Aetna Senior Healthcare or how to avoid getting medical treatment without really trying!

by Ilona Gartner Cecil

research
cause and effect

"Hello, welcome to Aetna Healthcare customer service; if you are a provider, press one. If you are a member, press two." I pressed two; although I was not the member, I was assisting my ill father. (There wasn't an option for that category.) "If you belong to Aetna IPA services, press one. If you are an Aetna Golden Senior, press two." I pressed two, since my father was a Golden Senior. It went on like that for over twenty minutes; I maneuvered my way through several automated menus. I finally reached a menu that allowed me the option of holding for a customer service representative. During the hold time, I was honored to know "...your call is important to us, please continue to hold. Calls will be answered in the order received..." As I sat there for ten minutes and listened to the "canned" greeting and "elevator music", I felt that my call wasn't really important to them. In fact, my call was an annoyance. Otherwise, Aetna would have more personnel to answer the important calls!

Then, without warning,...a live person! I expected my father to be assisted with what appeared to be a relatively simple request; he needed to transfer his current medical coverage from Aetna Northern California to Aetna Southern California. He still wanted to be an Aetna Golden Senior, only in a different location in CALIFORNIA. "Simple" or "uncomplicated" do not accurately describe my experience with Atena, a corporate bureaucracy. My dealings with Aetna to secure my father's medical coverage have been laborious due to the way Aetna's internal departments are organized.

Background information would be helpful at this point, to fully understand the situation. My father, Mort, had been splitting his residences between northern and southern California. He lived in Palm Springs during the fall and winter, then moved north during the unbearable desert heat months, May through September. However, the last two years, Mort has spent most of the year in Palm Springs. Perhaps age makes hot weather more desirable. (I found the September heat stifling.)

My father required open-heart surgery in 1996 and changed his medical insurance to Aetna in Northern California. Having his primary insurance in Northern California allowed him to choose a world renowned heart surgeon in Concord. The operation was a success and Mort has continued to have physicals, heart check-ups, blood tests, and other medical exams performed in Northern California.

Last month, my father was in Palm Springs, and he became critically ill. The paramedics took him to the Desert Regional Medical Center in a near-death state. He was slipping into a diabetic coma. During his eight-day stay at the hospital, he recognized the need to continue treatment; his life depended on it. Mort had become an insulin-dependent diabetic, recovering from total kidney and bladder failure, as well as, an [as well as from an] enlarged prostate. Additionally, he had developed a rapport with the treating physician.

To facilitate the transition of medical care to the Palm Springs physician, I called the local Aetna representative. She was a service-oriented woman. She came to my dad's hospital room, completed all the required documents to establish coverage effective October 1st and was confident and reassuring that "we were all set." He was released from the hospital on October 1st; I felt it was perfect timing.

The afternoon of Friday, October 1st, I called to schedule a Monday appointment at the local physician's office. Mort still had immediate medical needs. He left the hospital with a non-functioning bladder and an enlarged prostate. Imagine my shock, when after being placed on hold, the "billing manager" came on the line and said, "I'm sorry, your father isn't part of the Aetna Southern California Desert Oasis Medical Group IPA, and therefore we can't schedule an appointment."

I placed several calls to Aetna. First, I tried the General Number. Next, I called the Patient Management number. Finally, I called the "pre-certification" number. Each call required patience and fortitude as I worked my way through automated menus and waited an average of fifteen minutes to be connected to a representative. Without exception, each time I reached a person, I was referred to another department. The process became circular; I was recalling departments I had previously spoken to. Occasionally, I would speak to a representative who placed a degree of importance on my father's dilemma. This was not a commonplace occurrence. More often, I would speak to an employee who seemed bothered by the fact he/she had to work.

According to Charlene of Aetna customer service (Salt Lake City), my dad is transferred from the NorCal Aetna to the SoCal Aetna in theory, but not in finality. He's in "pending." He has been assigned a new SoCal member number and an October 1st effective date. But here's the "hang-up"; [:]Aetna Southern California has to treat my dad as a new member. A new member application must be processed by another bureaucracy, Social Security Administration.

Apparently, Aetna, although one corporate structure, operates two separate HMOs, one in Northern California and one in Southern California. These companies within a company, function completely detached from each other, without any procedures established for "inter-company" transfers. Even though Mort already has coverage with Aetna "North," as a Golden Senior, Aetna "South" can't "see" that coverage. The result is that my father is treated as a brand new member, necessitating Social Security approve the membership according to Aetna's procedures.

I have become quite experienced with Aetna's internal computer system over the last few weeks. I can tell a representative how to access the patient's referral information screen, the pending notes section and even supply tracking information. More than once a phone representative told me, "I don't see any record of your calls." Charlene was a "kind, helpful" employee and she provided me training on how to "see" Mort in pending status.

Charlene's instructions proved quite helpful. When I encountered an employee, who was "claiming," there was no record of Mort's "transfer", I'd "train" the employee on Aetna's system. I'd say, "To access, the pending notes, go to the referral screen and click on the notes icon. If you want more details, once inside the notes screen, hit the F4 key." Usually, the employee was surprised, when the information I'd been telling them for twenty minutes appeared on their computer screen.

