Insurance

more insurance drama
OK- over the last couple of days due to some more issues w/ my current onc, I have firmly decided that I have to find a way to change oncologists and I know the one I want to go to at UCSD/Moores Cancer Center. My insurance had told me in the past I "can't change doctors while you're already under someone else's care during treatment". I hadn't pursued it or tried to fight it at all until the past couple of days. I was thinking I was making headway because the sympathetic rep I spoke to at Aetna told me although that's their "official rule", it's actually up to the new medical group that I'm trying to become part of to decide to accept me or not. I was even willing to change my internists (primary care physician) within the new network so that all the doctors would be within the same network and referrals shouldn't be a problem. So, I pursued that (spent a lot of time on the phone yesterday and today) and got my answer just a little while ago- still NO! The new medical group rep said Aetna HMO "doesn't allow" them to ever accept new patients and that they "never" accept new Aetna HMO patients who are already under active care of another doctor outside of their group & that I need to continue care with my current oncologist. I was saddened and maddened at the same time!- and also surprised- I really thought they'd make an exception since I've already since specialists within their group and even had my liver surgery at their hospital! They wouldn't even let me tell my specific link with them that I already have. They said they weren't allowed to decide based on my circumstances, they just had to follow the insurance rules. So... the sympathetic Aetna rep helped me start the paperwork going on an appeal process. She said the state of California is really sticky with requiring the patients to appeal first to their insurance company before they can go on and appeal with the California State Medical Insurance Board. She told me that although it usually goes faster, but Aetna will have up to 30 days to give me an answer to my appeal. She said they may even still decide to make an exception and let me see this doctor since it doesn't seem that my current medical group even has an oncologist who actually has a specialty in my kind of cancer (isn't that maddening?!) If they still end up denying it, then I would then go on to appeal to the state medical insurance board. In the meantime, I don't think I'll let on to my current onc what I'm trying to do. I have an appt w/ him Monday to discuss my rising CEA numbers, which is happening while on my "maintenance" treatment schedule.
I don't know how anyone can work with cancer- not just because of the physical aspect, but because I seem to spend a LOT of time at appointments and ON THE PHONE with my insurance company- it's been that way off and on the whole time!
I'm trusting in God that this is going to work out. I've been praying a lot about it and I'm certainly trying to be as proactive in it all as I can be!
Anyone have any experience in filing appeals re. insurance decisions, especially in the state of California??

lisa42 said:

Serrana- re. insurance
Hi Serrana,

Guess what? After talking with the nurse practitioner last Tuesday when I was getting my Avastin infusion at my oncology office, the discussion came up of all my problems in the past of the onc not k-ras testing me, etc. I said to her "They ARE testing everyone for that now after all my problems with it and finding out I had the kras mutation and the Eributx never even helped me, right??" He looked around and shook his head "no". After the doctor walked through, he said he went to a conference just last month on it and another onc from the office was with him. This onc said to the nurse "we really need to start doing this, I guess". The nurse said he said to the doctor "WHY haven't we been doing this when it's now considered standard practice to k-ras test colorectal patients?" The doctor didn't really answer, just said again "I guess we need to start doing it". This is a full eight months after they found out they had put me on the Erbitux for nothing and that I was postive for k-ras! The very fact that they're still not doing what they're supposed to be doing, really upset me and makes me VERY hesitant to trust my oncologist with the future of my care.

SO... I spent the day yesterday on the phone pouring my story out to someone at Aetna and to see what I can do to get around their "rule" of "not being able to change oncologists while I'm still undergoing treatment". I finally was told that I could probably get around it by changing my primary care Dr. (internist) to a doctor within the UCSD medical group, that way all the UCSD oncologists would be within network. I told them I was told that before also BUT that I was also told that I wasn't allowed to change primary care Dr while still in treatment- period. NOW I was told while that IS their official rule, it's actually up to the new medical group (UCSD in this case) whether to accept me or not as a new patient. I wish I had known that before! I'm pretty sure they would accept me since I've seen specialists there before and had consulted with the oncologist before already. With living fairly far away from UCSD, I'm not real excited to give up my internist, but I'm definitely willing to do it if it will allow me to change! I'm going to do it! I have an appt. w/ Dr. Fanta for June 17- currently set up as a "cash" appt, but hopefully the insurance will cover it by then as a 2nd opinion appt on referral from my current doctor.
So before changing, I'm going to my scheduled appt w/ my current onc this Monday to see what his angle is. Also, I have a referral in from my internist to see a rheumatologist in a couple of weeks & it will mess it up in the computer if I go and change doctors and medical groups before that appointment. It all gets so complicated!
Anyhow, wish me luck (or better yet- keep it in prayer for me) so everything will end up working out!
Thanks for the encouragement!!
Lisa

