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AETNA U.S. HEALTHCARE |
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MEDICARE HMO MARKETING DECEPTION |
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"Aetna Upheld in Court Ruling," Two federal courts agree that Aetna can lie to patients without being held accountable: "In fighting the case, [re: Aetna violating racketeering laws in its advertising and membership materials] Aetna admitted that claims in its advertising that it was committed to 'maintaining and improving quality health care' were 'mere puffery' but said that did not amount to fraud. The New York Times, August 12, 2000, p. B14. Authenticated report.HARDBALL investigators attended an AETNA U.S. Healthcare recruitment "Informational Meeting." An AETNA HMO Marketing Representative used dirty tricks to lure seniors into the HMO. Nonresponsive, vague, and evasive information misled seniors into believing that AETNA would not bill them for use of emergency room (ER) services, if they were "prudent laypersons." Seniors aren’t stupid. A very astute woman asked if AETNA would consider a broken hip to be an emergency. The AETNA Representative hesitated… then reluctantly replied that a broken hip would not be an emergency. It would qualify as "urgent." AETNA’s Representative did not disclose evidence-based medical facts about the outcome of seniors’ broken hips. Experts, including the Chief of Geriatrics at Yale University School of Medicine, have observed that for many older people a fall that breaks a bone--especially a hip--causes them to lose their mobility and their independence and is the beginning of a downward spiral that ends in death. A HARDBALL investigator asked the bottom-line question: "Are there any circumstances under which ER payment is not included for a broken hip?" AETNA’s answer: "It is hypothetically possible." After the meeting, the HARDBALL investigator examined AETNA’s Recruitment Brochure. This document identifies a "partial list of WHAT’S NOT covered:" |
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| "All applicable services not referred by your network primary care physician—except for care received as a result of an emergency or a situation involving out-of-area urgently needed care. Neither original Medicare nor AETNA U.S. HEALTHCARE will pay for nonreferred services." | ||
| HARDBALL’S
PLAIN ENGLISH TRANSLATION: If you are in the area, the HMO’s GATEKEEPER
doctor must refer patients for emergency care or AETNA won’t pay. Payment
depends on that technicality. Being a "prudent layperson" is
meaningless, if the HMO’s GATEKEEPER does not refer the patient for ER
services.
"Urgent" doesn’t mean "emergency." Patients are expected to know, understand and apply AETNA’s legal definitions of commonly understood terms, when they and their families are under severe stress. The devil is in the details. HMOs hide the details in incomprehensible self-serving contracts written by HMO lawyers to take advantage of sick and disabled patients. |
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HARDBALL’S BOTTOM LINE |
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| "HMOS
keep you guessin' And don't do no confessin' What their inside secrets are. So patients don't know nuthin' About HMO handcuffin' And never win the war." |
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Lyrics, Make
It One for The Patient |
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POLITICIANS, PLEASE PROTECT US! Represents AETNA U.S. Healthcare (CT zip code – 06156*)
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Blue
Shield of California (Medicare Subsidiary) |
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Medicare Recruitment Fraud |
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GREED, NOT NEED Authenticated report by HARDBALL investigators who attended a Medicare HMO recruitment meeting at Denny’s restaurant. The jovial Blue Shield Sales Representative passed out menus, key chain flashlights and medicine spoons to the old folks…but didn’t hand out the HMO’s contract that defines the terms and conditions affecting whether or not patients get healthcare. Instead, he assured the participants that, if they joined Blue Shield, their primary care doctors would decide what is "medically necessary" for them. A HARDBALL investigator asked if the HMO has a written definition for the term "medical necessity." Blue Shield’s Answer "I don’t know. Ask your doctor. I have a problem with an HMO deciding medical necessity. You pay a price for ignorance. A blind lady recently joined us. [enrolled in Blue Shield] She’s tough! You’re just like her! You ought to meet her." HARDBALL Investigator's Reply "Define tough. Can you define it better than you defined medical necessity? HMO lawyers, not doctors, define medical necessity. It’s in the contract. I’m going to shine that flashlight you gave us in your eyes, if you don’t start telling the truth." WHAT’S WRONG WITH THIS PICTURE? After the meeting, HARDBALL Investigators obtained Blue Shield’s "Membership Information Booklet," which the HMO does not provide to applicants before they become HMO members. The Booklet defines the terms and conditions of "Your Right to Receive Medically Necessary Services." The HMO Booklet states: "When Blue Shield of California determines that a treatment is required and appropriate in accordance with acceptable standards of medical practice, that treatment is considered Medically Necessary…Blue Shield of California reserves the right to review all services to determine whether they are Medically Necessary." (emphasis added) |
