms, filled them out and sent them to the cancer clinic and the eye clinic for them to fill out their parts and then fax them to Aetna. While I waited, I also wrote an open letter to the chairman of Aetna which I sent to several local and big city news papers. I mean, who wouldn’t want to publish a scathing letter to the head of an insurance company? Of course, it rejected by all of the papers, but a few were very sympathetic and a reporter for a Raleigh Newspaper did call up to interview me. Here is a link to that article: Aetna's fee fight adds to cancer patient's stress (Unfortunately she interviewed me a day after my eye surgery and I was still a bit dopey on pain meds.)
As my cancer treatment and surgery date got closer, and I had not heard anything about my request, I called Aetna. When you call the Aetna member services number, you first get a computer voice that asks you to “describe why you are calling today.” If you ask to speak to a representative she cheerfully agrees to connect you but first she needs to “ask you a few questions to better direct your call.” She doesn’t give up. Yelling and cursing at her does nothing to get you a real person, I know that from experience. So I begrudgingly answer her questions. When I finally get to a person, they will ask me the exact same questions again. So I explained to the live person that I was calling to see if I had been approved for a Transition of Coverage for my upcoming treatment and surgery. After asking some more questions, he looked up on the computer and found no record of my applications. I asked to be transferred to the department in charged with receiving those applications and I was told it was a fax machine and no one would have that information until it was inputted into the system. Wasn’t there anyone I could speak to who could look through the incoming fax papers and tell me if mine was there? “No.” Isn’t there anyone in charge of logging in those faxes? “No.” Can I speak to someone in the department who makes the decisions about approving the applications for Transition of Coverage? “They wouldn’t know anything until it is in the system, and yours isn’t in the system.”
By the time I got off the phone, I had no more information and no one to scream at. I called up my doctor’s assistant to see if she had actually faxed it in. I’m not a religious person, and I may not believe in miracles and supernatural beings, but I do believe in angles on earth, and Jeanne G., my doctor’s assistant, is one of them. When she told me that she had faxed it the same day she received it and even had a confirmation that the fax had gone through, my resolve crumbled. Through my tears I told her all that was going on and that my treatment and scans were that week and I didn’t know if they would be covered and my surgery was in a couple of weeks and I’d have to pay upfront and that I was so stressed out about the surgery and my upcoming scans and no one at the insurance company cares and I hated that stupid computer person who won’t let me talk to a real person and that the real people there don’t know anything and it all really sucks… Jeanne calmly told me that after we hang up I should go get myself a cup of tea, put my feet up and just relax. She said not to even think about this, she will call the insurance company and get things all straightened out!
She called before she left work that day to say she had spoken to a nurse at Aetna who was one of the people who made the decisions about the transition of coverage and that she would call me as soon as she heard back from her. The next morning she called to say that a TOC was approved for TOC for Dr. Carey and the Cancer Hospital until May. I made a note to myself to take her a present when I go in for my appointments. After I hung up I realized that I still didn’t know about my eye surgery coverage. Enter now my second angle, Juan.
Juan is the financial counselor at the eye clinic. I called him and explained the situation, on the most part without tears. I gave him Jeanne’s phone number so he can get the name of the person she had spoken. It took a bit more time, and faxing some more papers to him, but I also got approved for the eye clinic and the surgery. For the first time in weeks I was feeling like things were looking up.
Then I got my first EOBs (Explanation of Benefits) from Aetna. They were all wrong, they were covering it at the out of network rate, not the in network my TOC allowed. Although a few phone called go that straightened out, for the next few months, every EOB came in wrong and I’d have to call up (and yes, go thought the whole rigmarole with Ms. Computer and again with a person) and get the bills resubmitted. With all the appointments I was having, it was an almost daily routine.
At the follow up eye appointment where I needed a consultation with one of the other doctor’s there, I had to get it approved by the insurance before I could see him. Mind you, back in the fall, when we had other insurance, the eye doctor had simply pulled his college into the room to consult. So another TOC request was sent in and an appointment was made. I didn’t even bother to wait for the acceptance; I wanted to see this doctor as soon as possible. However, when they wanted to do the tear duct procedure, I had to go into the financial counselor’s office to see if the insurance would cover it. Juan came through for me once again, not only getting it approved, but also getting them (he said it was their idea) to extend my coverage until August. It would have been a great relief, but I went straight from his office into the procedure room to have the punctoplasty on my blocked tear duct while worrying about Doug and his heart issues.
My next installment will deal with the good, the bad and the in-between of the Holsteins, but I do have to add some good news. As my August treatments were coming up, I decided to ask for one more extension of my TOC. I figured all they could say was no, but I decided to ask them to extend the coverage until the end of the year. Here is part of what I attached to my request:
To keep my cancer under control, I need to have treatments monthly and periodic scans to check for continued spread. Without the TOC, I will be responsible for over $18,000 of not allowed costs and out of network co-pay for just these treatments and one set of scans between August 14th and December 31st. The difference for Aetna in my coverage would less than half of that.
I appreciate you taking this under consideration.
Well, except for Ms. Computer. However I don't yell at her any more, I'm sure she gets plenty of abuse from other unhappy Aetna customers!
