Health Insurance: Weak Rant-Updated-Talked to Aetna

[Brovane]

In March my wife suffered through a migraine lasting over 7 -days. She eventually would up at the ER on a weekend. The doctor was concerned about the length of time for the migraine and ordered a Cat-Scan. So anyway first my insurance (Aetna) had the claim listed as needing more information. After a couple of weeks I called them to find out the status and they told me that they where waiting on records from the hospital. I followeed up with the hospital. The hospital told me that they faxed over the requested information. I then contacted Aetna and they told me they didn't receive anything. After a couple of times of being ping-ponged back and forth I contact the hospital and got the HIPAA form and had my wife sign it to release the records. I then went and picked up the records, they where in PDF format on a CD-ROM. I then faxed the records myself to Aetna. A couple of days later I followeed up and they told me that they received the records. I then waited and waited. I followeed up with them a couple of times and they told me everything was in review. So on Saturday I get a e-mail that the Claim was processed. I look it up and Aetna basically left me the entire $4k bill. Aetna claims that they never received previously requested additional information and as a result they are denying the claim. So now I get to spend my Monday making phone calls and dealing with Aetna on why they never processed the claim despite me sending them the information that they requested.

Cliffs:
Wife went to ER
Aetna kept claiming they never received the information requested from the hospital
I got the records myself from the hospital and faxed them to Aetna
Confirmed with Aetna they received them
Aetna is now deying the claim and saying they never received the information requested.


Update:

Called Aetna. Apparently the person that received the fax and responded to my e-mail never bothered to actually attach the documentation to the case. I was nice and patient on the phone. The rep on the phone apologized, but that doesn't do much. So anyway they are going to process the claim with the medical records that I faxed over. With this type of handling it makes me wonder it the hospital did fax over the records but Aetna's system never attached it to the records.

 

[AlienCraft]

If you want to have a career in Medicine, become an Insurance Adjuster.
Less schooling required, more power over people's lives.

 

[nboy22]

This is why no matter what company you deal with over the phone, ALWAYS get a confirmation number, and don't hang up until you do. Get the Confirmation number, get the employee ID, and get the Department name you're speaking to.

To often in large companies the left hand doesn't speak with the right hand.

 

[Brovane]

This is why no matter what company you deal with over the phone, ALWAYS get a confirmation number, and don't hang up until you do. Get the Confirmation number, get the employee ID, and get the Department name you're speaking to.

To often in large companies the left hand doesn't speak with the right hand.

I actually got the confirmation that they received the records in a e-mail reply. So I actually have written confirmation from them that they received the records requested. That should help make the converstation with them on Monday more lively.

 

[Zedtom]

Insurance companies have created an arcane bureaucratic mess that benefits the bottom line and creates hoops that must be jumped through to process a claim. Sometimes all of the paperwork magically disappears and you have to fight with providers to piece together the documents.

 

[Broheim]

I live in one of those "broken socialist utopias" (as Americans like to call it), so I don't have to deal with such, obviously superior, bureaucracy.
I just show up at the hospital and get treatment without any hassle, like the red commie I am >.>

 

[nboy22]

I actually got the confirmation that they received the records in a e-mail reply. So I actually have written confirmation from them that they received the records requested. That should help make the converstation with them on Monday more lively.

I think you'll be ok if you got that. Just stay calm while on the phone and you'll more than likely get the issue resolved.

I've worked in 2 call centers (total of 3 years experience) and was one of those agents that would track down the department and get the issues resolved for the customer. I hated how unorganized things were between departments, and if the customer wasn't a dick to me, I would get the issue resolved.

 

[UsandThem]

I had the exact same thing happen with Aetna. If I ever send them anything again, it will be by certified mail or it will be scanned and emailed. They have done the exact same thing to several of my coworkers as well. Seems they like playing the "we didn't receive it in the mail game". When I called BS on them not receiving the paperwork, they paid the claim right away.

 

[Hayabusa Rider]

I live in one of those "broken socialist utopias" (as Americans like to call it), so I don't have to deal with such, obviously superior, bureaucracy.
I just show up at the hospital and get treatment without any hassle, like the red commie I am >.>

I'm leaning towards liking you

As you have already done gather all information you have. Have the names of everyone you spoke to handy including those at the hospital. If they request hard documentation DO NOT SEND ORIGINALS. Send copies and get a signed return receipt. I rant about our wonderful government plans, but as far as screwing up paperwork goes private insurance can be just as bad. Write down notes as you converse, again taking down names, times and particulars.

If you fail to get a positive outcome PM me for other options which vary from state to state. I'm unfortunately familiar with third party billing issues.

 

[ultimatebob]

Don't screw around... just file a complaint now with your Attorney General and state insurance regulation commission. Judging from my past experiences with Aetna, that's the only way to get their attention and get your dispute settled in a timely manner.

 

[Ninjahedge]

I had something worse with US Healthcare.

I had cancer (suspected) a while back, and they sent me to 2-3 different places to get it looked at. Thing is, none of them were specialists in the type that was suspected for me. So I ended up getting BACK into surgery (twice) while my mother took a copy of the test results and scans over to Sloan Kettering on her own.

