I have been meaning to share with my blog readers the issues that I have been having with Aetna, but it is taking up so much of my time dealing with Aetna, between the phone calls and documenting the calls, etc. that I haven't had a chance to blog. But that proverbial straw that breaks the camel's back happened today and I am going to share my plight on my public blog no matter how much sleep it means I lose.
I have 3 ongoing issues with Aetna. It is impossible to get them to follow through on anything they say over the phone. They will do anything to not have to pay what they are obligated to pay. It's just ridiculous and criminal. At this point, I not only wish that they fix my problems, but they should compensate me for the HOURS upon HOURS of time I have spent (read wasted) on the phone trying to get my issues fixed and documenting everything since they can't keep track of anything they say, I have to do it for them. It's beyond ridiculous and that is why I say that Aetna Health Insurance Beyond Sucks.
We have a $1500 out of pocket maximum for each calendar year per person. Last year we signed up with Aetna on July 1st. By the end of October, I had already met the $1500 out of pocket for Chianna because of her therapy co-pays and a few doctor visits. So I stopped paying the weekly therapy co-pays and any other dr. visits when I knew I had reached over $1500 in October. In November, I realized that there was a problem when we went to the neurologist and they were trying to make me pay the $50 co-pay, which I did not pay since I knew I had reached the out of pocket maximum and started to call Aetna to straighten out the issue. To this day, the issue is not straightened out and I have spent so long trying to fight it, I guess they just hope that I give up fighting if they drag me around enough, that I will just give up and pay it myself or something.
Issue #1: I have met the $1500 out of pocket maximum for the year for Chianna, but they only seem to think I have paid a little over $400. I am at a loss as to how there is this huge discrepancy. They seem to "conveniently" not list some, if not most, of the doctor visits that I took Chianna to, even though the doctors have been paid and have the claim #s and reference #s from Aetna and the doctor's and therapists have all been long paid by Aetna too. I thought the issue would be easily cleared up the first time I called them in December. I spoke to an Aetna representative on the phone who said "oh I see that you have met the out of pocket maximum, I will send the claims back to the claims dept to be reviewed". Easy enough, right? That's what I assumed, and it was even easier than i thought, because I had spent 2 or 3 weeks calling all the doctors and collecting detailed billing summaries from them; Aetna didn't even ask for them. I don't even know how many phone calls I have made since then, because evidently no one else at Aetna other than the 1st person I spoke with sees that I met the maximum. One of the reasons they think that I did not meet the maximum is issue #2:
Issue #2: There is a claim from Chianna's therapy place for speech therapy that was dated wrong. Instead of dated August 31, 2009, it is incorrectly dated July 31, 2009. The reason that this affects the out of pocket maximum has to do with my Issue #3, (which I will get into detail later). Aetna only covers 60 consecutive days of therapy per diagnosis per LIFETIME! Yes, it is beyond ridiculous for a child with Cerebral Palsy, but I will get into that later. The issue for our purposes here of Issue #2, is that when they incorrectly dated this claim 7/31/09 rather than 8/31/09, it started our 60 consecutive day clock ticking 20 days before our fist visit for speech, which was on August 20, 2009. It seems like it should be relatively easy to clear up, right? WRONG! You would think it would be east to fix for several reasons: 1. the Speech Evaluation is billed and written separately than regular visit claims like the one we went to on August 31st. 2. they should not even be covering a regular visit on 7/31/09 BEFORE the evaluation was done since they require an evaluation to be done before they would accept a claim for a regular visit, and 3. two weeks of claims date August 2009 came in before one dated 7/31/09. So I call Aetna to find out how to fix this problem. The 1st time I called, they said just have the therapy place send in a "corrected claim". I said ok, and called the therapy place to let them know. The next day, they mailed a corrected claim to Aetna. A couple days later, my claims advocate from ADP (I acquired a health advocate company to help me with all these problems) called Aetna to follow up on these two claims Issues that she is helping me solve and the representative at Aetna tells her, "oh no, they cannot just send in a corrected claim, it is much more involved than that, they need to write a letter as well explaining the problem. WHY IS IT THAT EACH TIME I CALL AETNA, A DIFFERENT REPRESENTATIVE TELLS ME A DIFFERENT STORY? THIS HAPPENS ALL, AND I MEAN ALL, THE TIME! So, I call the therapy place back and talk to her and tell her that Aetna is now saying that they need to write a letter. The person who handles the insurance at the therapy place says, "ok, I will call Aetna and find out what I need to do". So she calls Aetna on their special provider phone # line and this representative tells her, "oh, no problem, you can just send a corrected claim directly to my fax (gave special fax #) and I will take care of it right away". This was on Thursday, January 21, 2010. Sounds like that would be taken care of right away, then right? OF COURSE NOT, WRONG! The following Tuesday, January 26, 2010, my advocate calls Aetna to follow up on this situation. And they tell her "it's not in the system yet". WTH?? Not in the system yet? It's been more than 2 full business days since the representative had them fax it to her desk to take care of "right away". Finally a few days later, the corrected claim shows up in Aetna's system and Aetna tells my advocate it will be about 7 - 10 days for processing. OMG can you explode? Do you see why I am frustrated? (Keep in mind that this issue is also holding up the out of pocket maximum issue and I am getting late notices from 3 other doctors that I took her to and did not pay the co-pay.)
