QUESTION: I no longer have Aetna (since 2009), but recently (April 2012!!) found myself in collections because Aetna decided to take back almost $400 from a provider I saw in 2007, that they approved and paid 2 months after my visit, but decided more than 1 year later to take the payment back because there wasn’t a referral (according to the provider’s office).
With copies in hand of the referral and the doctors (PCP) notes stating he wanted me to see this neurologist, I called Aetna to find out what I had to do to get refunded (I paid the collection agency). The Aetna customer service person said it’s too late to appeal, as the rules say I only have 120 days to appeal. “But they revoked the payment more than 365 days after agreeing to pay and paying for the services.”, I said. I was told the ONLY way to resolve it was with Aetna’s Legal Services Dept., but they couldn’t give me a number to call (not allowed). I was told to mail everything to the Legal Dept. in CT.
After waiting more than a month, I called Aetna Customer Service again. This time I was told my ID was “archived” and there was no way they could review the claim. I (innocently) asked and was given the tel. number to the Legal Services Dept. this time! I spoke with a woman who said they’d received my letter and documentation, but they don’t handle that type of case there so they forwarded my information “on”. I asked for the dept. to which it was forwarded as well as a number to call, but once again, I was told they could not give me the number, nor could they tell me the person’s position/title, but would forward my call. They did and I was able to leave a message more than a week ago and have heard nothing back.
The doctor’s office put me in collections. I only found out in 2012 when I went to see another physician in the same practice. They said when they tried to put me down for an appt. the computer wouldn’t allow it due to non-payment. She gave me a number to call and that’s when I found out about all of this. Aetna never told me, nor did the other doctor’s office.
ANSWER: I’m not sure that this is as much a health insurance issue as it is a debt issue. In this response, I’ll refer you to my 9 Tips to Ensure Your Insurer Pays Up.
When your insurer processes a claim, or changes their mind about a claim, they have to issue an Explanation of Benefits (EOB). Aetna does a good job of making these accessible on their website. Tip #1 is to check claims on their website everyday. If you are signed up for paperless statements, Aetna sends an E-mail anytime a new EOB is created. It sounds like you did not know, hence going past the 180 day window for an appeal. However, I would go online now, and check what that the EOB says.
For all providers, Aetna has a time limit on how soon the doctor/hospital might bill. I believe it is 4 to 6 months, or else they are not allowed to bill the patient. I do not think this is the case in this situation, but I do want to make you aware of this fact.
For in-network providers, their contract says they cannot bill you more than Aetna says, unless you signed something (we’ve only signed for physical therapy). So you need to check whether Aetna changed it so you actually owed something, or if they just took it away from the doctor. If they did not change what you owe, then that doctor had no business sending it to collections. It’s a debt issue than, not a health insurance issue.
If it has been sent to collections, you need to first ask the collections agent to do a “debt verification,” where they have to verify your debt. They also have to show whether that debt has been SOLD to them, or ASSIGNED to them. If only ASSIGNED, you may have been able to still negotiate with the doctor’s office, since they have not gotten the money. Be very careful paying collection agents for the following reasons: 1) they may not even own the debt, so your money is gone, hence the debt verification letter 2) the provider has little incentive to work with you once they have your money, nor is motivated to remove it from your credit report, and 3) the 7 year black mark on your credit report STARTS with the last payment. There’s a lot of good advice at this site on debt issues: http://www.creditinfocenter.com/forums/
Even if Aetna did change their mind, you could have still negotiated with the doctor if you had not paid them yet. Perhaps you could have sent letters to the doctor challenging that they never informed you about it. I believe this topic has been discussed at that website before too.
For anyone else reading this, that is why it is so important to follow Tip #1. It may be worth it to go paperless if your insurer sends you an E-mail everytime there is a new EOB, so you can monitor it. While we had a lot of problems with Aetna over physical therapy, I have to say that Aetna’s website for retrieving claims information, and Explanations of Benefits was excellent. We have switched to a different insurer this year and their online system for looking up claims is definitely not up to par as Aetna’s is.
I want to add to what I wrote earlier.
We are no longer with Aetna as of 2012. I have paperless statements and yesterday I received an E-mail from Aetna that a claim had been processed. By using the tools in Tipe #1, I was on their website and saw that it related to charges for the childbirth, close to 6 months ago. Almost all of it was paid, except for one charge of $700. I immediately sent an E-mail to Aetna asking them about it.
The next day I received an E-mail from Aetna saying that it was in error and they would redo the EOB to correct it, and the incorrect one would not be sent to the hospital. Aetna had overpaid the hospital, and they would work with the hospital to recoup the funds.
I just want to point this out that it is so important to stay alert about your claims, so you can respond quickly. Because the EOB came out yesterday, I would have had 180 days to appeal it, but there was no need. And I’m not even with Aetna anymore.