Author Topic: Problem with Health Insurer  (Read 2643 times)

OneCoolCat

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Problem with Health Insurer
« on: October 15, 2015, 11:59:02 PM »
I have an Aetna HSA policy with a $3,000 deductible.  I had a pretty major shoulder injury that required surgery.  I paid the entire $3,000 deductible to the hospital the morning of my surgery and have receipts to prove it.  The hospital sent the bills for the surgery to Aetna who said I'm responsible for $3,000 because my deductible hasn't been satisfied.  Consequently, I have been receiving bills from the hospital saying I owe them some $3,500.  I sent Aetna copies of the receipt showing I paid the deductible in its entirety and get a generic response saying I didn't satisfy my deductible; their online customer service is terrible.  I called Aetna's office and they were more helpful, they told me that the hospital charged me the deductible upfront which is generally discouraged but technically allowed and that the hopsital had filed an appeal with them on the basis that Aetna owes the hospital money as I paid my deductible.  The representative told me to basically wait for a decision on the hospitals appeal.  So I called the hospital and they basically said the same thing, that I paid my deductible, that they filed an appeal with Aetna, and they want Aetna to pay, not me, and that i can just hang tight while they appeal.  These conversations with Aetna and the hospital occurred two weeks ago and I have heard nothing from either since.  It appears as though the hospital still has me down as owing them money.  Apparently the physicians at the hospital are sending me the billing statements saying I need to pay them now while the hospital is telling me simultaneously that they have filed an appeal and that I don't have to do anything.  This is really annoying, and I'm concerned something will get turned over to collections since its been going on since late July.  What should I do?  File a complaint with some agency that regulates insurance?  I've been stressed out about this and nothing seems to be getting done to resolve this.  I submitted proof that I paid my deductible months ago but Aetna and the hospital are dragging their feet and threatening my creditworthiness as well as my bar license.
« Last Edit: October 16, 2015, 12:04:51 AM by OneCoolCat »

Hamster

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Re: Problem with Health Insurer
« Reply #1 on: October 16, 2015, 01:02:49 AM »
I have an Aetna HSA policy with a $3,000 deductible.  I had a pretty major shoulder injury that required surgery.  I paid the entire $3,000 deductible to the hospital the morning of my surgery and have receipts to prove it.  The hospital sent the bills for the surgery to Aetna who said I'm responsible for $3,000 because my deductible hasn't been satisfied.  Consequently, I have been receiving bills from the hospital saying I owe them some $3,500.  I sent Aetna copies of the receipt showing I paid the deductible in its entirety and get a generic response saying I didn't satisfy my deductible; their online customer service is terrible.  I called Aetna's office and they were more helpful, they told me that the hospital charged me the deductible upfront which is generally discouraged but technically allowed and that the hopsital had filed an appeal with them on the basis that Aetna owes the hospital money as I paid my deductible.  The representative told me to basically wait for a decision on the hospitals appeal.  So I called the hospital and they basically said the same thing, that I paid my deductible, that they filed an appeal with Aetna, and they want Aetna to pay, not me, and that i can just hang tight while they appeal.  These conversations with Aetna and the hospital occurred two weeks ago and I have heard nothing from either since.  It appears as though the hospital still has me down as owing them money.  Apparently the physicians at the hospital are sending me the billing statements saying I need to pay them now while the hospital is telling me simultaneously that they have filed an appeal and that I don't have to do anything.  This is really annoying, and I'm concerned something will get turned over to collections since its been going on since late July.  What should I do?  File a complaint with some agency that regulates insurance?  I've been stressed out about this and nothing seems to be getting done to resolve this.  I submitted proof that I paid my deductible months ago but Aetna and the hospital are dragging their feet and threatening my creditworthiness as well as my bar license.
Who is threatening your creditworthiness and bar license? I would call all of the people sending you bills, note the date and time, and who you spoke with, informing them there is a disputed charge, and then send them something in writing with all of that information along with the letter from the hospital stating that the appeal is in process.

I assume when you talk to someone at Aetna, you have asked to speak to their manager, and their manager and... Where I work, it is amazing how different the support can be depending on which person you reach on the phone. Some people like to solve problems and actually feel compassion and empathy, others like to get things out of their work queue as quickly as possible without fixing anything so they can go back to Facebook.

I kept getting bills for a vaccine charge 9 months after the fact (something which I can't be legally charged for under the ACA) for my child. After about 6 phone calls over that time it finally disappeared without anyone bothering to tell me it had been resolved. And I am one of the doctors in this institution...

 I am sorry any of us has to deal with this mess.

Sibley

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Re: Problem with Health Insurer
« Reply #2 on: October 16, 2015, 12:41:04 PM »
Congrats, you're stuck in the terrible communication loop that happens in insurance. You are not at this point yet, but if you get to the bitter end of appeals, etc and it's still not right, file a complaint with your state's Department of Insurance.

Keep all documentation, copies of checks, etc. Do what you can to prod both parties into figuring it out. And in the future, call the insurance company ahead of time and ask specifically how you handle payments. It's often better in these types of cases to have the hospital file their claim with the insurer and then the insurer send you a bill.

AlwaysLearningToSave

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Re: Problem with Health Insurer
« Reply #3 on: October 16, 2015, 01:22:21 PM »
These conversations with Aetna and the hospital occurred two weeks ago and I have heard nothing from either since.   

