(C) Illustration by Mark Matcho

Either knowingly and maliciously or unwittingly and incompetently--it is hard to know which is worse--Aetna's health insurance ends up scamming members out of contractual benefits. I can only imagine this ends up aggregating to tens of millions of dollars nationally. I have also seen Blue Shield of California do this exact same thing and would bet many other health insurance companies follow the same procedure.

Here's how it works: Assume Memorial Sloan-Kettering is "in network" (which it is for me.) But following treatment, when you get your bills  they aren't always just from "Memorial Sloan-Kettering" they are often from a bevy of different group names within the hospital, for instance one might be "Memorial Cardiopulmonary Group" (which is a bill I recently received). These various names are all part of the originating hospital, in this case Memorial Sloan-Kettering and are all definitively "in network" but for billing purposes (so the hospital can correctly track expenses) they come from different groups and tax identification numbers. BUT what Aetna does is process the claim as "out of network" the first time they receive it. Therein lies the scam. By processing the claim as out of network, they force the member to pay a greater percentage of the claim and end up paying less themselves. To have the problem corrected, the member must then call in to the customer service number. But the elderly, less educated (don't understand their benefits), rich (who don't look carefully at bills) or just less anal folks out there most likely never catch these mistakes and up and getting royally screwed. 

Being young and fastidious, I read every single Explanation of Benefits ("EOB" in industry parlance) I receive and catch hopefully 100% of theses "errors." I'd estimate in the past 24 months I've caught somewhere between 150 and 300 such "errors." Now remember, I know to look for this issue and I make the time to call customer service. So Aetna I am calling you out. This is either an administrative error of gross negligence or it's a knowing and deceitful con hidden behind the sham of a technical glitch in your  conveniently Byzantine systems. My bet is that it is malicious. You deny and mark claims as "out of network" knowing full well that only X% of customers will call in to have these mistakes corrected. You then pocket the difference. To make matters worse, there is no systematic way for customers like me to prevent this from happening over and over again. I feel like Bill Murray in Groundhog Day every time I read an EOB and it shows" Memorial Sloan XXXX Group" or "Northwestern Memorial XXXX Group" which should both clearly be in network but you have decided to make them out of network. There's just no way you can be so incompetent as to not know what's in network and what's out of network and 100% of the time assume it's out of network without some level of maliciousness. I just had my bill for "Memorial Cardiopulmonary Group" fixed. The supervisor I spoke to said there's no way for me to proactively prevent this from happening...probably because it is convenient for Aetna's bottom line.

The sad truth is I know there's going to be dozens more like it in the future and there' nothing I can do as the little guy but call to have them individually corrected. Oh, yeah and perhaps write about your scam on my blog.

A ferocious, time-sucking whirlpool of bad customer service

Somewhere between my countless doctors visits I became caught up in a vast, time-sucking, Homeric whirlpool of paperwork and phone calls. Facsimile terminals in New York, San Francisco and Chicago diligently beeped at each other at my behest. I spent three to four hours a day on the phone calling, calling back, getting transferred, re-transferred, hung up on, mis-transferred and attempting to leave voicemails on mailboxes that were already over capacity-all while mentally dealing with the reality of cancer. For every one task I needed to accomplish that should have been accomplished in one phone call, I estimate it actually took on average six phone calls. Why? Partly because when our cell phone bill is incorrect by $1.09 we place an angry call to AT&T and when Comcast doesn't show up for an appointment we fill out 15-page FTC and BBB complaints in triplicate, but when a hospital fails to fax our medical records or a doctor fails to call us back, we simply grin and bear it. (The hospital of which I speak was not MSK. MSK is the exception to this rule and warrants their own post on why they succeed.)

Disturbingly, we voice our outrage over the smallest customer service infractions for consumer products, but sit as silent accomplices when life and death is on the line. And don't be fooled. It might "just be" a fax of your medical history that fails to get placed on the first call, but if you're in the operating room and something goes wrong it very well could cost you your life when the doctors don't have access to the records of your preexisting conditions. Think about how much care Apple and Google put into the customer experience for their latest mobile phone operating systems from the color of the icons to the feel of the box and response time of their customer service reps. Yet, when I call a doctor to get blood lab results or my insurance company to find out about the status of a $30,000 bill I am treated like third-class citizen. "But, Tom!" you scream. "There are good reasons the healthcare industry is like this. They can't afford good customer service." Untrue! If you want an example of amazing customer service in insurance, look no further than GEICO. Every time I call them, I am blown away by how customer-fcoused they are. If you want examples of hospitals and doctors who get it, I would suggest you spend a week in Memorial Sloan-Kettering diagnosed with cancer...on second thought, you may not want to do that.

