Monday, April 26, 2010

Update on Health Care: I'm Still in Aetna Hell

Well I've had a lot going on to keep us busy lately, so I didn't have a chance to update on what's happening with my Aetna Insurance problems, but seem to be suffering from a lack of help since I have been quiet for over a month now.

In my last post on March 21, 2010, I was ranting about how I received a collection notice from a doctor bill that should have been covered because I had met the out of pocket maximum for 2009; in addition to several other ongoing issues that I was not getting answers about.

I expected to have an immediate response due to the urgency of the matter and because of how upset and distressed I was with the gravity of the issue. By the end of the day on the 21st, I called the doctor's office that I received the collection letter from and, to my surprise, she told me that Aetna had called her about 30 minutes before to let them know that they were going to be covering that claim and that it was not my fault that the payment was delayed. I was very relieved to hear this, but still upset that Aetna did not contact me to let me know they were working on it, not to mention upset that it had gone so far in the first place anyhow!

Aetna did reply to my email on March 23rd saying that he needed to talk to me about these issues. I didn't get a call, but got an email on March 24th stating that Aetna was going to cover our occupational therapy that we had to date, but that in reviewing my plan, since it says that they don't cover chronic diseases, that they made a mistake in the first place and should not have covered any therapy at all, and would not cover the remainder of the 60 consecutive days that was originally told to me because of this review.

I didn't event know what to think about this! I'm very happy that the occupational therapy is being covered, however am I supposed to think they are doing me a favor? It appears that every time they look at my plan, they come up with a different definition of what is supposed to be covered or not covered. It's proof that no one at Aetna knows what is going on or what they cover. It's proof that they word their policies so ambiguously and verbosely that no average person can read and understand them. If you have a medical degree AND a law degree, then still, good luck in understanding an insurance policy!

I wrote them back and asked [again] for a detailing of the co-pays for therapy because the credits did not make sense and I still don't know what the co-pay amounts were or what they are supposed to be.

On March 31, 2010, I received another email update from Aetna and they let me know that the doctors that I was past due with were being paid and that I have indeed met the out of pocket maximum for 2009!

But I still have no idea what the co-pays were and why they are not consistent!

I didn't hear anything for over a week, so on April 11th I wrote asking the following:

Checking in on the co-pay amounts for therapy from August 2009 - October 2009. I would like to have an accounting of what the co-pays were for each visit and why they were different co-pays for some of the days that we had two visits, but not all the days that we had two visits. While I am thrilled to have a credit, I am wondering why the amounts are not consistent and why I was not told about it sooner so that I could have adjusted the schedule at the time and made sure that we would have had the visits on the same days.

(To re-cap: Aetna originally told me that there is a $50 co-pay per 30 minute therapy session. Then in October 2009, they updated to say that the therapy co-pays were $37.07 for physical therapy, $43.03 for speech therapy and $44.70 for aqua therapy. I was issued a credit from the therapy place. Now they are telling me that on the days that we had two therapies in one day, the co-pay was much less, however I have no detailing of what the amounts are. The amounts are inconsistent and I have credits for some of the days we had 2 therapies in one day and not others, and the credits that I was issued are not the same amounts! I was never told about this until I probed and probed!)

So, on April 15th I received a reply to that request, which did not include any of what I asked for. He basically told me that Aetna's co-pay rate is based on the procedure code, each code has an assigned rate and that I am responsible for the remainder that is not covered. WHAT!!!??? He also said that the co-pay issue was not addressed before because some of the claims were processed after????

OK, NONE of that makes sense to me, nor does it answer my question or solve my problem! And to even further add to my confusion, the same diagnosis and procedure codes were used for each therapy claim.

Then, as if to add insult to injury, he says I can dispute claims and gave me a fax number to send in a dispute to. HELLOOO!!!??? I wouldn't even know what to dispute, because Aetna is not sending me the information I need. And furthermore, when I log into to download the claims, they are not updated, so I cannot get an accounting of anything!

On April 18th, I received a return email from Aetna with an excel file, that was supposed to detail all the claims I asked for. At first, I was all excited, thinking that I finally have a detailing and some answers! WRONG!!! The excel file was very confusing! (Just like everything else Aetna does!) Each claim was listed in the file twice and then was listed three more times with a $0 amount next to it. I began to try to edit it and make heads or tails of it, and after 30 minutes of staring at this file, I hadn't gotten anywhere, so I decided not to waste any more time on it, going cross eyed trying to figure out their voodoo accounting of my claims. Instead, I composed my own excel file of all the dates we had therapy, the type of therapy and the co-pay amount I paid. Then I color coded the credits we were given and the same situations that were not credited and sent it back to Aetna. I sent this back on April 21st. I asked for someone to actually LOOK at the file and answer my questions as to why the credits were not consistent. I also [again] asked for the documentation of where in my policy is says what the co-pay amount is.

This evening (April 25th) I received a return email that is completely incoherent! Two sentences! Is that even a response? Aetna wrote me back to say that when service is provided by 2 providers under one name there should be 2 co-pays, and that in this case a co-pay should be applied to speech therapy and a co-pay should be applied to physical therapy.

WHAT? That doesn't answer my questions, solve my problem or make any sense whatsoever! I keep mentioned that if the claim is not submitted consistently from the therapy place, that to let me know so that I can have them fix it, since she had the same therapies and as far as the therapy place has told me, they are all billed exactly the same way.

I am really hoping that something gets cleared up soon, this is completely ridiculous!

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.


Tammie said...

I don't even know how you can keep this all straight in your mind Shari! Perhaps it's time for a call to the Insurance Commissioner? AETNA sucks for sure!

Mary said...

Unbelievable, and at the same time -- when one considers what you have been through with Aetna -- not surprising.
It might be time to contact the media. There is strength in numbers, and I sadly doubt you aren't the only one who Aetna is scr*wing.