Perjeta: Denial of Service Confirmed

William writes: ”

“If tracking financial matters interests you, read on.

We ended the business week with an apoplectic AETNA case manager. She impresses us to be a fighter. I heard sincere frustration – not just in words alone, but tone and actions also. It turns out PERJETA, the miracle drug as I call it, which is being withheld by Dawne’s medical provider subject to payment by AETNA has been an approved/authorized AETNA drug since Dec 2012.

Get this.

There is nothing in the AETNA system our case manager can find that would explain why the medical provider isn’t being paid based on AETNA POLICIES AND PROCEDURES. We are left, both AETNA AND US, to conclude the medical provider’s use of a diagnostic/billing code J9999 (indicative of a non-standard or experimental therapy) is the culprit. For the sake of understanding the proper code for AETNA is C9292 which is a dead-on match for Dawne’s condition and therapy.

So like a good soldier I write up my findings and forward the above research to Dawne’s doctor offering up the AETNA case manager as a personal contact to verify a very simple resolution. She offers that the medical provider needs to submit the doctors script (which I guess is medical talk for a prescription) citing HER2 Positive pre-op therapy to shrink the Tumors along with the proper code. Job done you would think. Oh, and I attached a demand for written confirmation by end of day wherein Dawne would be given the Perjeta without delay or being held hostage to a $60,000 plus personal liability, fronted by $500 treatment deposits.

The doctor called late yesterday.

No!  That is the decision from the medical provider’s corporate represntatives. Keep in mind this professional medicine man, a good man, is an employee in a larger corporation. He’s a grunt – no corporate policy authority. He fights the good fight, but loses. His bosses have instructed him to tell us that even with AETNA providing written assurance of payment they will not change their policy or provide Dawne an exception to policy. Straight up they are sticking to their “pay the $500 per treatment fee” or take a hike. And they’re still selling these fees as “deposits” to be refunded when AETNA actually writes the check with us personally liable if they don’t which they fully expect to be the case regardless of my research and AETNA giving them the proper billing instructions.

So apparently the medical provider remains happy to have doctors selling hope to desperate patients without fully disclosing their last minute $500 refundable deposit which has historically never been returned because their billing clerk hasn’t submitted a proper doctor’s script with a proper diagnostic/billing code but has no problem billing the patient in full for $60,000 instead of pursuing a contractual solution as an approved, contractually compliant medical provider. Forgive me, but this has to be corporate insanity at its best. Even the average person on the street gets it, I think. Is it that some folks can’t admit to being foolish?

Our next move is to try and get the AETNA folks who contracted with the medical provider to call the obstructionists at the medical provider’s corporate office. I’m hopeful that AETNA sees the medical provider’s tactics as a breach of contractual terms for approved medical care. It is my contention that by extension the medical provider is denying service and putting Dawne’s life at risk. What it gets down to now is essentially asking AETNA to push implied legal or corporate action including, but not limited to pulling their business from the medical provider if they don’t cooperate and immediately provide Dawne all approved therapies without collecting off-schedule fees. In effect the medical provider is holding Dawne hostage to their incompetent billing clerks and that is not a proper business remedy. They have made their business problem Dawne’s personal problem at the expense of her health and welfare.

There is always hope. Fortune is with us – our AETNA case manager is willing, and we hope able to get the AETNA provider contract department to essentially become our advocate. It’s not a given because these contract folks rarely get involved with individual cases – things like this don’t hit their radar until a large group of complaints come in. And of course it’s Christmas week, so finding people at work and not home for the holidays is going to be real tough. I’m feeling confident that even if the above is too much to ask for on such short notice that at least the AETNA folks will give us written assurance that the bill will get paid which provides all that we need to proceed. In the end it may be that Dawne and I will submit a billing reimbursement request to AETNA and then walk the check into the medical provider. Whatever it takes.

I’m reminded that there are many paths to desired outcomes. Dawne’s absolutely must have and will have the Perjeta infusion on Jan 7th. We will make it happen. This means being prepared with a backup plan to find $500 per treatment and comply with what amounts to demands by corporate bullies who have no comprehension that their business practices constitute bad faith, particularly with people facing a horrid disease like HER2 Positive Breast Cancer. None-the-less, this is no time to over-commit to principle; pragmatically Dawne has started a therapy that requires her to wait 30 days afterwards to undergo surgery to remove her tumors. A full regime of drug infusions is needed to significantly shrink, if not entirely kill the tumors before undergoing surgery.”




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