Broken

We hear how the health system needs to be reformed and all this other wonderful stuff being promised to us now by politicians lately. Well, it does, and really is it going to be changed? Not likely I feel.

I pretty recently went from partially disabled to fully, and I had to fight, and dig deep to endure this far. The good news, I have. The bad news, after making it this far... Sadly my home may be soon foreclosed on... Not in the process yet, but being over 2 months behind is a sure way to get things started.

I mean you would think having a medical condition that you have sought every possible non surgical treatment for and nothing resulting in long lasting resolution, and with the last medical treatment leaving me fully disabled would be enough to just about make anyone's life.

No, add to this the Medical Insurance System... In my case Aetna, and my durable medical equipment needs, AKA a wheelchair. Ah, now do not let that single word confuse you, as it can cover a wide range of wheelchairs. In my case the realm of manual ones, and in particular one TiLite ZRA with Spinergy Spox Wheels, and customized configuration.

While I did start this all out to be about me, and my needs... I soon discovered was not my problem alone, and what was worse about this is how much extra money Aetna, or any other medical insurance company doing things using the model as used by Aetna... I am not talking just some chump change either. I am talking the very high several million, and much more per year just wasted using a system that is so broken I a simple layperson was able to go over point by point what was broken, also fully support my medical need, and have the denial overturned all in the span of four days. This was after months of trying it the expected way, using the current model and methods in place... Which by around the end of a year from the start I might be just getting approved. Where on 4-25-08 I do the unexpected and contacted Aetna. And, 4-30-08 I was approved, my efforts cost me nearly nothing. Even if I where to say pull down $100 an hour I think I put in a total of 4 maybe five hours into my efforts at that point.

I was able to site, and actually prove many important issues, that got Aetna's 100% full and complete attention. Not once did I ever need to threaten anyone, or yell, in fact I kept a sense of humor about it all the time. And, what took Aetna by surprise was my entire effort of appealing, and doing what I did... Was not to find fault with them, as I inadvertently did end up doing. My intent was to save them as much money short, and long term for my DME needs. In fact the young lady I was speaking with, who represented the top most level Medical Director at Aetna, she asked me it two more times. Look I know it is very rare to have a customer/member who follows the health policy as it pertains to them. But, to also understand the policy they wrote better than they do, as well as know my full rights, and how the entire medical system is supposed to work to help people, how medical insurance companies can not do what it was I discovered, and then proved was the fact... Is rare for a layperson to be able to do this, what makes me even more rare still is I also could read and fully grasp, and understand medical information as it related to my medical conditions as good or better than any Dr., I also found that I understood the ERISA law policy and actually laughed at how insane it is written. Not to mention the Section 502(a) part of it... That was priceless as it could only help me after ALL internal appeal processes where used, and if I could prove that Aetna picked on poor little me, and willfully made my life a living hell... Even if I could prove Aetna was questionable about many other important factors...

The reality was, is, I am using a loaner TiLite ZRA, and before my approval it was being gently asked for back. I was able to talk the local Durable Medical reseller into allowing me to use it until the company TiLite requested it back. As, otherwise I would be left to risk falling, and even living in my own excrement. Not a very healthy option for me, and risking a broken bone, or neck was out of the question.

I am at a crossroads here, and need as much input as I can get for the next step.

My wife and I being married 15 years 5-22-08 together 17, no kids... Live in the cold, and then hot humid up state NY area. I can not take much more living here due to the chronic pain the cold causes me, and oddly the humidity does not help either, do darn damp for my condition now. The reality is we need to move, and I have a few ideas to try to help get this done...

One, I can attempt to become published and write a tell all book, that explains in layperson speak what I know, and just how to work within today's, and in fact any health care system... No matter the changes made to it. I would hope this would become a good seller, and help many, many people, and allow us to move. I would not do it for the money solely, as no amount of money can make me not disabled at this time. I wish it was that easy. The money would be to move us out west, to the coast area around San Diego, or the hotter still Las Vegas, NV area. Where we would rent an apartment for a year or two before we might buy a condo, or town house, or if we fall in love again with another house... Except, I used to be able to do much more outdoors, and due to constant pain... I need to really be careful now...

