Insurance woes
| My employer switched us to Aetna insurance at the beginning of the year, and it has been a giant pain-in-the-ass the entire time. I'm thankful for the fact that they allow me to have a Certified Nurse Midwife (CNM) as my primary care provider, and they are paying for my birth center birth (at least I hope), rather than a traditional hospital birth. However, I have had nothing but problems with the claims that have been filed to date. They are refusing to pay for my 20-week ultrasound despite THREE customer service reps telling me that it is covered under my insurance policy at 90%. Ever step I take is a battle. I have considered switching to Mr. Savvy's insurance, and paying the additional premium for foregoing my own insurance, but then it's like rewarding my employer for providing crappy insurance. On top of that, Aetna administers our FSA plan as well. The $1,000 bill they won't pay for the ultrasound is also denied as FSA because of the fact that it was denied by my Aetna medical insurance. So not only do I owe $1,000, but I have to pay it with post-tax dollars?!?! Sounds like a scam to me. I have had no special treatments this pregnancy. Prenatal visits every four weeks, I opted to skip any extra tests or screenings, with the exception of the ultrasound. Nothing out of the ordinary, no additional costs. As a matter of fact, a midwife-assisted pregnancy and birth costs less than half that of an OB/GYN assisted pregnancy and birth. Update: I just spoke with the ultrasound provider and the woman in the business office said that they have never had Aetna pay an ultrasound claim. She said the next step is to file a formal appeal with Aetna, and then a complaint with the Wisconsin Office of the Commissioner of Insurance. Unfortunately, she said this is all standard procedure. Labels: Aetna |
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post a commentPlease keep us posted as to what happens with Aetna. I am covered under Aetna's HMO and DMO plans at work and have stuggled with them as well. I have found if I call them enough and keep enough records, I have been able to get everythig covered so far, but it has been difficult. Especialy with an injury in Hawaii on vacation over a holiday weekend (they are closed), trying to get the new HPV vaccine covered, and general other issues involving who I am allowed to go to, when, etc. Thank you for sharing your story.
I'm not 100% sure of how Aetna operates, but I've heard it's different to other insurance companies. Perhaps it varies from company to company, but my husband's company uses Aetna, and his company actually pays out the insurance claims...it's just managed by Aetna.
Personally, we've had no problems with them. I had an out of network doctor before Aetna, and I chose to keep her because I was comfortable. So we paid a bit more out of pocket, but it was still about 80% of the "reasonable" cost. At one point, they didn't want to pay for an ultrasound, but it was the doctor's office fault because they miscoded the item. They kept reminding me about the outstanding payable, and I kept reminding them that they needed to resubmit the claim with the right code. Eventually, they stopped reminding me, so I can only assume it was paid. I ended up having a c-section (absolutely not what I had hoped for, but that's another story), and the final hospital bill was about $40K. The hospital was in Aetna's network meaning they had a pre-negotiated fee set in place, so they paid about 10% of the bill and we paid $100. Another thing in our favor was the max out of pocket of $1K.
Good luck with the appeal. And make sure to keep your eyes peeled for mistakes on medical bills because we found at least 1/2 dozen over my pregnancy.
I know someone who processes claims for Aetna and this person suggested asking the Dr if there are any other diagnosis codes they can bill with. you can also look under clinical policy bulletins on Aetnas website under ultrasounds and it will list how its covered. This will give you the diagnosis codes it will cover for. Good luck. This also means your office will have to re-bill and put some effort in because Aetna legally cannot change the code. Only the office can. I have found alot of times the Dr's office is half the problem since they do not always want to put the extra effort in when required. Remember that you are there client and they need to help you.
That's discusting that you have to go through any lengths to get a completely routine pre-natal test covered. I'm appalled.
I also have Aetna insurance. They didn't pay for my 20 week ultrasound and when I called, they said they consider it "experimental" and never pay for them. Aetna says that the doctors eventually write them off. My doctor's office kept submitting the bill to Aetna over an 8 month period and I would see the new billing periodically, but my doctor evidently did write it off in the end and I never had to pay the bill. Maybe the same will happen for you. Good luck!
I thought my insurance company should have written me a thank-you note for saving them so much money by giving birth with a midwife instead of an OB.
3.5 years after giving birth, I'm still waiting for that thank you letter. ;)
I also have Aetna insurance and ran into the same problem. Luckily my OB office had plenty of experience dealing with Aetna insurance and as the previous poster mentioned used special "codes" to get my ultrasound covered. Hopefully soemone will help you get your ultrasound covered as well. Good luck with the rest of the pregnancy!
Good luck with your Aetna fight. This post and the comments to this post make me very thankful to have a good insurance company that doesn't jerk me around. However, my dental insurance is another thing entirely.
Aetna won't pay for three visits to our pediatrician because they claim that we didn't choose a primary care provider after our daughter was born. The reason they didn't have our PCP listed is because some dumbass didn't at Aetna didn't record the info. As a matter of fact, they didn't record her existence until she was 4 months old. Unfortunately I can't prove that we notified them the day after she was born (which I did) and the insist on hiding behind a technicality to get out of paying. Anyone else have this happen and how did you resolve it?
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