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Column: Insurer pats itself on the back for approving a medical claim it twice denied

Insurance claim form
Aetna says a reporter’s call had nothing to do with it deciding to cover surgery for a man with fractured ribs, despite previously denying his claim and his appeal.
(Getty Images)

Joseph Pero, 37, was in a bad way. He’d recently divorced from his wife. He was facing financial issues. He was, as he put it, “in a dark place.”

Pero loaded his Glock 17 handgun. He aimed at his heart.

He pulled the trigger.

And missed.

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The bullet punctured Pero’s lungs and fractured six ribs.

Call it providence. Call it a stroke of luck. Call it whatever you like, the bottom line was that Pero realized then and there that he wanted to live.

Now he had a new obstacle to overcome: An insurance company that deemed the procedure required to mend his ribs “experimental and investigational,” and refused to pay for treatment.

After having his initial claim and a subsequent appeal denied, Pero, who resides in Colorado Springs, reached out to me.

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“I’m in incredible pain,” he said. “At this point, I’m looking at taking out a loan and paying for the surgery in cash.”

Even with a steep discount offered by the hospital, Pero, a software consultant, was still looking at an out-of-pocket cost of about $30,000.

Let’s cut to the chase: Shortly after I reached out to Pero’s insurer, Aetna, a spokeswoman for the company said it just so happened that they’d had a change of heart and had decided to cover the procedure.

“This was two days before you contacted me about Mr. Pero, so it appears that he’s not aware of the approval,” said Anjie Coplin. “One of our customer service representatives left him a voicemail earlier today.”

Now there’s a strange coincidence. I’ll get back to that.

First, let’s take a closer look at a dynamic that will be familiar to millions of Americans — the hoops that often have to be jumped through to get a health insurer to uphold its end of the bargain after receiving years of policyholder premiums.

Incredibly, it’s very difficult to determine how many health insurance claims are denied. The federal government doesn’t track such data on a regular basis.

A 2011 study by the California Nurses Assn. estimated that the state’s top insurers rejected about 26% of all claims. A separate study that year by the federal Government Accountability Office found that denials were reversed in about half of all appeals, suggesting that many claims were denied for questionable reasons.

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Pero’s injury occurred in 2017. His doctor waited a year before determining that two of his six fractured ribs were failing to heal correctly, causing Pero intense pain.

The doctor recommended surgical rib fixation, also known as rib plating, which involves using plates and screws to fuse broken ribs back together.

Denver Health, where Pero was being treated, is one of the country’s leading providers of the procedure, performing about 3,000 such operations annually. The Mayo Clinic says that “surgical stabilization of fractured ribs is becoming more widely accepted,” especially for patients with two or more fractured ribs.

In a letter dated Dec. 6, 2018, Aetna informed Pero and his doctor that it wouldn’t cover the procedure.

The insurer said it considers rib fixation medically necessary only when a patient is unable to come off a ventilator used to help him or her breathe, or when the patient’s chest must be opened for other reasons, such as to operate on the heart or lungs.

“Aetna considers internal fixation of rib fractures experimental and investigational for all other indications,” the company ruled.

Note that it didn’t cite the injury being self-inflicted as grounds for denial, which Pero said he might have understood. Aetna made its ruling based solely on the medical criteria.

Pero appealed the decision, arguing that the procedure is necessary to alleviate chronic pain and breathing trouble. His doctor submitted a letter of medical necessity along with clinical documentation attesting to the legitimacy of rib plating in such circumstances.

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In a letter dated Jan. 9, which Pero said he received on Jan. 25, Aetna stood by its initial call. “We have found our previous decision to be correct based on your medical plan provisions,” it said.

Which is to say, nothing about Pero’s situation had changed and the insurer wouldn’t cover the claim, regardless of his doctor’s insistence, with supporting documents, that the procedure was warranted.

On Jan. 27, Pero was admitted to an emergency room with breathing difficulties. He was medicated and told that he could expect more such episodes for the foreseeable future. A day later, he informed Denver Health that he would pay for the surgery himself.

Pero told me the hospital lowered its list price by 75% to about $30,000, and agreed that if Pero paid $8,000 up front, he could pay off the remainder in monthly installments. The operation was scheduled for March 6.

Still, Pero said the experience left him feeling “livid,” and that’s why he got in touch with me last week, to vent if for no other reason. I contacted Aetna on Feb. 6.

I’m getting microscopic about the timing because of Aetna’s unusual assertion that it made this decision on its own, independent of my asking questions.

As noted above, Aetna responded to my call and email a day later by saying it had reversed not one but two claim denials on its own after receiving “additional clinical information” from Pero’s doctor.

Coplin declined to say how the new information differed from previous materials submitted as part of the appeal.

She said that when the new information arrived, it triggered a fresh review of Pero’s case and, this time, Aetna’s medical director decided to green-light coverage.

A letter from the insurer received by Pero on Wednesday said that “coverage for this service has been approved” and made no mention of the two previous denials.

“I’m thrilled that they’re going to cover it,” Pero told me, “but I can’t believe what I had to go through to get there.”

He added that when he spoke the other day with an Aetna rep, “the first words out of her mouth was that she understood I’d spoken with a reporter.”

All this leads me to a point I’ve made all too often in the past and probably will make again in the future: It shouldn’t be this hard.

Private insurers are businesses, and as businesses they have a responsibility to make money. The obvious problem is that insurers only make money when they take in more cash in premiums than they pay out in claims.

In Pero’s case, he was in such medical distress, he was prepared to go thousands of dollars into debt to pay for treatment on his own, despite having steadily contributed to his insurer’s profits.

If he hadn’t persisted in the face of repeated claim denials, that’s likely how it would have played out.

Then there’s the seeming arbitrariness of Aetna’s decision-making process. Pero would have been out of luck if his doctor hadn’t tried again to persuade the insurer that rib plating was medically necessary.

And for some reason, Aetna’s medical director made a completely different decision upon reviewing what would seem to be largely the same clinical documentation.

Maybe Pero’s trip to the ER was a factor, although Coplin didn’t mention it to me and Aetna didn’t indicate in its confirmation letter to Pero that it’s even aware of the incident.

Maybe the insurer is rethinking its stance on broken ribs. Maybe the medical director was just in a better mood the third time around.

The fact that so little transparency exists for such important decisions should be a wake-up call for everyone.

Go ahead and tell me this is a healthcare system we can be proud of.

Tell me this is how you’d want to be treated.

David Lazarus’ column runs Tuesdays and Fridays. He also can be seen daily on KTLA-TV Channel 5 and followed on Twitter @Davidlaz. Send your tips or feedback to david.lazarus@latimes.com.

David Lazarus’ column runs Tuesdays and Fridays. He also can be seen daily on KTLA-TV Channel 5 and followed on Twitter @Davidlaz. Send your tips or feedback to david.lazarus@latimes.com.


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