I am on the phone with them a couple of times a month to question a claim decision or to follow up on something I've appealed before. I don't think I submit a large amount of claims, but it seems that every single thing I submit is denied or short paid for one reason or another. Usually it takes awhile to get it figured out but eventually it does...it's just super annoying and a HUGE waste of my time.
Last year I saw Dr X. His office submited the charges. Aetna refused to pay because they said that Dr. X was not covered under their plan and that if I would just look under the docFind link on their website I could find a huge list of everyone who is covered. I told them I had looked there. The woman told me to look again.
I hung up and looked again.
There he was.
Listed as covered.
So I called back and talked to some man who told me to look under the docFind link. I told him I did. I even walked him through the steps I took to find Dr. X. He put me on hold forever and came back and said he would resubmit it because it did indeed look like Dr. X was covered. A couple of weeks later I got a letter from Aetna saying the claim had been reviewed again and was denied.
So I called.
The woman told me to use docFind because Dr. X wasn't covered. I asked to talk to a manager who told me Dr. X wasn't covered. I walked the manager through the steps and he said it was a mistake. I told him that his company's mistake shouldn't cost me. He told me to appeal the decision but that there was nothing else he could do.
So I appealed.
Aetna denied the claim.
So I went online to the docFind and printed off the pages showing Dr. X's name. That's right. Dr. X was still listed as in-network even though supposedly his contract with them had expired well over a year prior and I had been talking to them about this claim for over 6 months (which one would think would be plenty of time for them to update/correct their website - in fact, just for fun I went in tonight to look one more time. Sure enough 15 months after this all started Dr. X is STILL listed as in-network).
Then I appealed.
I sent in 20 pages of documentation. This time the appeal went to my employer. A few weeks later I received a letter from my employer saying that my appeal was approved and Aetna was responsible to pay. They paid 10 months after the charges were incurred. It had taken me hours of time spent listening to hold music and hours of time gathing information, but I swear when that letter arrived I thought I was going to run through the snow naked I was so happy.
So several weeks ago I started going to a new chiropractor (Dr. Y). He was recommended by someone I know, and before I made my first appointment I went to docFind to make sure he was covered. Sure enough, there he was.
So I went to my first appointment and second and third. Each time I happily paid the copay. And today I received the first notice of the claim. They told me I would need to pay 30% of the total bill - not just the copay. WTF? So I emailed Aetna and asked for clarification of why I had to pay 30%. Their email back to me:
Dear Ms. Cmuser:
Thank you for using the Aetna Navigator website to contact Aetna Member Services.
This is in response to your claim question on yourself for 12/03/08 from Dr. Y for $XXX.
We have processed this claim according to your non-preferred level of benefits because this provider does not have a contract with Aetna.
Search for Aetna providers by logging in to Aetna Navigator and selecting Find Health Care in DocFind.
Blah, blah, blah.
You have got to be kidding me. This cannot seriously be happening to me again. But it is. I went online tonight and there is Dr. Y listed as in-network.
This isn't the only type of problem I've had with Aetna. Everything from them saying I couldn't have two physicals in one year (I only had one - they paid for it after I faxed them proof) to them saying blood tests couldn't be covered because they weren't medically necessary (they were ordered by their in-network PCP, but I guess that doesn't qualify - or at least it didn't right away. They paid for them after I sent them paperwork and a letter from my doctor).
So, tomorrow I will call Aetna. I will start all over again. Then I will report them for being the lying scoundrals they are. What's the point of having insurance if you have to fight them all the time?