Aetna Doesn't Want To Cover Colonoscopy Anaesthesia

Aetna Insurance doesn’t want to cover propofol anesthesia during colonoscopies. They say general sedation works just as well and is cheaper. Doctors says that propofol lets them tell their patients that they won’t experience any pain, which is important to calm their fears and get them into the needed surgery. Coolorectal cancer is the number two cancer killer in the US. Wonder if health insurance executives ever have to pay for their medical costs using their own insurance system.

Docs oppose Aetna plan on colonoscopies [AP] (Thanks to Brandon!)

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  1. shadow735 says:

    I dont know about you but I have always wanted to be able to see my own intestines…..

  2. AlteredBeast (blaming the OP one article at a time.) says:

    Those insurance companies are really a pain in th…okay, I can’t even bring myself to finish. :-P

  3. matt says:

    Sounds like this particular insurance company is just like mine. Every possible charge is denied, waiting to see if I put up a fight. Which I do, and win consistently, but it really stresses me out.

  4. bohemian says:

    It is like them not wanting to pay for zyban or chantix for smokers who can’t quit on their own. So do you want to pay for $200 worth of chantix or $200,000 worth of lung cancer treatments.
    Deterring people from getting preventative care is stupid.

    I heard it explained that insurance companies have figured out that insureds turn over about every 3 years so they have no incentive toward preventative care. By the time the problem becomes expensive it will be on their competitors plan.

  5. bohemian says:

    @matt: I was averaging 15 hours a week just dealing with our insurance company refusing to pay charges for about 3 months. When I showed up in their lobby with paperwork in hand they knocked it off. Living in the same town as the corporate office of your health insurance company does have some benefits.

  6. NotATool says:

    This is just screaming for a joke about getting reamed up the a$$…

  7. m4ximusprim3 says:

    @bohemian: which only works if everyone else does give preventative care, rather then fucking them over too.

    Nice to know our health care system is presided over by two kids fighting over two cookies and saying “ok, let go on three” and then trying to grab both cookies anyway.

  8. wimpkins says:

    Hard to believe they would try to avoid payment, this is what the put up your ass.

    [en.wikipedia.org]

    I’m sorry but the doctors are right.

  9. matt says:

    @bohemian: You’ve got a good situation, being able to throw a fit in person. I, am luckily in good health, so I don’t have to worry about it too much, but I will sit at the optometrist and literally have them fighting for me with the insurance company, who consistently will transfer them, drop calls, pretend my insurance doesn’t cover my visit, or pretend like they’ve called the wrong company. I do phone support for a living, and never, never treat even my worst enemies like this.

  10. Greasy Thumb Guzik says:

    I have Crohn’s Disease.
    I’ve had seven colonoscopies.
    The last four have been without any sedation of any kind!
    The only pain is when the scope has to turn the corners.
    You don’t need it, plus you get to watch the whole thing on the TV screen!
    It’s fun to see your insides!

  11. warf0x0r says:

    Just get a bunch of Fentanyl and some Versed you’ll be fine. You don’t need to go under for a colonoscopy.

    The cost of having an anesthesiologist in the room doubles the cost of the procedure.

    (Most colonoscopies cost health insurers around 3 to 4 thousand… the actual procedure can last around 15 to 30 minutes depending on individual circumstances)

  12. matt says:

    Also in regards to preventative care…my particular plan has a clause which allows the company to refuse payment if I encounter any of a list of 100-some odd symptoms. So, for example, if I go to the doctor for dizziness, and he tells me that it’s probably nothing, and I end up with brain cancer, the insurance company will not pay for the cancer treatments because I had dizziness beforehand and didn’t pursue treatment immediately. That’s at least my understanding.

  13. davere says:

    I’ve been on the receiving end as well. I agree with those who have been through this as well. Sedetion is more than plenty. There is no reason to be knocked out.

  14. warf0x0r says:

    @Greasy Thumb Guzik: I feel for you. Anyone who’s had one knows that the worst part isn’t the procedure its the Prep. Doctors need to figure out a better way to deal with that!

  15. geekfather says:

    Aetna is full of shit.

    My premiums doubled this year and I can’t get out of my group plan unless I change jobs. Come November 2008 I will go to ANY other insurance I can. They will never see another penny from me.

    Screw them and their accountants.

  16. Amelie says:

    Putting someone under entails much more risk than using sedation that keeps one awake. But I guess the insurance companies don’t care about risk – other than their own.