So angry!
I am reading all your stories here in this thread and it just makes my blood boil!! Some of you know that I have been on a rant about the insanity of the state of health insurance in other threads and through that I have actually learned a lot about the Canadian insurance system that I did not know before. For instance, I did not realize that Canadian insurance varies from province to province, even though it all falls under the same umbrella that every Canadian citizen is entitled to affordable healthcare, no matter what their walk of life.

Having said that... how can people who work for insurance companies sleep at night, knowing they are working in an industry that is built for profit at the expense of the most vulnerable and sick? I realize that everyone needs a job and the insurance industry obviously hires a lot of people from the clerical help up to the specialists and their own doctors, so a wide range of experience and intelligence... and yet, how, in good conscience, can anyone work for a health insurance company knowing that people are dying because the industry is more greedy than helpful?

I know we are forever telling newbies, "Don't go by the survival statistics, they are only numbers and they are usually 5 years or more out of date." That is true and the statistics are scary but I really have to wonder if one of the reasons there are so many deaths from Stage IV cancer is solely because of insurance? If it's because there are so many out there who can't afford insurance so don't go to doctors because they know they can't afford any visits, let alone treatment, or because those WITH insurance are given the run around and who knows if they ever did get the best care when they feel they could have gotten better elsewhere but their insurance company wouldn't let them?

It just boggles my mind the amount of running around, filling out forms, hours spent on the phone and everywhere you turn you are turned down. Then there's the process where you have to go through all this hassle with your insurance company, knowing you are going to be turned down, before you can go to the next step... and must go through that before you can file with another agency... and then go through that, repeat the process and then, MAYBE then you can get your treatment or change your doctor... then again, you might go through all of that and you are denied! Meanwhile, weeks, maybe months have gone by and you are getting more and more stressed out over the process and we all know that cancer THRIVES on stress!! In some cases, it is stress that caused the cancer. The insurance companies know this, and yet they purposely put people in situations that surround them in stress... why don't these same insurance companies just give sick people a gun?? It's obvious that as long as you are young, healthy and in top shape, these are the people insurance companies will bend over backwards to offer great coverage... knowing full well, the odds are it will be years before said young, healthy person is ever going to need insurance... meanwhile the company gets to rub their hands together in glee as they watch all these young healthy payments come in every month. But, along comes someone who has been diagnosed with a serious illness and the insurance companies want to turn up their noses at them. They are no longer useful and aren't the cash cow they have been for years and years. Oh sure, they are still paying the high premiums but now that they are in need of insurance for the medical nightmare they have to go through, they are spending more money than they contribute to the plan (who cares about the money they were contributing for years and not making any claims!). Now, all of a sudden the words "patient service" mean nothing. The company changes gears and treats the claimee to the run around. The front end staff who talk to the patients first, are trained to give them the run around (hence why you have to cut through all the BS and ask to speak higher up the ladder). When they turn down a claim "no, that med is not on our list of covered meds" they don't tell the patient the reason it isn't covered (if it's an employer benefit plan then the employer has negotiated with the insurance company as to what are the common meds that most people would need and make up a list of the covered meds) and that the patient must talk to their employer so the employer can call the insurance plan and have that med covered for you. Noooo... they just tell you it's not covered so that most patients will accept that that is that and either pay for it themselves or go without the med because they can't afford it... and meanwhile the insurance company has saved themselves the cost of that expensive med/procedure.

I wonder if any stats have been done to show where patients (of any serious illness) have died because they didn't get proper treatment because the insurance company interferred and wouldn't pay for certain items, or, like in Lisa's case where the patient is just not 100% trusting of the doctor she has and she can not change to another one because the insurance company won't allow it. And for this you are paying over $1300/month???