This sucks, but I'd just relax and let it play out.  Large organizations like this move at a glacial pace, especially when there is a formal appeal involved.  Document all of your conversations and make sure you hold on to the hospital documentation.

I paid the entire $3,000 deductible to the hospital the morning of my surgery and have receipts to prove it. 

. . . they told me that the hospital charged me the deductible upfront which is generally discouraged but technically allowed . . .

The lesson here is to not try to do anything unusual when dealing with large institutions unless you are dealing with senior executives or the organization's attorneys.  Yes it "should" not be an issue to go about it the way you did.  But because you did it that way, you are immediately outside of their normal claims-processing routine which means no one will have authority to do anything with it until it gets to the desk of a high-enough ranking employee. 

In the future, just play by the normal rules and wait for them to process the claim and send you a bill. 

Cathy

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Re: Problem with Health Insurer
« Reply #4 on: October 16, 2015, 09:10:00 PM »
...This is really annoying, and I'm concerned something will get turned over to collections since its been going on since late July....

Sending you a bogus bill may not be actionable by itself, but if you don't owe the hospital money and they nonetheless disseminate a false statement that you owe them money (e.g. by retaining a collections agency and/or reporting the false debt to a credit bureau), that may be defamatory. You could look into suing the hospital for defamation if they take those steps. I express no view on whether the claim would succeed; it's just a suggestion of something you may want to research.
« Last Edit: October 16, 2015, 09:15:33 PM by Cathy »

yuka

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Re: Problem with Health Insurer
« Reply #5 on: October 17, 2015, 01:14:15 AM »
I'm not sure if this falls outside their purview, but I've heard a lot of good coming from sending documentation and a complaint to the FTC when someone's giving you a runaround on money not actually owed. In a way similar to FCC, I've heard they really bring down the hammer and straighten people out. If FTC isn't applicable, there may be some similar organization that is.

Tom Bri

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Re: Problem with Health Insurer
« Reply #6 on: October 17, 2015, 01:34:29 AM »
This is my area. I work for an insurance company resolving just this sort of problem (not Aetna). First, how much was the total bill? It looks like $6500? Or was it $3500?
If I am understanding your claim, the hosp bill was $6500 of which you paid $3000 up front. Aetna has nothing to do with that, and has no way of knowing that you paid, unless (as very rarely happens) the hosp bothered to note on the claim form that you had paid. I see that once in a thousand claims, maybe. Usually what happens is that the hosp sends the claim to us, we process and send out an EOB, and a check for whatever is left over after the deductible.
So what I imagine happened is that Aetna got a claim, processed it and sent an EOB to your hosp, showing that you owed $3000, and they paid the remainder. Then, your hospital's billing dept got ahold of the eob and fired off a bill to you, without bothering to check their own accounting department's records to see if you had paid anything already. Your problem probably isn't with Aetna, but with hospital billing. Call them, and start faxing them copies of your receipt. Call them again and again until you get someone to admit that you already paid. Once you have that admission on file, get ahold of the bill collector and tell them the bill is paid. If they continue to harass you, then it is time to take a complaint to the state. You will also need to get your credit records updated.

OneCoolCat

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Re: Problem with Health Insurer
« Reply #7 on: October 17, 2015, 07:21:37 AM »
This is my area. I work for an insurance company resolving just this sort of problem (not Aetna). First, how much was the total bill? It looks like $6500? Or was it $3500?
If I am understanding your claim, the hosp bill was $6500 of which you paid $3000 up front. Aetna has nothing to do with that, and has no way of knowing that you paid, unless (as very rarely happens) the hosp bothered to note on the claim form that you had paid. I see that once in a thousand claims, maybe. Usually what happens is that the hosp sends the claim to us, we process and send out an EOB, and a check for whatever is left over after the deductible.
So what I imagine happened is that Aetna got a claim, processed it and sent an EOB to your hosp, showing that you owed $3000, and they paid the remainder. Then, your hospital's billing dept got ahold of the eob and fired off a bill to you, without bothering to check their own accounting department's records to see if you had paid anything already. Your problem probably isn't with Aetna, but with hospital billing. Call them, and start faxing them copies of your receipt. Call them again and again until you get someone to admit that you already paid. Once you have that admission on file, get ahold of the bill collector and tell them the bill is paid. If they continue to harass you, then it is time to take a complaint to the state. You will also need to get your credit records updated.

Thanks!  I was compiling a very detailed record of everything and while drafting my letter to Aetna it hit me that the hospital probably never revealed that I had paid.  What bugs me is that I did get the hospital on the phone and they admitted I paid but they erroneously told me they were trying to get the insurer to pay it when its now know its their fault!  Ill call again on Monday but this is insane how much effort this is taking me to resolve their error. 

Tom Bri

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Re: Problem with Health Insurer
« Reply #8 on: October 17, 2015, 08:46:55 AM »
I answer phones every day and talk with people who have this problem.
I re-read your original statement and I see that I misunderstood that you have not yet been sent to collections, so that is good. At this point you are probably fine.
My suggestion at this point is to call any provider that bills you and let them know that the hospital is appealing the claim and request that they hold tight until the process is done. But, I think they are simply wasting time if they are trying to get Aetna to pay the original $3k for your DED. Ain't gonna happen.
Have you gotten anesthesiologist bills or surgeon's bills yet? Those are probably separate from the hospital bills. Did Aetna pay those? If not, call Aetna to ask why. Since they applied your DED to the hospital charges they should be paying on everything else, even if the hospital charges are in appeal.