What a stupid healthcare system we have.
When friends my age and I get together we often talk about our health and our experiences with what must be the stupidest healthcare system in the industrialized world.
Or sometimes we intentionally don’t talk about it.
It isn’t good for our health.
And by that I mean talking about it and the system itself.
But here goes.
As a retired public school teacher I am covered by Medicare and Aetna’s Medicare Advantage provided by the state as part of my retirement pension.
I have recently needed some tests and procedures that are not unusual for somebody my age (75). Some of the tests and procedures require pre-approval from Aetna even though my doctor has prescribed them based on what he knows about me.
Who knows better what I need? My medical team or a for-profit insurance company that makes money by denying services?
And another thing: Which procedures require pre-approval? You never know.
Aetna changes the list all the time.
As a result my medical provider doesn’t ask the insurance company for pre-approval until the last minute since they don’t know for sure if they need pre-approval or not until the last minute.
If Aetna decides I don’t need the test or procedure and denies authorization, my doctors can appeal and often get it but too late for my appointment and the procedure gets delayed.
As I said, the stress and the delay are not good for my health.
And another thing.
Aetna outsources the pre-approval process to a third party called Evicore.
Evicore uses what it calls an “evidence based” process for denying services which is nothing but a computer algorithm, not by looking at an actual patient.
The algorithm checks boxes. Half the time the doctor’s orders are over-ruled when pre-authorization is required and the case ends up on what they call a “pending approval” list which delays medical treatment again.
Literally.