  17. deadlizard says:

    I may agree that the sedation in question may be a little too much,
    but I disagree an insurance company should tell doctors what to do.

  18. beavis512 says:

    Health insurance companies are right on this one!! The real argument as to why they are denying coverage is that they are already up your a## so frequently that you should be used to it by now and general sedation should work just fine. See all of you are wrong!!

  19. bohemian says:

    @matt: I didn’t throw a fit. I knew showing up in person and politely calling their bluff was going to be enough to create claims department pucker factor.

    They had been playing games with a couple of providers repeatedly claiming they never got claims submissions from them for months at a time while the providers were repeatedly sending them again and again. Finally one of the providers tipped me off that this was a stalling tactic to delay payment.

    I drove around and picked up copies from the various clinics in question along with their note of when they faxed the document (repeatedly).

    I politely showed up in the lobby of the corporate office and asked to hand deliver these claims submissions to a claims manager. I explained that there had been some mix up with all of these claims getting lost so I was here to help! I hand delivered them to the corporate claims manager and asked for a written receipt of the documents. They complied with glazed over eyes. I was polite, organized and had proof that they were busted playing games but I never accused them of anything or lost my cool. It made it pretty hard for them to refuse me or throw me out. I also made sure I went in business attire. The claims were in the system by the next morning.

  20. bohemian says:

    Your putting what where? Not unless you knock me out.

  21. jaydez says:

    @geekfather: My premiums quadrupled for 2008. My other choise is United Health Care…

  22. arthurat says:

    Our company just left Aetna, big reason was their unwillingness to approve celebrex for my wife. We almost had to elevate this to the state AG to get results. The funn thing is my wife once worked for them and this article is standard practice at Aetna

  23. JessiesMind says:

    Why do we even have doctors when we have our friendly insurance companies willing to give us such great medical care?

    If I want knocked out before someone rams a camera up my ass, then I should be allowed that comfort and the insurance companies can kiss my scope. It’s not like I’m asking them to line my rectum with cashmere.

    On a side note, my Mom had a colonoscopy done a few years ago on Groundhog’s Day. We’ve never quite let her live that one down.

  24. Black Bellamy says:

    If you want to be knocked out before someone “rams” a camera up your ass, you should pay for it out of pocket.

    General sedation is good enough.

  25. alice_bunnie says:

    Going to chime in here also and say that you don’t need to be knocked out. IMHO anesthesia adds more complications than just sedation as well as adding unneeded time and costs. I don’t remember a thing about my colonoscopy.

  26. IrisMR says:

    @Black Bellamy: Doctor disagrees.

  27. Szin says:

    General Sedation works fine for me

  28. While I feel the doctor’s request should be honored because they SHOULD be the one aware of their patient’s needs the most….. BUUUUUT.. these days docs are almost as tainted as politicians and who knows if the anesthetic maker is pushing for wider use of their product.

  29. Amelie says:

    @Black Bellamy: It generally helps to know what one is talking about, before making a comment. It also helps to read the article.

    general anesthesia – a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation.” ada.org

    *wonders how many of the “NOT clever wits” on this thread, are just assuming they know what a colonoscopy entails?* But that’s never stopped the jerkwad contigent before.

  30. schiff says:

    I have acid reflux and had my esophagus scoped to make sure there was no serious erosion or growths. Acid Reflux disease has been directly linked to esophageal cancer and is a real problem in developed countries. Aetna has been fighting the anesthesia claim because the procedure was deemed exploratory because they didn’t find any serious problems. Talk abut being penalized for NOT having cancer…

  31. IrisMR says:

    @schiff: Are you serious? That’s outrageous.

  32. Elvisisdead says:

    OK. Here’s the way this works. There is a medical director at Aetna that sets policy on this type of thing. The claims people say, “Hey doc, there was a propofol charge that came in with a colonoscopy. Should we pay it?” Doc says, “no. general is the standard of care, and that’s what we pay for.”

    That is well within the insurance company’s right. I agree that docs should decide what the best care for a patient is, but please remember that the insurance company keeps your doc in check. PBMs keep the docs and the drug companies in check.

    On the claims submitted getting lost, here’s how that works: If a claim is FAX’ed in, it’s usually sent to a 1-800 number. Some companies will do OCR to pull the info off the claims sheets, but some scan them and then send them offshore for manual keying. Very easy to lose a claim when there are 5 handoffs before it ever makes it to the claims department for payment.