They looked at it, offered a different diagnosis (from 3 different doctors) that only required removal and nothing else.

We returned with that info just as they were setting up to do even more invasive and life-changing surgery.

Now here's the kicker(s).

1. Since Sloan was not "in network" we had to pay for them. Eventually USHC paid it, but only after hounding. It was only $500.

2. When we filed a malpractice case against the hospital that misdiagnosed, USHC actually had the NERVE to ask for all the money they paid BACK after the case! THEY did not refer us to the proper people and THEY wanted money from US!

3. When we saw the monies paid by USHC (~$75K) it shocked us because we knew that if we did not have insurance, we would probably had to pay well over $250K!!!

Why the HELL do Insurance companies get to pay less for the same treatment? At the very least we should enact legislation forcing all charges to be the same regardless of method of payment AND a cap to the profit margin of private insurance companies.

Actually having insurance companies raise your companies rate because they could not get a 25 cent on the dollar profit margin is absolutely criminal.

 

[HAL9000]

Just cancelled my private health insurance. It sounds like a massive pain.

 

[JSt0rm]

I fucking hate our system.

 

[Brovane]

We have received the necessary information, and we are currently
reviewing this claim for reprocessing. In general, claims are processed
and completed within 14 business days once the review has been
completed. A revised explanation of benefits will be available shortly.


When I emailed them last night. This is how they responded to me today. WTF does that mean? Aetna has had the information since 4/15/11. Great looks like they are playing games with me now.

 

[JimW1949]

I hear people talk about horror stories about the medical systems of Canada and countries in Europe, and maybe they are true, or maybe not. However, by the same token I am also quite certain there are a lot of horror stories concerning health care and insurance companies right here in the United States too. But when someone wants to make changes to our health care system, a whole lot of people are dead set against it.

 

[BUTCH1]

I had a local hospital try to bill me when I had Aetna, 2 yrs after the fact. I told them I'm not paying, I supplied all the info needed for them to file the claim, if Aetna lost it "forgot" to process it that's between them..

 

[Acanthus]

I hear people talk about horror stories about the medical systems of Canada and countries in Europe, and maybe they are true, or maybe not. However, by the same token I am also quite certain there are a lot of horror stories concerning health care and insurance companies right here in the United States too. But when someone wants to make changes to our health care system, a whole lot of people are dead set against it.

Over here they just bankrupt you and take everything.

You get to live though.

 

[Hayabusa Rider]

We have received the necessary information, and we are currently
reviewing this claim for reprocessing. In general, claims are processed
and completed within 14 business days once the review has been
completed. A revised explanation of benefits will be available shortly.


When I emailed them last night. This is how they responded to me today. WTF does that mean? Aetna has had the information since 4/15/11. Great looks like they are playing games with me now.

This is the weekend in the US. All that means that they have the information and will process it within 2 weeks. To the dismay of many you'll probably get a fair settlement

 

[alkemyst]

well in all fairness picking an ER to go to after 7 days with the headache was a bad move...urgent care and the like should have been your destination.

 

[senseamp]

This is pretty standard runaround you have to deal with when you get sick in America. I remember dealing with this exact type of BS when I got a CT scan. They'll probably pay up in the end, but they only need to weasel out of paying one $2K CT scan to make it worth-while to mess with dozens of people like this.

 

[alkemyst]

In all fairness as well, his policy probably has verbiage declaring ER to be for life-threatening cases and for prior authorization if not.

People running to the ER for petty things because they feel they are 'insured' is part of the problem. Many even call for an ambulance.

 

[Brovane]

well in all fairness picking an ER to go to after 7 days with the headache was a bad move...urgent care and the like should have been your destination.

Actually it was a migraine not a headache. They are two different things. Unfortunately one of the best things to do with a migraine that lasts this long is to basically get a specific shot, with a specific type of medicine. Unfortunately Urgent Care cannot despine the shot, only a hospital can. Also my wife had called into the Aetna Nurse line and the nurse had told my wife to go to the ER. I do agree about sometimes that people are to quick to run to ER. I prefer Urgent Care over the ER anyday.

 

[senseamp]

Yeah, people should self-diagnose and triage themselves as "life-threatening case" before going to the ER.

 

[Brovane]

This is the weekend in the US. All that means that they have the information and will process it within 2 weeks. To the dismay of many you'll probably get a fair settlement

The part that I cannot figure out is that they had the information on 4/15/2011. The 14-business days has already passed since they got the information. I think a phone call will be in order on Monday to figure out what they are doing.

 

[alkemyst]

Actually it was a migraine not a headache. They are two different things. Unfortunately one of the best things to do with a migraine that lasts this long is to basically get a specific shot, with a specific type of medicine. Unfortunately Urgent Care cannot despine the shot, only a hospital can. Also my wife had called into the Aetna Nurse line and the nurse had told my wife to go to the ER. I do agree about sometimes that people are to quick to run to ER. I prefer Urgent Care over the ER anyday.

7 days worth of migraine. There was plenty of time to go to a doctor.

Urgent care here can give Toradol and I believe any other migraine specific drugs...

I know many _think_ urgent care can't do much, but short of surgery they can do a lot usually.