So now fast forward to today, I receive an email from my advocate that Aetna DENIED the claim for the corrected date adjustment that was sent in! WHAT? CAN YOU HEAR ME SCREAMING? ARE YOU SCREAMING YET TOO? IS ANYONE AT AETNA LISTENING? DOES ANYONE AT AETNA HAVE A BRAIN, NO SCRATCH THAT, THEY OBVIOUSLY HAVE BRAINS TO SKIRT PAYING FOR CLAIMS, A HEART IS THE ORGAN THEY LACK. Besides sending in a complaint to the state board, I will also be seeking legal council, and contacting my senators and congresswoman, and President Obama at the White House too. Can't someone at Aetna fix a freakin date? OMG!!!!
So back to my problem / Issue #1, even after considering all this, and having them review the out of pocket maximum payments for a second time in January, they come back saying that I only spent $400+. When in actuality, I have spent, and have detailed receipts for $1596.99. Yes, that's right, somewhere along the way, I actually have a $96.99 credit! And if you don't include the speech therapy for the time that is affected by this date problem, that accounts for $129.09 in co-pays. Yes, that puts me over the top, but I have no idea, where they get off saying I only paid $400. Now, I have to wait until Issue #2 the date problem gets resolved so that I can send in all of my receipts and show them that I have indeed met the out of pocket maximum for the year.
If anyone reading this can help me in anyway, I would so appreciate it. I have tried talking to supervisors, I have tried talking to the same representative (they are usually not available at the time I call), I have tried having them call me back, (they do not), I have tried, crying, I have tried screaming, I have tried to be nice, I have tried to be mean. I have even suggested that they fix this before I have a nervous breakdown and then they will have more claims to cover. Nothing has worked. Getting an advocate hasn't worked, sure it has helped me share the burden, but I really assumed that Aetna would listen to and work with a health advocate company, that didn't work either. It actually frustrates me further in some ways because I hear from the advocates that this type of thing happens all the time. Can you say broken health care system? Can you say broken health care company? it is laughable that Aetna even has " health" or "care" in their company name. I have applied for other insurance and did not qualify, I am working on getting her social security card so that I can see if Medicaid covers some of what is not covered. But all of that is secondary to the fact that Aetna owes me this coverage and I will see it through til the day I die that they pay what the policy says is owed to me.