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| HARDBALL’S BOTTOM LINE | ||
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"Approval’s not guaranteed, |
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Lyrics, The
HMO Blues |
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To understand the nitty-gritty reality of how an HMO’s "medical necessity" definition wrongly denies healthcare, click here to read Chapter One of my book, How to Play HMO HARDBALL. POLITICIANS, PLEASE PROTECT US! Represents Blue Shield of California (CA zip 94105-1813)
E-Mail: Sorry! This governor doesn’t believe in e-mail for "plain folks." Two libraries came up empty. The governor’s website…forget it. Try calling? Only if you’re into hanging out on his automated phone system that won’t connect you to a person. However, the Governor has been eager to meet in several exclusive "by invitation only" fund raisers with HMOs and their allies. I wonder if they have his private, exclusive, by invitation only, E-Mail address?
UPDATE: After two years, Governor Davis finally gave his e-mail to plain folks, governor@governor.ca.gov. HMO HARDBALL used the Governor's e-mail to express concerns regarding healthcare document shredding/ destruction (during the period Oracle documents were being shredded by state officials). Governor Davis didn't reply. No one from the Governor's office replied. So we replied. Click Limerick.
BACK to Patient Rights Violators List |
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CONSUMERS UNION (violator enabler) |
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WILLFUL BLINDNESS RE: FRAUDULENT USE OF “CONSUMER REPORTS” RATINGS/REPORTS IN MEDICARE HMO ENROLLMENT |
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Consumers, Enforce Our Policy (if you can find it) Consumers Union (Consumer Reports, Jan 2000, p.4) states in "microdot" fine print that:
CU Non-Enforcement Enables HMO Fraud On Tuesday, November 9, 1999 at 3:00 p.m., HMO HARDBALL investigators attended a Kaiser Permanente Medicare HMO enrollment meeting at CoCo’s Restaurant. The HMO sales representative softened up the old folks with free pie (loaded with bad cholesterol) that her own HMO’s health promotion staff advises patients to avoid. HARDBALL investigators refused to succumb to temptation. It took cast iron willpower and fear of heart disease to resist pecan pie with whipped topping and apple pie a la mode. The sales pitch lasted for more than an hour, while the usual eye-glazing HMO hype was presented. But, before the sales rep closed in for the metaphorical "kill" by handing out enrollment applications, she referred to her best "talking point:" "Consumer Reports' survey rated Kaiser Permanente as the best HMO." HMO HARDBALL Does Consumers Union’s Job The sales rep had violated CU’s no-commercialization policy, evidently not for the first time. She had intentionally misstated CU report content to defraud consumers to enroll in the Kaiser Permanente Medicare HMO. She was confident that CU would not enforce its policy to prevent this. She was right! CU "enabled" Kaiser Permanente to defraud Medicare enrollees. However, this time HMO HARDBALL investigators were on the job to stop patient rights violators. They had read Consumer Reports’ HMO survey (August, 1999 issue). They told the group:
The sales rep’s reply: "I don’t remember word for word." HMO HARDBALL investigators added that the Consumer Reports Rating to which the sales rep referred did not even apply to Medicare HMOs at all. Her reply: She did not reply! |
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HMO HARDBALL’S Advice to Consumers Union HMO HARDBALL is in agreement with the Medicare Rights Center’s statement that:
It is HMO HARDBALL’s mission to identify and enforce patient rights, but HARDBALL suggests that CU enforce its own no-commercialization policy by taking these steps:
HARDBALL'S Bottom Line CU, take responsibility. Don’t depend upon readers to enforce your policies. You know or should know that your no-commercialization policy is violated with impunity at will. CU staff should be out in the trenches to insure that HMOs don’t misuse CU reports to victimize consumers, in this case patients. My HMO Songbook sums it up: "HMOs do slick talking,
when they go out stalking." BACK to Patient Rights Violators List |
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Foundation
Health (Medicare Subsidiary) |
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Medicare Enrollment Fraud |
