Managed Care Service Requires Patients With Patience
The Whittier doctor whose suit against Aetna U.S. Healthcare I wrote about recently has lost most of his case. The health care industry may have problems, but defending itself isn’t usually one of them.
Murray C. Zimmerman, 78, a dermatologist and professor emeritus at USC, was awarded $714 in Small Claims Court for medicine he gave a diabetic patient after Aetna, at first, declined to pay for a prescription.
But court Commissioner Gerald N. Mansfield turned down Zimmerman’s plea for $3,200 for his costs in researching medically supporting evidence to make appeals to Aetna to pay.
Aetna, in its rejections of his prescription, had suggested twice that Zimmerman could “submit additional information such as articles from peer review literature” to support his appeals. But an associate of Manfield said the court commissioner felt that in doing so, Zimmerman was acting as a “volunteer” and was not entitled to remuneration for his research.
In an elaborate brief from a downtown Los Angeles law firm and other legal representation that probably cost Aetna far more than was at stake in this suit, the point was also made that Zimmerman had continued his research, priced at $400 an hour, even after Aetna finally approved the medicine.
It is fair for Aetna to note, in the matter of its defense costs, that had it lost the case, many other doctors might have come at health care firms with their “research” charges to justify prescriptions.
Robert E. Kelly, Jr., an attorney for Aetna, said Zimmerman should have realized “there is no way Aetna can run through its deliberative process” on prescriptions in such a short time. Zimmerman, he said, had been in “a precipitate rush to do things [research] that weren’t needed.”
But I wonder. After all, it took Aetna 39 days to approve the medication, and a lot of things can happen to a patient in that time. Fortunately for the patient, Zimmerman gave the medicine to him out of samples he had.
Meanwhile, on another managed care matter, I continue to get a considerable number of calls and e-mail messages commenting, after three columns, on the subject involving service by Prudential Healthcare.
Two cases are particularly worth noting:
* Rebecca Matasso, a 20-year-old San Diego State student, said Prudential took so long--eight months--to pay claims of a little over $100 for an emergency room visit that the hospital sent its bill out to collection.
By the time Prudential finally paid, Matasso had a bad credit rating with the collection agency, Progressive Management Systems, and prospectively with Experian, the nationwide credit bureau, and it appeared it could last 10 years.
However, in this case, Prudential acted in no uncertain terms on behalf of its client.
Mark Jenkinson, a Prudential vice president, wrote Progressive Management and Experian saying it was all Prudential’s fault.
For instance, Jenkinson told Progressive Management, “The delay of payment . . . was an error made by Prudential. . . . I am requesting that the claims that have been paid be removed from her credit history. Our failure to provide timely claim processing should not impact Rebecca’s credit history.”
The collection agency now says it has taken steps to erase the bad credit reference, and Experian says it will keep a watch if one shows up. An Experian vice president, Maxine Sweet, warned that in such cases it is important that the party affected be sure to double check with everyone involved--the credit bureau, the collection agency and the billing hospital--a few months later to be certain the bad references are not there.
* Gail Wilburn, wife of the dean of the School of Public Policy at Pepperdine, James R. Wilburn, sent me an e-mail message some time ago reporting that Wilburn was having trouble collecting on claims from Prudential.
I sent a fax of the message to Prudential corporate spokesman Kevin Heine, and in a short time the company had taken care of Wilburn’s problems.
“Charlene Smith from Prudential called Jim and apologized for all of the hassle we have been experiencing,” Mrs. Wilburn messaged me. “She said that it all had been straightened out and the bills to various doctors and laboratories would be paid. . . . Indeed, checks began arriving and notices of bills paid were sent. In addition, the president of Prudential called to speak to Jim.
“While the above is great for us, it doesn’t solve the problem of all the others working at Pepperdine. Sheryl Kelo, Jim’s assistant, has made 17 calls to Prudential about a toe on which she needs minor surgery. While she is waiting, she has taken a needless round of antibiotics. She also received a new card saying that her personal care physician had been changed--this without her knowledge or consent. When she called, they told her that she could try to change back to the original doctor, but her request for toe surgery would then be denied and the process would have to begin again. . . . Sheryl finally called Charlene Smith, who intervened.”
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There is more of this, and it turns out Dean Wilburn has had some later problems with Prudential. He continues to call Smith, who, judging from numerous messages I’ve received from Prudential claimants, would be getting lots more calls, if her number was readily available.
It is frequently the case that companies have special representatives, sometimes called “escalation” personnel, available to expedite matters. The question is how ordinary customers can find these people. It is sometimes easier, as in the Wilburn case, if the claimant in question is well placed.
But both the Matasso and Wilburn cases go to show that Prudential, and probably other companies as well, can ultimately treat their customers right, if they wish to.
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Ken Reich can be contacted with your accounts of true consumer adventure at (213) 237-7060, or by e-mail at ken.reich@latimes.com