Now onto issue #3. This issue is a big one, as I mentioned before, Aetna initially covers only 60 consecutive days of therapy per diagnosis per lifetime. When this initial 60 days was coming close to an end in October 2009, I called Aetna to find out what I could do to get more therapy coverage for my daughter since she definitely needs much more than 60 days of therapy in her lifetime for Cerebral Palsy. At that time, the Aetna representative told me that if her pediatrician wrote a letter stating that more therapy was "medically necessary" then Aetna would cover more therapy. Sounds easy enough, right? Well as you can tell from the other two problems I have with Aetna, its not that easy; not easy at all. I am currently on my 2nd appeal, because even though her pediatrician wrote the letter stating that the therapies are medically necessary for Chianna, they denied the claim stating that they only cover 60 consecutive days. I have spent so much time back and forth, with Aetna on this issue, it has been going on for months. Aetna tells me to have the dr. write a letter, the dr. writes a letter, they deny it. I called Aetna and asked why was this letter denied if you just told me that this is what I needed? The Aetna representative told me that they didn't realize that letter was asking for more therapy. What? (I know!It's silly at this point, right? But this type of dialog is what I deal with constantly from Aetna!) So I have the doctor write another letter stating that she knows that the first 60 days are exhausted but its medically necessary for Chianna to have more therapy for at least a year. That is word, for word, what the Aetna representative told me the letter should say. They denied that claim too, stating they only cover 60 days. So now, I pull up the Explanation of Benefits and see that it is written that they do cover more therapy in some cases of medical necessity , and not for others. It is written in such a manner that it often contradicts itself. Most likely, so that Aetna can get out of covering anything. I am truly hoping that they do own up to what they said and cover the therapies because Chianna sure does need them. In addition, I think they owe me after putting me through all of this lies, and red tape. So, below is some background on Chianna and her therapies, and I will keep my blog readers updated on what Aetna does and doesn't do. From now on, actually, I am going to keep a very detailed public log of all this back and forth BS Aetna is putting us through, And now some background info:
My daughter has a right sided weakness (medical term is Hemiparesis) of the right arm and right leg due to cerebral palsy. In case you are reading this and not familiar with me or my blog, Chianna is 4 years old and my husband and I adopted her from Vietnam in April 2009. She is the joy of our world and is an amazing, resilient, determined, smart, and independent, beautiful little girl. She is currently getting speech, occupational therapies and physical therapies, as part of her physical therapy, she was also getting aquatic physical therapy in an indoor heated pool. For the insurance purposes, I should note that I was taking her to occupational therapy to a therapist that came recommended but did not take Aetna insurance, so the occupational therapy is not included in the issues #1 and #2, but now I am taking her to an Aetna network occupational therapist, so I am also asking them to continue coverage for occupational therapy past the initial 60 days. These therapies are helping her tremendously! She gets speech therapy, not only for dialect and learning English, but to help her learn to use the muscles and parts of her mouth that have been affected by the cerebral palsy and/or from just not using them. She did not know or speak any English in April 2009, and currently understands English at the same level other children her age understand, she does speak a lot of English, but is behind other 4 year olds in this aspect. She has problems with pronunciation and cannot say certain sounds. She gets physical therapy to strengthen her muscles, help her gain balance, and coax her to use her dormant right hand to help her in activities. Physical therapy also helps her motor planning, and coaches her to use her stronger left arm and hand and practice fine motor skills. When we adopted her in April, she came from an orphanage in Vietnam that housed about 300 children and has about 20 nannies on staff. She did not know how to feed herself and could not hold a fork or spoon even in her stronger, left hand, she was in diapers and took a bottle with formula. She has come an long, long way in a very short while, but these therapies are an integral part of her progress, growth, and strength. Part of the Explanation of Benefits from Aetna says that for chronic disease, the short term therapy is provided for and recommended to be continued in the home. We practice with her as best we can what all the things she does in therapy. However, we do not have the space or tools to make the obstacle course that she does at the gym in physical therapy, we do not have a tricycle for her to ride with a chair on wheels to pull her and help her along (or the space to do that either), we do not have a treadmill for her to practice walking on like she does in physical therapy, we do not have the climbing ladder she uses in physical therapy, nor a gym with cushioned pads in case she falls, there are tons of other equipment and educational toys that we do not have, and most importantly, we do not have the knowledge and expertise of a therapist to correct her when she is doing something wrong and make therapeutic adjustments to push her when she has mastered a skill, or change up the therapy if the therapist realizes that it is not for Chianna just yet. Chianna was also getting aquatic physical therapy in a heated, indoor pool once a week. Chianna loves the water and responded so well to this type of therapy, she could move her right arm in the water so much better than out of the water due to the buoyancy. She was getting strong from using all her muscles and had learned how to swim in just a few short months of aquatic therapy. This is important, on a therapeutic level because swimming uses and strengthens all the muscles, these muscles that Chianna has never learned to use correctly, are used and strengthened and developed while swimming in aquatic therapy. This therapy is so important for her to continue in her strength development, it also helps with some issues that are covered in occupational therapy as well. It helps focus on balance, motor planning, and physical multitasking. However, my husband and I are not able to continue this type of therapy at home, not only do we not have a heated indoor pool to use, we do not have the correct types (and many different styles) of flotation devices, nor do we have a licensed life guard standing by, and of course, neither of us have gone through the years of training and many years of experience that her therapist has. Speech therapy is probably the easiest for us us to practice at home, however, the speech therapist has far more knowledge and skills needed to get Chianna to the speech level that she needs to be at to communicate on the level required for school and just plain communication. A trained speech therapist is necessary to coach Chianna through saying things properly and can recognize when she is not saying things correctly and diagnose why. The speech therapist can recognize whether Chianna is not putting her tongue in the right spot, she can tell if Chianna thinks she is saying something correctly and explain to her why that is not correct. There are many nuances and aspects of speech therapy that I certainly did not know about prior to witnessing the therapy 1st hand, and I can attest to the need for a trained speech therapist, the therapist went to school and had all this training and acquired all this experience for a reason. It is not something that an untrained parent can successfully complete at home without weekly help from a therapist.
