03 January 2008

Insurance Companies' Playbooks

A Cornell doc vents at the LA Times on Cigna's deadly tactics, denying care to its "consumers" until it's too late. This time it was leukemia patient Nataline Sarkisyan's liver transplant.

Nataline, who was 17 when she died, was buried 28 December.

UCLA doctors had put her on a list for a liver transplant earlier in December, and a liver became available four days later. Her doctors told Cigna that Nataline had a 65% chance of living six months if she received a liver transplant. Cigna deemed the transplant experimental and refused to pay for it.

The California Nurses Assn., the Armenian community and Daily Kos publicized the case — which resulted in a telephone and e-mail campaign to urge Cigna to reconsider. It did, but too late for Nataline.

Giuseppe Del Priore has some details I didn't know about, such as the fact that denial of coverage always come with "a sentence to the effect that the doctors must provide whatever care is necessary and that the payment is a separate issue."
I agonize over having to choose whether to wait one more day for approval or to go ahead with the surgery and potentially damn the patient, his family, and the institution, to assuming the financial consequences. If I do go ahead without approval, no one comes to my defense when administrators ask me why so many of my patients' insurers are not paying. No one rescues the bankrupted families.
Another nasty bit of work is calling procedures "experimental" in order to avoid paying for them. Nataline's procedure, he writes, wasn't experimental in any sense of the word.

Ironically, this puts the lie to the idea that American health care is so advanced. We predictably call procedures experimental that are routine in Europe.

Del Priore says the third insurance stall used to kill Nataline was the use of "expert" review — their bringing in what is little different than hired killers to deny care.
Insurers that review my denials define any has-been, retired, unemployed failure with a medical license an expert, paid to deny care. This is practicing medicine without examining the patient or seeing all the data. In effect, the licensed nurse or doctor working for an insurer is practicing medicine unprofessionally and criminally.

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