Sunday, March 13, 2016

To Aetna: I am NOT in your network

Dear Aetna,
I would contact you directly, but believe me, I've tried. 

Perhaps you could help me.  I am a psychiatrist is Baltimore and somehow my name is on Aetna's provider panel.  I never filled out an application or request with Aetna and I have no desire to be on their panel.  Over the last couple of years, I had gotten a few calls from prospective patients, clarified that I am not an Aetna provider, at least not willingly, and left it at that. Recently, the calls have escalated to as many as 5 a week.

I have called Aetna repeatedly, and I can't seem to find a voicemail option that allows me to speak with a human.  I received a call (left as voicemail) from Aetna the other day saying I must refund a patient because I charged more than the allowable rates for an Aetna-cover patient, and the  patient told them I was not in network, and a number was left for me to call. When I dialed that number, the automated answer machine knew who I was (I suppose by my phone number?) but then none of the prompts led to an option to discuss network participation or to speak with a human.  I have also gone to their website, where there is a place to report network issues, and I reported there that I am not in network and never heard anything.  I googled the Chief Medical Officer and tried to call him, without success.  This is a lot of time and effort to dis-enroll from a company I had never enrolled with!  Even your contact page is a fiasco.
  Network inadequacy is an enormous problem for patients and Aetna makes it extremely difficult to address.


Joel Hassman, MD said...

And this is to make us wonder why doctors are dumping insurance as a form of reimbursement especially since Obamacare has taken hold across the country?

Hey, think about this, one reason why I am done with insurance, as well as private practice as a long standing income source, god forbid I ever try to do it again in the future: 90 day supplies of meds are now mandated by a lot of insurers, and where is that in the standard of care for psychiatry? It's been over 8 years ago when a colleague told me of his experience making the poor choice to give 90 days to a patient who cried poverty for 30 day supplies vs the cost of 90 days, and while the patient wasn't suicidal or a risk of harm in any other way that day the script was given, 2-3 weeks later when she impulsively committed suicide over a psychosocial issue, who do you think the family wanted to scapegoat first?

When the Discovery process was concluded, the psychiatrist was exonerated, but the process taught him simply this: NEVER AGAIN WOULD A 90 DAY SUPPLY OF MEDICATION BE PRESCRIBED! Fast forward to today, and I see his point fully. Think insurers will be culpable for the looming next incident to happen to one of us providing care?

Piece of advice, document on paper, never by phone or even by computer!!! That is what saved that provider's rear end!

Aetna, I wish I nevvah met yah!!!

R. said...

While I understand and agree with the objection to being essentially forced to provide 90 day scripts, I also think that the flat objection to them based on one patient is excessive. As a patient, if my medication regiment is stable, getting 9 day scripts decreases the chances that I will miss medication doses, since it makes access to medication easier. I have to refill 1/3 as of often and have a larger window to refill, decreasing the chances that I will forget to refill on time or have to negotiate refill around travel, pay day and life in general.

Joel Hassman, MD said...

Of course there are exceptions to rules, rules made by people who appreciate individuality. Insurers have no clue what are exceptions, unless you are willing to exhaust yourself jumping through multiple hurdles to make the insurer realize you are willing to persevere their hassles.

To "R"s point, yeah, I respect making it easier helps compliance, but, the patient's convenience does not trump standard of care. Sorry, it is what it is, the doctor does what is right, not popular, easy, and, yep, not convenient in and of itself.

It is nothing less than amazing when patients have to personally deal with the crap insurers dump on physicians, I think PK gets that! If one is foolish enough to call, you spend 20 or more minutes just to get an authorization for a medication that has been generic for 10 years, or, talk to someone who has no real clinical background telling you how to diagnose and then what treatment interventions their plan will approve.

You think I am kidding here?! You have a case load of 200 + patients, and these intrusions and disruptions are dumped on your doorstep, what, 5 times a week at least, each time taking 20-30 minutes of your time outside of patient care time to make calls or fill out forms?

Look up the term "SCUT work", a term used in medical training. Then think about when people made you do Some Common Unfinished Task that was basically dumped on you because someone else at the job wasn't willing to do their job responsibilities.

I hear some physicians now are charging THE PATIENTS to do authorizations. That is heinous and unacceptable to me. But, when insurers make health care interventions points of contention and aggravation, everyone has a WHEN moment.

Back to the point of 90 day scripts, to "R" here, when is that random chance moment you as a physician made the wrong choice to give 90 days? Hmm, when it is someone you, "R", know?? I write for 90 days when appropriate, I document completely my concern of doing it, and the patient is aware I am not happy with this definition of care. And, I have a "90 Day Rx Letter" I give to patients, pharmacies, and insurers documenting what is my standard of care to either agree to 90 days, but more importantly, when I won't!

This kind of documentation is what saved that doctor's career 8 years ago. Are colleagues here thinking this through every time you do it....

You better! Because the people who make the biggest deal out of expecting this 90 day supply are more likely the ones who seem to have problems with it later on!

Case in point, you give 90 days but expect to see the patient back in 6-8 weeks, and then 20-30% don't keep the appointment. Now what do you do, oh, and guess what, the ones who don't show, they expect another 90 day RX before they make their next appt.

Yeah, convenience, now that is a standard of care that will defend you in a court room someday...

Sorry, but the issue is personal and ruining my ability to practice psychiatry the way I was trained. I don't get why other psychiatrists just go through the motions and realize later they might be screwed!

So cue Forrest Gump, that's all I have to say about this.

moviedoc said...

Don't take money from anyone but your patient.
Sue Aetna for using your name without your permission.

Unknown said...

I wish we could eliminate the whole 'carve out' crap of special management for 'behavioral health care.' it just means much less care is actually provided, to fewer people. The idea that these illnesses are not biologically based is fiction. California is a state that claims to have parity in behavioral health care. Anthem BC limited the number of counseling sessions arbitrarily, paying nothing for 'excessive sessions' and reimbursing about $25 for each session by an out of network licensed therapist. (Her charge of $160/session is on the low side for the Bay area, believe me.) Clairesmum