Mort's PCP (Primary Care Physician) in Palm Springs, who technically is not his PCP yet, granted him an office visit, anyway. He told Mort he must be seen by a urologist to determine the extent of bladder damage and begin appropriate treatment. Because Aetna South still hasn't recognized him, the "PCP" who referred him to the urologist can't execute that referral.

Having been around HMOs long enough, I do understand how the system works. My father must have a primary care physician prepare a referral form for the required specialists. Both specialists must be part of the same Group or IPA (Individual Practitioner Association). The administrative firm for the IPA must approve the referral form. The system was designed to "manage care"; but, there are no provisions for exceptions.

Charlene of Aetna customer service assured me and the urologist's office (via conference call) that Mort could be approved for treatment by a physician in Southern California. All we had to do was call her back the next day when her supervisor was in. The urologist's office manager and I spent the better part of the following day trying to reach Charlene in Salt Lake.

Aetna's system has, yet another, stumbling block. All incoming calls are first routed to the Fresno call center, with the overflow calls being switched to the Salt Lake City center. Try as we might, we never were able to reach Salt Lake, where Charlene was located.

Interestingly, the phone system is not set-up to transfer calls to Salt Lake from Fresno. We spoke to eight reps and no one could connect us to Charlene in Salt Lake, nor was anyone willing to help approve a visit. I was flabbergasted. But I also was more determined to "beat" the system designed to prevent medical treatment.

Despite the overwhelming task I faced, getting an approval for a referral to an outside of the area IPA, I picked up the phone and dialed Aetna Customer Service again. Sometimes, luck is with you, and it was with me that day. Juliet answered. (I had only been on hold for a minimal amount of time, less than five minutes.) I spoke calmly, but with a firmness that demonstrated my weeks of Aetna experience; "Hi, Juliet, my name is Lonnie and I am the daughter of a member with a serious problem. I have tried to work within the framework of the rules and procedures for over two weeks, it is now time to get results. I will not hang up today until my father has an approval for a needed medical appointment."

After I supplied her with my dad's old member number from NorCal, the new member number from SoCal and delineated the entire history of Mort's illnesses and attempted transfer, she responded to me with conviction. "I will stay on the line with you until Mort has a confirmed appointment with a urologist in SoCal." First, she willingly conferred with her supervisor. During my "tenure" as an Aetna quasi member, I discovered supervisors are not to be bothered, and certainly they don't speak to "members". They will call you back after they research the problem. I'm still waiting for a return call from Trish in Fresno.

After conferring with her supervisor, we conferenced in the doctor's office in SoCal to supply Juliet with first hand knowledge of the procedure the urologist needed to perform on Mort. Next, Juliet, conferenced in an Aetna pre-certification unit. A woman named Peggy answered; we, Juliet and I, explained the details to a non-interested Peggy. Her only comment was that my dad's supposed new number wasn't valid because Aetna never issues only letter Id's. The Ids are always alphanumerical.

I trained Peggy on the new system at Aetna. I explained that beginning October 1st, all new Ids would be Alpha only and the reason was, more Alpha combinations are available for Ids. Peggy abruptly put us on hold and was hostile upon her return. She told us she cannot approve anything for Mort because his IPA is in NorCal and she has no jurisdiction. She told us to call the IPA administrative firm in NorCal to obtain a "STAT Referral."

It took us twenty minutes to get into the IPA administrative firm. No one at the firm had ever heard the term "STAT Referral." We were transferred to a supervisor who told us the only option for out of area approval is the "pre-certification unit at Aetna." We had to call back the same pre-certification unit where Peggy worked and had failed to provide us assistance. When the Aetna pre-certification unit answered, Juliet insisted we speak to a supervisor.

Once again, from beginning to end, we had to explain the situation. We were placed on hold and then a miracle occurred. We received approval for an urologist's visit. We quickly conferenced in both my father and the doctor's office to ensure nothing could go wrong. When we had finished, Juliet and I had spent two hours and ten minutes on the phone. But we had been successful in securing my dad a much-needed doctor's appointment.

I have witnessed first hand the effect of medical bureaucracy on Senior HMO's. From the perspective of the patient, the system is designed to delay and frustrate those needing medical care. Aetna has some very serious issues, the most critical being a lack of internal training and communication. Beginning with the first phone calls, service to the senior community never appeared to be a priority. If I, the younger daughter, had not assisted my frustrated father, he still would not have any appointments. As he was told by an Aetna nurse (who remained nameless), he could receive treatment "out of area" if he went into the Emergency Room and "forced an emergency". To have an Aetna rep give guidance such as that demonstrates the inefficient system and resultant apathy in its customer service.

I wish this tale had a happy ending, but as of today my father is still not a Southern California Golden Senior; and, he needs prostate surgery. We will prevail. Juliet of Aetna customer service, whom I respect and appreciate, advises me to contact Social Security to "push them to respond to Aetna". Once Social Security responds, my father can move from theoretically being covered to really having coverage. I started the process today by placing a call to Social Security, "...Press one if you are inquiring about your monthly benefit check; press two if you have questions about Medicare..."

Aetna Customer Service (Fresno, CA or Salt Lake City, UT)
Aetna Pre-Certification Unit (San Ramon, CA)
Hills Physician Medical Group, Danville, CA
Doris, billing manager for Dr. Peter Wolfson, Urologist
Tracy, billing manager for Dr. Peter Rowe

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