Recently and Arizona Central article http://www.azcentral.com * noted: “Cliff Faraci sustained first-, second- and third-degree burns after trying to save a teen girl after a car accident in March 2013. He stayed in a hospital burn unit for a week to get treatment for his injuries. Days later, Aetna told him it wouldn’t cover the stay.”
“Cliff Faraci suffered first-, second- and third-degree burns trying to rescue girl from a deadly accident last year. His insurance company denied his claims and hit him with a $165,000 bill, saying his injuries were not severe enough to require acute-care treatment for a week.”
“After a week of intense treatment, Faraci was discharged from the hospital. But he hadn't been home two full days when he received a letter from his insurance company informing him that he wasn't covered for the hospital stay.”
“Aetna claimed Faraci's injuries were not sufficient to warrant a weeklong stay in the hospital's burn unit, which was deemed an out-of-network facility. Maricopa County Medical Center had billed him about $165,000. He filed an appeal with Aetna. It was denied in August.”
“Almost overnight, the freeway Good Samaritan had become a victim of a health-care nightmare. His case is an example of what can happen when an insurance company decides to question the administration of care provided by doctors and other medical experts directly involved in the patient's Faraci said he tried to talk with Aetna and got nowhere. He said he provided doctors' letters and statements, to no avail. In an August denial letter, Aetna officials told him his coverage extends only to services and supplies Aetna deems medically necessary.
"The member had no signs of respiratory burn and was otherwise stable," the insurer wrote. "Ongoing wound care, including medications, does not require acute hospitalizations. Further treatment of this member could be provided at a less intensive level of care, or in another setting, e.g. non-acute facility, other outpatient setting or home."
“Faraci kept fighting the claim denial. …"It was not my choice to stay in the burn center for seven days," he said. "This was a decision made by medical professionals who treated me on a daily basis. To have the doctors' judgment questioned and overruled by an insurance company who did not treat me or see the extent of my injuries is unthinkable."
An…” independent examiner determined that Aetna should pay for half of Faraci's hospitalization, leaving him with a remaining bill of $82,500.” In February… Maricopa Medical Center waived bills for any of Faraci's hospitalization not covered by Aetna.
* to read the full Arizona Central article, “Health care nightmares Day 5: Injured Good Samaritan billed $165,000 by Aetna” by Robert Anglen, highlight and click open hyperlink http://www.azcentral.com/story/money/business/consumer/call%2012%20for%20action/2014/04/24/injured-good-samaritan-billed-aetna/8129925/?utm_campaign=KHN%3A+Daily+Health+Policy+Report&utm_source=hs_email&utm_medium=email&utm_content=12602330&_hsenc=p2ANqtz-9hR7lbVO9m_FjqB-YQyARewFjiGRwhbm_n-NwL2aBd46doSGKWoxFjfKQutYXaykZBR_rUb3DMc9w4MxG5YKDS5KPKA2MmCtd7BRTBfnesJz7zrkQ&_hsmi=12602330
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Jonathan M. Metsch, Dr.P.H., is Clinical Professor, Preventive Medicine, Icahn School of Medicine at Mount Sinai; and Adjunct Professor, Baruch College ( C.U.N.Y.), Rutgers School of Public Health, and Rutgers School of Public Affairs and Administration.
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