    I’ve seen FAX lines go down for days, numbers change with no notice, and quite literally, thousands of claims go down an electronic rabbit hole with not a lot of concern raised other than “we really need to fix that”. That’s why I left that industry after a very short time.

    That’s why your hand-delivered claims got in the very same day – because someone in claims put them in rather than depend on the system to get them in.

  33. brodskylaw says:

    @warf0x0r: No prep necessary for this colon screening, but it is expensive. [www.dnadirect.com]

  34. HOP says:

    let the shitheads that make the policy for the insurance co. take the test under the covered conditions…..insurance gos are vultures………

  35. Amelie says:

    @HOP: Have you even read the article?

    Oh, if it’s not too much trouble, consider the old-fashioned format, called a “sentence.”

  36. polyeaster says:

    I have to chime in and let folks know that it’s not, “Preventative,” the correct word is, “Preventive.” Seriously.

  37. Zelle999 says:

    Tomayto tomahto.

  38. MBPharmD says:

    @zouxou: Not just you, but damn near everybody else on this thread doesn’t know WTF they’re talking about. You are correct in that general anesthesia is more risky, but propofol _is_ a general anesthetic! It also has *NO* pain relief properties; if it were me getting the scope I’d want Fentanyl (narcotic) and Versed (sedative). Moderate sedation like Fentanyl/Versed can be administered and monitored by a CNRA whereas propofol (at least according to the package insert) requires an anesthesiologist. I love how some people in this thread are bitching simultaneously about health care expenses and then complaining about how this overly expensive full sedation isn’t covered.

  39. Sir Winston Thriller says:

    Better thn my insurer. This year, things like diagnostics that aren’t for emergency care as well as “maintenance” prescriptions (blood pressure, diabetes, etc.) no longer count towards my deductable.

  40. CurbRunner says:

    I’d be willing to bet that Aetna’s removing the anesthesia from this rectal video ramming procedure will be just the first step.
    After they’re able to get away with doing that a few times, next to go will be the general sedation – after all that costs money too!, and who cares, it’s not like any Aetna execs will be the ones actually having cameras shoved up their asses, without any anesthesia or sedatives.
    Kind of gives another new meaning to holding that Bottom Line.

  41. vision646 says:

    Aetna is by far the most frustrating company in the world to deal with. My mother just switched to them and they have nixed all of her doctors that she is seeing. She has been dealing with a certain rare medical condition for the last 6 years and now Aetna is making her see all new doctors who have never seen this condition. Genius!

  42. Sian says:

    The twilight stuff works just fine, by unfortunate personal experience. I really hardly remember anything.

    They gave me Demerol and Versed.

    I think people are just scared of having a 6 foot long camera up their backsides.

  43. KleineFrau says:

    While Universal Health Care has its problems, I am looking forward to it. With my condition, I can no longer afford to deal with private insurance companies. I make a very good living, twice that which should more than adequately support a family of five. But the medical bills are killing me. U.s. makes me sad.

  44. coolkiwilivin says:

    Universal Health Care is NOT the solution. Insurance companies are bad enough but at least they can respond to public pressure. Don’t like your options, which government bureaucrat will you complain to? Look how responsive the DMV or the IRS is and you want those people making decisions about what kind of treatment that will be covered? Yes our current system has plenty of problems but a system where I need to put my life in the hands of the government is NOT a good solution for our country.

  45. Elviswasntmyhero says:
  46. CurbRunner says:

    @coolkiwilivin: “Insurance companies are bad enough but at least they can respond to public pressure.”

    The efforts of the insurance companies’ lobbyists will continue to trump any public pressure results and their bean counters will continue to make those medical treatment decisions for you, after all … what’s the point of letting the correct medical care get in the way of that bottom line?

  47. ms3e says:

    @Greasy Thumb Guzik:
    My first scope, they used a little bit of Versed and that was fine (except for “turning the corners” as the Thumb says).

    The next time with a different doctor a couple years later, I told them to go with the Versed again so I could see what’s going on but the hospital would ONLY do the procedure fully anesthestitized (propofol) claiming it was their new policy. (New source of revenue was probably the more accurate reason…)

  48. timsgm1418 says:

    @coolkiwilivin:amen! the last thing I want is the government deciding when I can go to a doctor. Without some kind of competition there is no need for a doctor to be any good. I’ve suffered from kidney problems all my life, and I have sadly ended up with a few bad urologists, under the system we have now, I was able to find someone who knows what they are doing. Now I’m just waiting to get this f’ing stent to come out, after my 6th surgery in 2 years. This doctor is confident the surgery he did worked. Without the competition of some doctors trying to be the best in their field, I would be stuck with lifetime pain, and end up on permanent disability. Keep insurance private, and stop all the stupid outrageous malpractice awards so that people can afford insurance. It’s the lawsuits that are making insurance so expensive. I hardly think the huge monetary awards are necessary in most of the malpractice cases. The “someone else is to blame” attitude is what makes everything so expensive.
    sorry this is so long..but I remember when my sister worked for a city in AZ and someone actually sued the city because their child went to the top of the slide at a playground, jumped off and broke their leg. Um how about watching your own kid parents?