How many have died because they have just been too sick, physically and/or emotionally and don't have the energy to wade through all the paperwork and phone calls it takes to be sick?

No, I certainly don't meant to gloat or be smug (I am too angry at the system who puts patients in danger), but I have to wonder if one of the reasons I'm doing so well (at the moment) is because I've been pampered by the BC system. The only paperwork I've ever had to do is fill out the waivers that state I understand the surgery, it has been explained to me, and that I give permission to go ahead with X surgical procedure. I happen to have lucked out and gotten the best oncologist in the world but if I were having doubts, or questions or felt that I would get better treatment elsewhere, I could just up and change doctors (assuming he/she was taking on new patients) without having to give any reason... and it would be up to my current doctors to transfer all my files to the new doctor once they had been requested. In other words, the onus is not on the patient to work things out, pick up their med records from everywhere and bring to the new doctor. The onus is on the doctors to communicate and arrange for said documents to be sent over.

Having compared the two systems, I would LOVE to know what the survival rate percentages would be if EVERYONE had that kind of coverage/treatment and did not have to deal with the stress of wondering if they could afford insurance/treatment, let alone how they were treated. I bet we'd see a whole different set of figures and the survival rate would take a huge jump up.

I feel for all of you

Cheryl

lisa42 said:

thanks!
Thanks Serrana and Hatshepsut for your info and links!
I will definitely follow through-definitely a pain, but I am determined this time. I dropped it once before a few months back, but I am not ready to drop it this time!
Cheryl, I appreciate your sentiments! If no one gets riled up about all this, then nothing will ever change. I know the big argument in the U.S. now is HOW to go about about those changes. It will interesting and scary to see what is going to happen in this country with it all.
I've got an appt w/ my current onc Monday afternoon. I'm not going to mention anything to him about wanting to see the other onc, filing an appeal, or anything like that. I want to first discuss his angle on my rising CEA, what he thinks, etc. Then, I definitely AM going to bring up this time my frustration with several things that should have been done differently in the past for me, and how I will expect him to be "up" on the "latest" in colorectal cancer treatments. I will have to still get my treatment from him in the meantime while I'm working on this appeal process. He'll probably find out soon enough, but I don't want to "burn my bridge" (too much anyhow) in the interim while he's still my onc.

Well, I'll report back to you all if I have any more news on all this later in the week.

I'm taking deep breaths now- I don't want to let myself get too stressed out over it, because I do believe that stress does feed cancer.

Blessings to you all & enjoy the rest of your weekends!
Lisa

the "latest"
I actually posted another thread on this issue "I may actually get to change oncologists", but thought I'd comment here since this is where the whole insurance discussion started.
I got a telephone call this morning from someone identifying herself as my case manager from my medical group. (the medical group isn't the same as the insurance- the medical group is the network of doctors and specialists they use). Anyhow, I don't know why, but I had never thought of talking to/appealing to the actual medical group- I had just talked at length with someone actually from Aetna (a few times) and then also someone from the Dr's office of where I'm wanting to go. Well, this dear angel of a woman was so sweet and said to me, "I noticed your internist had put in for a referral to Dr. Fanta (the onc I want to see), but it's been denied." "I also see that you saw him already in November, so I'm wondering if perhaps you're wanting to change over to him." I said, "What?! That's what I've been trying to do! Aetna kept telling me "no patient is allowed to change doctors while still in treatment." She agreed with me that that's an insane answer or rule, considering as a stage IV patient still on treatment that I might technically not ever be done with treatment, and that would then preclude me from ever being able to change doctors. She said she's never heard that rule before (that's VERY interesting as how she would never have heard that rule but the Aetna reps I spoke to spout that "rule" off as if it's carved in granite.) She then informed me that Dr. Fanta IS within the network of our medical group, as well as the fact that he's also contracted with Aetna, and that I could have picked him as my oncologist right from the start if I had wanted (of course, I didn't know about him back then, though). So, this case manager is checking into it more for me. Nothing's solved yet, but I definitely have hope here that things will turn out well for me!!! In the meantime, I had already gotten the ball rolling for filing an appeal against Aetna. The case manager said don't stop that process in the meantime, but she's hopeful that I won't need to do that.
As before, I'll let you know when I find out more info. It may take a while.