Every business is benefited by understanding and catering to their customers, no matter what industry. That is an immutable law of both business and charity. It's no wonder healthcare is so broken. Any business that fails to understand or care about their customers' opinions is likely to face serious trouble. This is even more concerning when it's an industry-wide culture and that industry is the single largest slice of US GDP. This means two things. First, we as consumers need to demand more from our healthcare providers. Second, there is significant opportunity for healthcare providers (hospitals, doctors, insurance agencies, etc.) to differentiate themselves by radically re-imagining their services from the points of view of their customers.

A recent photo of the author

THE FACTS.

I was recently diagnosed with a tumor, known as a choroidal melanoma, in the back of my right eye. The tumor likely started off as a benign nevus (a mole that is common in the back of the retina) but then started growing. Last week I underwent treatment at Memorial Sloan-Kettering Cancer Center (MSK) where radioactive seeds were placed on a small metal plaque and sutured onto the back of my eye for three days. The plaque was then removed in a second surgery and the tumor was also blasted with a laser. Everything went as planned. The tumor was large enough for treatment to be the recommended course, but small enough to be on the very earliest and smallest side that such treatments are used. I will follow up with the doctors in four weeks and also every six months. There was very little pain associated with the treatment. The outside of my right eye is black and blue in the corners of the eyelid and the eye itself is quite red. It looks like I got socked in the eye. I also have some blurry and double vision which should go away within a few weeks. Overall though, a miracle of science considering how good I feel. I have asked the doctors if any superpowers, including but not limited to monocular x-ray vision, might ensue. I haven't gotten a straight answer yet, but I have my suspicions.

HOW WAS THE TUMOR DETECTED?

I had started noticing increased floaters in my vision and then some flashing lights some months ago. I couldn't determine if the source of the symptoms was an eye, neurological or neuro-opthamological, given that the symptoms emanated from the exact center of my vision and the flashing lights appeared in the same spots even when I closed either eye. At first my doctors thought it was an ocular migraine, given my past medical history of migraines. Next, I went to an opthamologist, but they failed to see the tumor in a visual inspection of my eyes using glass lenses. To make a very long story short--after my insistence they eventually found the tumor after taking some photographs of my retinas and doing a computerized "visual field test" and noticing I was developing a blind spot in my right eye. That prompted other tests including an ultrasound of the eye which verified that the area of concern was malignant. (Biopsies are not performed. Ultrasound radio signatures are 98%+ accurate.) The floaters and flashing lights were caused by the tumor pushing up and detaching an area of the retina, which turned out to be a fortunate occurence. Many choroidal melanomas are asymptomatic and thus are not detected until it's late. All in, I am doing very well and looking to return to school just a few short weeks after formal treatment commenced. My fantastic doctors from MSK assure me that given the size and stage of my tumor, along with my relatively young age, my prognosis is extremely good. The probabilities are very, very much on my side. Nonetheless, it has been an intense and scary experience that quickly reminds one of what's important in life.

ADVICE.

It's amazing how many little things in life seem important until something potentially catastrophic slaps you in the face. All of a sudden you push everything off your calendar and spend your time with family and friends. Things that seemed so important and necessary reveal themselves as un*. Take a moment to evaluate your own life through this lens. You'd probably spend more time with your family and friends. Going through this process has radically changed my perceptions of healthcare. In the future, I will be writing about the insights I have gained from this experience. My immediate advice to you is, of course, to get your eyes examined once a year (and get photos of your retinas while you are at it--I wouldn't trust the lenses) and be your own advocate when it comes to your health. Doctors these days are often so jaded by other patients' hypochondriac complaints and internet-inspired patient paranoia that they dismiss real symptoms. If you are experiencing real and tangible symptoms that worry you, don't let up without exploring your options. It just might save your life. It probably saved mine.