In case anyone has any question about the broken health care system in this country and the power that insurance companies have, please read on. If you are not familiar with the history of my health insurance problems with Aetna, please read prior posts on my blog: http://FindingChianna.blogspot.com
At this point, I am detailing a step by step account of the communications in an effort to present the facts and let people know what an average middle class family has to deal with.
I spoke with the office manager at the therapy place today regarding the billing issue. I explained that Aetna says that the reason why I didn't meet the out of pocket maximum for 2009 is that the therapy place over charged me co-pays when Chianna had speech and physical therapy the same day. She said that their contract with Aetna does not say anything about one co-payment if two different therapists are seen in one day. She said that this has never come up before in their history of working with Aetna. She also said that they were paid by Aetna minus the co-pay for each visit separately.
So I am stuck in the middle of this mess with no resolution in sight!
I have requested a phone conference later in the week so that all 3 of us can be on the phone at once and attempt to get it settled, rather than me going back and forth with them for another 3 months! I hope that it gets resolved a lot easier than the outlook is right now.
In other insurance problem news. . . . I receive the denial letter today in the mail from Aetna regarding my appeal for more therapy to be covered for Chianna. They stated that the coverage is only for the initial 60 days per condition. They even acknowledged that I stated that numerous Aetna employees told me that additional coverage would be available if a doctor letter of medical necessity was sent in. But stuck by the story that my benefits only list the 60 consecutive days, blah, blah, blah.
I am exploring what my next step is and what recourse I have since Aetna employees told me that more therapy would be covered with the letter. I took their word for it rather than reading through policies and documents that can barely be understood by anyone.
In the mean time, I am going to have them re-bill the claims for different diagnoses that the doctor has given me prescriptions for. I know that will be another nightmare trying to get the claims fixed with a new diagnosis and new prescription. I really wish I had never signed up with Aetna Insurance in the first place. It would seem that they don't stand by the word of their employees.
The first time I even called about therapy for Chianna in August 2009 and was told they only cover 60 consecutive days, I said that she definitely would need more therapy than that and the first person I spoke with said that there is a "doctor hotline" that I could have the doctor call once the initial 60 days was up and the doctor could speak to somebody at Aetna about extending the coverage. And that is what I did, when the 60 days coverage was coming to an end, I called Aetna in October. And I was first given a phone number for the doctor to call, after 2 weeks, the doctor's office called me back to say that the dr. cannot get through, she is left on hold for 20 to 30 minutes every time she calls and ends up giving up and hanging up. That is when the first doctor letter was faxed in; first I was given the wrong department to have it faxed to, and when it was finally straightened out with the correct fax # of the correct dept, it was declined. Now my 2nd appeal has been denied and I am frustrated beyond belief. If I was told in the first place that it was 60 days and that was it, rather than being led to believe that additional coverage was a sure thing, I would have started to make other insurance arrangements rather than pursuing the matter further with Aetna.
To make things even more frustrating, the denial letter still had the wrong date of initial coverage for her speech therapy starting on July 31, 2009. I have been told that the date issue was corrected, but evidently not according to the letter they sent me!
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.