I am a cancer survivor who recently needed a biopsy of my cervical spine. As a retired registered nurse who worked at and had all my health care at a downtown Los Angeles hospital for the last 35 years I assumed that this would be done at my hospital.
My insurance is Medicare through this hospital retirement Aetna Golden Plan HMO (health maintenance organization) for the IPA (independent practice association) at this hospital, and all my doctors are in this IPA. I was authorized for consultation with a neurosurgeon from the IPA who only works at this hospital, however when he recommended the biopsy, it was denied because Aetna and the hospital had not signed a contract this year. Aetna wanted me to start again with a different surgeon working at one of their contracted hospitals. I appealed, and used some of my contacts to finally win authorization, but was delayed in having my biopsy as a result of the dispute.
At open enrollment last December, I had spoken with the Consumer Relations Dept. at Aetna and been assured that because my basic insurance was Medicare, there would be no problem of this sort as the reimbursement is the same no matter which facility I get treatment. The hospital insurance representative agreed with this when I contacted them. All this BEFORE I re-enrolled. Because I know a bit about the way things work, I was able to fight the denial. Were I an average patient without this knowledge and without powerful contacts, or were I less able physically or in need of emergency care, I fear I might have suffered much more, both mentally and physically, from this episode. We DO have restricted health care in this country. Choice IS restricted and by a variety of things outside our influence which we do not always even understand, most of them having nothing to do with our medical needs. I did have the biopsy and am recovering.