  49. leftystrat says:

    All great comments.
    We’re in this handbasket and we’re rocketing downward at a frightening pace.

    Now think for a moment… with the next President Clinton’s insurance plan, do you really want to add the GOVERNMENT to this mix?

    And let’s face it – the gov’t is only going to subcontract it to their old buddies the insurers anyway.

  50. Greasy Thumb Guzik says:

    @ms3e:
    My doctors at the huge university medical center prefer no sedation.
    And we all agree that the clean out prep is the worst part.
    If you’re awake, you lie there, talk to the doc & ask questions about what’s on the screen.

    @leftystrat:
    Even if Universal Health Care were to be subcontracted out, they would have to follow government guidelines on care. And those guidelines are going to be developed by doctors with Congress mandating certain forms of care.
    No more of the doctor having to call the insurance company & have to be told by a nurse that a procedure is not the proper care.

  51. synergy says:

    Health insurance executives can probably afford to pay for their entire bill with pocket lint.

  52. synergy says:

    @leftystrat: “And let’s face it – the gov’t is only going to subcontract it to their old buddies the insurers anyway.”

    Hear hear. I think you’re one of the few people I’ve read to actually say this.

  53. skeleem_skalarm says:

    Aetna’a getting lousier by the day. In September of last year, my husband had a chest x-ray. He’s been having these x-rays every 3 months for the last 1.5 years, and Aetna always paid their part. This time, though, we received a bill from the doctor for the full amount of the service, with the notation that Aetna didn’t pay because the x-ray wasn’t pre-certified. I called Aetna to see wtf was going on, and the csr told me Aetna changed the terms mid-contract, and starting in June (or so), 2007, these x-rays had to be pre-certified. We received no notice and neither, apparently, did my husband’s doctor, since when I called they were as shocked as we were that Aetna had changed the terms. I’ve appealed, but I’m not optimistic that this is going to go easy. I will fight the sobs tooth and nail, though.

  54. Tonguetied says:

    “Wonder if health insurance executives ever have to pay for their medical costs using their own insurance system.”

    Actually that’s a very good question. I do wonder how much those execs have to pony up for coverage and how often their claims get denied. Of course they are probably raking in so much cash they don’t even use insurance…

    I wonder about a law requiring all corporate Presidents and above to have the lowest level of their own insurance coverage would go over. Economically I know it’s unworkable (whatever the insurance doesn’t cover they’d either have a supplemental plan or pay out of pocket) but there is a nice sense of irony to it.

  55. pestie says:

    Coolorectal cancer? Cancer is never cool.

  56. chatterboxwriting says:

    @timsgm1418: I feel your pain on the stent issue. I had a narrowed ureter and had one put in in 2005. It was supposed to come out 30 days later (to reduce infection risks) but my urologist canceled on my 3 times and it didn’t come out until 4 months later. That was four months of pain! You definitely don’t want a shoddy urologist. I have chronic kidney failure, too, and I’ve had some terrible nephrologists.

  57. dabofug says:

    Hey, folks, I’ve been on both ends of the scope.
    Diprivan (Propofol) has been generic for quite some time, and is dirt cheap.
    What they’re not paying for is an M.D. to administer meds, watch your O2,BP, rhythm, fluid balance while you have an invasive procedure.
    Even if it’s one in 1,000 or 1 in 50,000, stuff happens.
    Also, Propofol has a very short half-life and is out of your system in minutes. Excellent safety profile when used properly, and MUCH nicer/safer for the patient.Fentanyl/Valium/Demerol/Versed last much longer, and you feel like crap for hours. Much nicer to have one Doc do the procedure and another who is totally dedicated to your monitoring and safety. The insurance companies also do not pay your doctor to administer the Versed et al (pennies), but if the scope hits the fan, the Doc is liable. Even if you trip & fall leaving & get run over by a truck, ‘cuz you are still officially “sedated”