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The HMO Senior Scam Authenticated report by HARDBALL investigators who attended a Medicare HMO recruitment meeting at CoCo’s restaurant. The HMO Sales Representative treated the old folks to food and drink to soften them up for the "sales pitch." The HMO’s Enrollment packet was distributed. It contained the HMO’s Enrollment Application. One sentence hidden in the middle of this mind-numbing legal document states…"I understand that services contained in my Evidence of Coverage document (also known as member contract or subscriber agreement) will be covered." HARDBALL investigators asked the HMO representative why the Evidence of Coverage document (a.k.a. member contract or subscriber agreement) was not in the Enrollment Packet. The answer: Seniors receive the Evidence of Coverage document after they sign the Enrollment Application and are accepted as HMO members. Later that day, HARDBALL investigators reviewed all the documents in the HMO’s enrollment packet. In one 17 page document, they found the statement: "Once you become a Member, you will receive an Evidence of Coverage. Be sure to read your Evidence of Coverage carefully for clarification of benefits, as it contains the full terms and conditions your coverage." What’s Wrong with this Picture?
HARDBALL’S
BOTTOM LINE
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| "Health
plans suck seniors in This is how they begin. HMOs do slick talking, When they go out stalking." |
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Lyrics, The
HMO Rap |
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POLITICIANS, PLEASE PROTECT US! Represents Foundation Health Systems (CA zip 95670-7955)
BACK to Patient Rights Violators List |
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Kaiser Permanente - San Diego |
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Defective Vacuum Tubes |
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Authenticated report to HMO HARDBALL reveals that defective vacuum tubes, which attach to needles, are in use at Kaiser Permanente's labs. Injuries have occurred to both staff and patients, when needles slipped or separated from vacuum tubes while drawing blood samples. The labs' Director acknowledged the defect but refused to recall the defective tubes. On 9/29/99, Senator Harry Reid (D-NV) reported on the Senate floor that 800,000 needle stick injuries occur each year. This figure doesn't include unreported needle sticks. Twenty diseases, including AIDS, hepatitis B & hepatitis C may infect injured health care workers. Accidental needle sticks can be prevented by using "safe syringes," which cost less than a postage stamp. Kaiser Permanente should cut back on stamps and protect its health care workers. |
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HARDBALL’S BOTTOM LINE |
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| "Don't trust no HMO
jive Or you won't stay alive. You must watch your back For HMO attack." |
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Lyrics, The
HMO Rap |
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POLITICIANS, PLEASE PROTECT US! Represents Kaiser Permanente Zip Code (92120-2507) (92120-2507)
BACK to Patient Rights Violators List |
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PacificCare |
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Preview of Coming Attraction HMO HARDBALL investigators unmask paid HMO patient "cheerleader" "champion" who lures seniors to enroll, without disclosure of his conflict-of-interest. |
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BACK to Patient Rights Violators List |
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School
of Medicine University of CA--San Diego (UCSD) |
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Patient
Privacy (Social Security Number--SSN) |
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UCSD Radiology Department clerks inform all patients that tests cannot be scheduled, if they refuse to provide their social security numbers, stating that this is mandatory university policy for patient registration. In fact, UCSD policy permits scheduling of radiology tests without entering patient social security numbers. Patients are not informed that university policy provides for registering patients who refuse to provide their SSN. The patient informed the Dean of Clinical Affairs in writing of this patient rights privacy violation in 1996, but clerks continue to insist that patients provide their SSNs as mandatory information for registration. |
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HARDBALL’S BOTTOM LINE |
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| "HMO
privacy Does not apply To patients like you and me." |
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Lyrics, Make
It One for The Patient |
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POLITICIANS, PLEASE PROTECT US! Represents UCSD Medical School Zip Code (92037) (92037)
BACK to Patient Rights Violators List |
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