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Re: [IP] Re: Insurance ????
> We were just talking about things like this. Is anyone else paying attention
> Michael, if you think this isn't relevant just say so. Buddy '-)
> By Michael Conlon
> CHICAGO (Reuters) - The American Medical Association has
> told Aetna Inc./U.S. Healthcare, the second biggest U.S. managed
> care company, that its policies could be depriving patients ofproper care.
> In a letter sent to Aetna more than a month ago and released
> Wednesday, the AMA said a contract the company uses for doctors
> in Florida and elsewhere is vague and allows the company too
> much leeway to deny benefits.
> The company's chief legal officer, David Simon, told Reuters
> that one provision of the contract to which the AMA objected has
> already been deleted, and denied that the company was being
> vague in the way it outlines benefits to patients andphysicians.
> The exchange is the latest in an increasingly loud debate
> about the direction medical care has gone. The debate has seen
> members of the medical profession complaining about restrictions
> imposed by profit-driven health care firms and insurance
> companies who specify levels of care and providers.
> Ted Lewers, a member of the AMA Board of Trustees, in a
> statement commenting on the group's letter, said there was ``a
> trend developing in which managed care companies with large
> market shares offer one-sided contracts on a'take-it-or-leave-it' basis.''
> ``The companies refuse to allow negotiation, yet physicians
> who sign these contracts are virtually signing away their
> ability to properly advise their patients and provide the care
> they believe is clinically indicated -- the very service they
> entered into the contract to provide,'' he added.
> In its letter, the AMA said it had received similar
> complaints about Aetna from physicians in five other states. The
> group said the Aetna contract in question -- in which physicians
> agreed to accept Aetna-covered patients in exchange for certain
> limits and guidelines for care -- is representative of others in
> the managed care industry.
> ``We believe these contracts clearly are not in the
> patient's best interest,'' Lewers said.
> ``These provisions completely blur the line between services
> that are medically necessary and services that the plan simply
> does not want to cover,'' he added.
> ``Perhaps most troubling is the shroud of secrecy that
> surrounds the existence and impact of these provisions. Patients
> as well as physicians are kept in the dark,'' he said. The
> AMA said the Florida contract contains a ``gag'' clause that
> could limit what a doctor may tell a patient, a provision it
> said may violate state law.
> Simon said the so-called ``gag'' clause was ``in no way,
> shape or form'' anything like that, and in light of the comments
> it had eliminated the provision from all of its contracts.
> He also said the services covered are explained in detail as
> demanded by companies contracting with the insurer for their
> employees. He said they were spelled out in handbooks and more
> information was available through an 800 number.
> ``Members aren't kept in the dark,'' he said. ^REUTERS@
Blue Cross Blue Shield of Indiana will cover a pump if your doctor can
prove you have gone through hell first keep 6 months of blood sugars,
have tried multiple does of insulin, follow your diet, have high hbaic
results, have swings from high to low and are showing damage ie kidneys
or eyes.. They will NOT HOWEVER cover the costs of your training to
learn how to use the pump or the training on dietary management.
Smart aren't they?? There are a few pointers on how to get action that
are true for anywhere you live and for any insurance company. If
coverage is rejected - call and write requesting a review of the denial
be sure that you take names and do what they do record their
conversation to you this is important because they tend to twist what
they say when confronted by the state insurance board investigation.
If that is refused or rejected ask for the name and address and phone
number of the president or board chairman of the insurance company and
send them a letter of complaint and request a response. be sure you send
this by certified mail so you have a receipt they got it. still not
happy write to your state's insurance board. they will investigate and
get a response for you. Its amazing what you can achieve if you just
dont sit back and say I guess I'll have to pay this myself also write to
your state congressman they can also propose legislation to have the
state insurance companies forced by law to cover your diabetic needs go