Sunday, March 21, 2010

And Today the Aetna Crap Starts to Hit the Fan!

In an effort to preserve my [in]sanity, I am going to paste here what I sent in an email to the Aetna representative today. But here's the story, slightly modified to protect some private info and names.


I don't want to be rude, but the frustration is really getting to me here and the problems are multiplying rather than being solved. First of all, I received a collection notice in the mail today for a $50 co -pay from the neurologist's office. I expect someone from Aetna to contact them immediately to clear up the matter and ask them to recall it from collection. I still do not know if with the credit from the therapy place if I meet the out of pocket maximum or not. Even if I still owe the neurologist this payment, I will pay, but I need Aetna to explain to them what the delay is and that it is not my fault. I need to be assured that my credit will not suffer because of this mess.

Regarding the out of pocket maximum:
I need to know when the last day of the 60 day period for speech therapy is and physical therapy is according to Aetna.
The 1st speech therapy evaluation was on August 20, 2009 and her 1st speech therapy session was on August 24,2009. According to the calendar, October 18th is the 60th day, is this what Aetna is counting?
and the 1st physical therapy evaluation was on August 19, 2009 and her 1st physical therapy session was on August 24, 2009. According to the calendar days, October 19th is the 60th day, is this what Aetna is counting?

Regarding the occupational therapy issue:
In other conversations with Aetna representatives, they had mentioned the two separate start dates (referring to her evaluation dates) and that each start date started the 60 consecutive day count down for that type of therapy. (Do they start counting from the day of the evaluation or the day of therapy?) So that still makes me question why the occupational therapy is not being covered, and even still, it says no where in the explanation of benefits that ALL therapies need to be completed within one 60 day period. Furthermore, there are specific outlines in the occupational therapy bulletin for explanation of benefits that allow for continued occupational therapy, where it does not mention that for physical and speech therapies, so I expect them to further review the case for continued occupational therapy past the 60 consecutive days, which she is currently missing for the second week now because I cannot continue to bring her to therapy until this gets resolved and I know that Aetna insurance will be covering the visits. It is taking longer than it should to be resolved. Once they realize this therapy is supposed to be covered, I expect Aetna to make provisions to extend the 60 days therapy for the amount of time that I had to pause her therapy because of this mix up.

Regarding the co-pay credit for physical and speech therapy:
I am EXTREMELY UPSET that I was not made aware of this issue sooner. I had someone from Aetna evaluate the account in October and said that the co-pays were not the $50 amount I was paying at the time and the therapy place had issued me a credit at that time stating that the contracted rate that Aetna gave them was $37.07 for physical therapy, $44.70 for aquatic physical therapy, and $43.03 for speech therapy. Why was this problem not discovered then?

Why is the co-pay now different for different days and so much less some of the time and not all the time? As I mentioned before, she had speech and physical or aquatic therapy 30 minutes each on Mondays. She had a 2nd physical therapy session for 30 minutes on Wednesdays and then a 2nd speech therapy 30 minute session on Thursdays. The co-pay for those 2 therapy sessions on Mondays with the credit I have been issued is significantly less than the co-pay for the same 2 therapies she had later in the week just because they were on different days. A credit should be owed to me for those days as well then. No where in the explanation of benefits from Aetna is this co-pay policy listed, nor was it told to me or the provider, the therapy place and I would have never known about it had I not reached the $1500 out of pocket maximum and pushed the issue with no cooperation from Aetna whatsoever.
I don't even know what the co-pay was for the visits, and I expect a full explanation of this from Aetna as to why the same therapy co-pays are different amounts on different days.

Here is what I would like to see happen this week:

A full accounting detail form Aetna of the co-payments I have made and where I am at with the $1500 out of pocket expense for 2009. I have the credit document from the therapy place, but I am still very confused as to why I received a credit on some days and not others, and the credits stop on Sept 21, 2009? Attached is an excel file detailing of what she gave me. We had therapy on more days than what is listed, so as you can see, it is quite confusing! Why are some days $6.97 and then one is $5.30? Why are not all the days she had 2 therapy appointments considered here, and as I've asked before, why is the co-pay different on different days? I really feel like I am getting ripped off here. Is Aetna just making adjustments now to make sure that I don't reach the $1500 out of pocket maximum? It sure seems like this is the case.

I expect Aetna to contact the neurologist's office regarding the co-pay of $50 that I have now received a collection notice for to explain to them that there has been an issue with insurance and the co-pay will be paid once Aetna clears up the issue.

I also want Aetna to call the orthopedic's office about an outstanding bill I have with them for $38 and the physiatrist's office about a $50 co-pay issue I have with them. Once I receive an accounting detail, if I owe them the co-pays I will make those payments, however Aetna needs to contact them to clarify the issue we had was not my fault and explain why the payments were delayed.

If this is something that you cannot handle, please pass it on to someone higher and let me know. I expect to hear from you Monday that this is being worked on and need to have something resolved by the end of the week. This is dragging on far too long and consuming too much of my life. However, that does not mean I am going to go away, I am going to continue blogging about my issues with Aetna. I think you know that I am going to see this through and the sooner that Aetna can clear up this matters, the sooner I will get out of their hair (and yours too). I feel as though I am stuck in the middle between Aetna and the providers going back and forth with he said, she said. I need someone to handle this and get it taken care of. I would hope that after all that Aetna has dragged me and my family through that some priority could be given to these problems and let's get this resolved.

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: 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.

1 comment:

Anne said...

O.M.G. I seriously can't believe that you are still having to deal with this crap! This is criminal!!!!