LymeNet Flash: Need help with Aetna Coverage for friend

This is topic Need help with Aetna Coverage for friend in forum Medical Questions at LymeNet Flash.

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Posted by imagine2 (Member # 3136) on :

Hi! I did a search on insurance problems and found that others have had problems with getting coverage from Aetna. A friend has just started rocephin and was denied. She has appealed but doesn't expect the appeal to go through. Just wondering if anyone who has been through this with Aetna can tell us what, if anything, she can do to get the much needed coverage through Aetna.
Many Thanks!!

Posted by docdave130 on :

if she has positive pcr's for lyme then you can go thru the local state senator or congressman, they help meany times in insurance cases and some have task forces just for this purpose.
aetna is the worst provider for lyme and since us healthcarebought them out, they turned into one of the worst companies, even worst than blue shield.
you can also contact state medical boards and they can refer you to the right place to contact, usually state insurance commission,.
however the congressman is the best bet.

Posted by nannie (Member # 5250) on :

I would copy the embedded info below and include it with the letter to your congressman insurance board and/or AG's office.

FYI-Bill Donaldson from the SEC is a former boardmember and interim CEO of Aetna. My be is that he still owns sock in the co. Copy him in?

http://www.hmocrisis.com/update_110303.html
November 1st, 2003 - Judge Moreno Issues Order Providing Final Judicial Approval of AETNA Settlement

Miami, FL - US District Judge Federico Moreno issued his order granting final approval to the landmark settlement agreement between AETNA and 950,000 physicians in Miami on October 24, 2003. The Order approves the May settlement of a national class action pending in the federal court for the Southern District of Florida before Judge Moreno, as well as multiple state court actions filed against the company. The sweeping document includes industry-leading improvements to physician-related business practices as well as cash payments to physicians in accordance with terms outlined within the agreement. Finally, the settlement provides additional funding for an independent foundation dedicated to improving the quality of health care in America. The agreement will enhance communication between physicians and AETNA, reduce administrative complexity in the claims payment system and help improve the quality of the health care delivery system. These changes will result in increased predictability and speed of claims payment, creating significant value for physicians by reducing time-consuming and costly administrative burdens and giving physicians and their office staffs more time to focus on their central mission - providing health care to patients. To view a copy of the Orders issued on October 24, 2003 click here: Aetna Settlement Approval - Order 1 | Order 2.

For additional information concerning HMO litigation, please visit the HMO Crisis Newsroom.

Posted by MarieElaine (Member # 5408) on :

You need to find out if your medical plan is self-funded. If it is self-funded the State Insurance Commissioner can't help you.

I was told to try the Dept of Labor.

I wish we could find a lawyer to file a class action suit against Aetna on a contingency basis.

Good luck....it is worth fighting, even if we lose...our voice needs to be heard by the legislators if it is ever going to change.

Marie

Posted by imagine2 (Member # 3136) on :

Thanks everyone! This is really helpful information. I am wondering if letters from LLMDs are any help at all. Her LLMD won't get involved. I'm trying to get in touch with Jilly. Does anyone have a phone number for her? She went through this fight with Aetna last year.

Posted by nannie (Member # 5250) on :

The LLMD has the responsibility to ensure that medical recommendations that are made during BILLABLE consultation time are covered by insurance, even if they DO NOT take insurance.

Forcing an ill patient to battle their insurance company by themselves because you have aleady cashed the patients' check or billed insurance is not helpful to the patient; it does harm, and the physician can and probably will be investigated, if they are not under investiagtion already.

You are the patient, as such, you are a customer of this physician. LLMD's lend NOTHING to the Lyme disease cause by refusing to help patients recieve insurance reimbursement for MEDICALLY NECESSARY MEDICAL TREATMENT.

Posted by imagine2 (Member # 3136) on :

Thank you, Nannie. My sentiments exactly!!