To wrap up my rant, it is just plain crazy to expect that these type of therapies could be done (correctly & successfully) by parents at home. And the expenses that the therapy is costing my family is outrageous. Until this gets straightened out, and even if it is covered, until I meet the $1500 out of pocket maximum for this year. I had to cut down therapy sessions since the co-pays for all the recommended therapies for her would be over $300 PER WEEK! Yes, that is per week! Its the cost of another mortgage, we cannot afford that type of payment, I am quite certain that most families in America could not afford that. Instead, we currently are scaled down to speech once a week (instead of 2x per week), physical therapy once a week (instead of 2 x per week) (no aquatic therapy at all instead of 2 x per week), and occupational therapy once a week (instead of 2 x per week). That "reduced schedule" comes to $138 per week, and with the economy the way it is, this 2 income family is having a very tough time surviving on that. We have given up many luxuries that we used to know. But even beyond that, we are sacrificing groceries to pay for therapy. We are sacrificing going places like the park or the beach because we cannot afford the gas. Please note, that this expense is in addition to the weekly fee that comes out of my paycheck after my company already pays their end of the insurance, about $250/ week comes out of my paycheck for mine and Chianna's health insurance. Myke's is extra, he has his own plan that comes out of his check too. With the proper physical and occupational therapy, she will gain much more usage of her right hand and arm, she will grow stronger and will be able to lead a "normal" and independent life, without it, I fear that she will not reach the potential range of motion and use of her arm that is possible. Time is ticking too, these motions need to be taught while she is still young and growing. Just put yourself in her shoes for a moment, whichever hand is your dominant hand, imagine you cannot use that, try to get through an hour, much less a day, or 4 years. Imagine further, that each time your brain tells your dominant hand to move or open, or close, it doesn't respond. That is what my daughter goes through every day. Despite that, she remains a happy child with a great outlook on the world. We want to make sure she has every opportunity to be all that she can be. We are prepared to do whatever necessary to pay for her therapies and to make sure that she gets all the therapy that she needs.
Based on the problems I have had I am sure that seeking legal council is not far off. Hopefully a complaint to the state will get their attention, if not, I will be seeking out a lawyer to take my case on contingency and hope that it leads to a class action suit of all the families that did not have the time, resources, knowledge or wherewith all to see out what was due to them. Many may be currently institutionalized in mental institutions, b/c I can tell you this sure is driving me crazy, quite literally!
Evidently Aetna saw my blog post. Maybe they are listening? Someone from Aetna called me on Tuesday to try and help me resolve my claim issues. I received an email today (Wednesday) from them, but I do not know yet if the corrected date has been settled for sure. He did mention "the corrected claim" when he said that with it, I have only met $1200 of the out of pocket maximum. He said that they would be gathering a detail of all the claims. I wrote back and mentioned again that I have bills and receipts totaling over $1500 and that I wanted to get this cleared up very quickly. I will keep you all updated! I should also mention that I have an appeal hearing for my request for more therapy next week. (That is not new, it was already scheduled.)
If you are reading this for the first time, this is only a piece of the puzzle and the drama that we have been put through. You can see details on this whole insurance debacle with Aetna on my blog: http://bit.ly/Chianna and if you would like to help, feel free to link to the blog and share my story with anyone and everyone who will listen. I am not just doing this for me and my family, I am doing this for all the families who have been wronged by Aetna and other insurance companies who make it their policy to deny claims in hopes you will not notice, make it hard enough to fix problems that they hope you will give up, and state incorrect things over the phone just to get you to shut up and hang up and then they do not stand behind what was said.