The other option is to try and see if it might be worth it to contact Aetna, and explain I would like to provide the blueprints to doing this much more efficiently, and how to best avoid the potentially very costly issues we discussed when I appealed for my wheelchair system. I feel that my idea(s) could actually make them more profit, as well as lower costs, and improve access to more medical options to Aetna's customer base, while expanding it even more than it is now...

At first the idea of making any changes will seem to be against making profit short and long term, but I also feel that if things get re-routed from doing in-efficient things they do now, to doing efficient ones instead... The profit will be realized in a shorter time, and more of it than ever imagined possible using the current model of doing things...

I do know the chance of me being able to to this, is something like a ga-jillian to minus a ga-jillian... But, based on the odds of me locating the issues I did, and being able to go point by point over them with the top most level Medical Director with out using all of the internal methods to appeal Aetna... I would say, that maybe, just maybe my plan and my ideas just might prove just as accurate as my own appeal letter was about my medical needs... 99.9% correct, and the error I made was based on not knowing the difference between comfort, and efficency in the rear drive wheels the Spinergy Spox... I was not in pain, so to me this was the same as being easier to self propel and thus, means more efficient than other wheel options. Oops.

I was 100% right about all of the other issues I was able to point out. So, while not a multi-billion dollar deal maker that was... It does show just how well I do things, to insure a WIN/WIN for all sides involved.

My goal was to have Aetna cover just what was most effective at providing me the needed comfort to remain as independent as possible. I made this goal clearer than any picture to everyone involved. I will also do that with how Aetna, could in fact go from a clunky method of doing things, to a profit making, customer/member pleasing super top rated private business offering the countries Gold Standard in everything they do... If they think they have done it to this date... Well... Let's just say that all I can promise is that the ideas I have would best Aetna's most profitable time span, and double it. I would even say quadruple it or more.

And, of Aetna has to ask for any proof... Consider, that in four days I was able to provide you with everything needed for me to prove my points, and get final approval.

When it comes to making money or rather when I used to be in sales... I liked to only state "No one on the planet can outsell me." Then I would just go to it. I do not place any weight, or value in past track records, as it has been proven way to many times that someone might have done something once, or twice... But, how often do these same people take a great company image, or the company an nose dive it into the ground?

The problem with me, is I am the average looking, sounding layperson and much is taken for granted...

Life is not fair, and so here I am fully disabled, yet my mind works... Just this pain... That current medical science can not do a darn thing about... Sigh...

And, if I where able to actually work the deal so that Aetna did use my model and method, I would not ask for anything other than have them cover the cost of my living conditions, and if or when we buy a condo or town home I hope they buy it in my wife's name... We can cover taxes, and it would be of modest means, as we could not afford any more than such...

And, yes, Aetna I can in fact produce the clinical documentation proving that people in my condition where currently known medical methods fail to bring some resolution to the pain... Living in what many would consider paradise where the climate stays the same, and it is warmer year around... Has somehow helped people live fuller lives... In less overall pain. Not completely gone, but better than what current medical science can provide...

In the end if Aetna allowed this to happen, it could benefit many more people. As the word spreads that Aetna IS THE BEST possible medical insurance to have... More companies hire them to cover more people, and rates can be reduced, as efficency goes up... And, all this means people happy with the current system as it is, and no need to change the profit off of health system we live in now... As, everyone would be in a WIN/WIN situation...

My model can be scaled to fit any sized company, and function better than current the system in place... Leaving room for far, far fewer issues, as Aetna is now aware of.

In the end, I need to move. I also want to help as many people as possible on both sides of the equation, as no matter what medical insurance as we know it today is not going to be changed overnight... And, it leaves much to be abused on both sides. Nothing will ever fully prevent that, but my idea does at least provide the best means to catch it, and the most profitable way to run it. Why allowing people who have medical needs the access they deserve to all medical options available today, and in the future. My plan would naturally grow, and change with little or no need to re-write it... How is that for efficient design?

The last option is just post my plan here for everyone to see... I mean with a team of actual people who can write, not legalize but layperson speak, so the system is designed with the customer/member in mind who needs to understand it in the end... Providers can only go so far into what it means to be who you are, and how your life is fully affected by the medical condition you have. And, even the most well meaning providers can miss, or leave out key details that could leave you fighting for your independence in a broken health care system.

Wheelman
Based on the actual problems, and life experience of my life...
The Proactive Patient & Advocate

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