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Insurance disconnect
Old 06-19-2015, 09:13 AM   #1
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Insurance disconnect

I have a bronze-level health plan with Aetna and have been having all sorts of problems getting them to accurately process claims from various providers recently. As of today, it has come to a point where one of the providers has notified me that unless I pay a roughly $500 bill they say I owe, it will be turned over to collections. I have spoken to Aetna about these particular charges from this provider numerous times, and they have been telling me that Aetna is responsible for paying this because I have already met my deductible. The problem seems to be that Aetna has not sent the provider an updated EOB (explanation of benefits) yet. The original EOB the provider received said that the $500 was my responsibility.

I basically feel like I'm just caught in the middle and kind of powerless at this point. My only options seem to be a) pay the bill and hope for reimbursement later once Aetna sends the updated EOB, or b) let the provider and Aetna figure it out and watch my credit get damaged due to the debt collector getting involved. (On a side note, I wonder what happens if the bill goes to collections and then Aetna later ends up paying.)

Anyone have any advice for the best way to handle this? I do plan to call both Aetna and my provider today (once again), but I was hoping to maybe get some other ideas for how to approach this before I make those calls.
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Old 06-19-2015, 09:17 AM   #2
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Can you get both the provider and Aetna on the phone with you (3-way conference call) so Aetna can explain to the provider that you have met your deductible and the claim will be paid and Aetna can explain why there has been a delay?
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Old 06-19-2015, 09:29 AM   #3
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Something similar happened to me a couple years ago. I called the provider and asked to speak with the practice manager. The practice manager is the ultimate decision maker for medical practices, and it's important to discuss this with them directly. Other staff within the practice cannot handle anything other than routine billing issues, and discussing this with them is a waste of time.

Explain what is going on, agree to pay them, and get a commitment from the practice manager that you will be reimbursed once they receive payment from Aetna. Then follow this discussion up with an e-mail to the practice manager, if possible. I did this....and it still took over a year to get reimbursed...but I finally did.

Good luck.....
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Old 06-19-2015, 09:51 AM   #4
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Originally Posted by pb4uski View Post
Can you get both the provider and Aetna on the phone with you (3-way conference call) so Aetna can explain to the provider that you have met your deductible and the claim will be paid and Aetna can explain why there has been a delay?
Thanks for this idea. I think this is exactly what I'll try to do today, although it's usually not possible to directly speak with the billing manager (see my comments below).

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Originally Posted by Silver View Post
Something similar happened to me a couple years ago. I called the provider and asked to speak with the practice manager. The practice manager is the ultimate decision maker for medical practices, and it's important to discuss this with them directly. Other staff within the practice cannot handle anything other than routine billing issues, and discussing this with them is a waste of time.

Explain what is going on, agree to pay them, and get a commitment from the practice manager that you will be reimbursed once they receive payment from Aetna. Then follow this discussion up with an e-mail to the practice manager, if possible. I did this....and it still took over a year to get reimbursed...but I finally did.

Good luck.....
Yes, I learned this a few months ago when this whole drama started. The problem is, the practice manager is virtually impossible to get on the phone. I have left numerous messages and rarely get a call back. She does sometimes respond to emails, but generally the emails are just like "I spoke with Aetna and they said this bill is your responsibility, and we haven't received an updated EOB, so there is nothing more I can do." Sooo very frustrating.

Thanks for the input... much appreciated.
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Old 06-19-2015, 10:01 AM   #5
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There's no way I would pay the bill. I wouldn't hold your breathe waiting to get reimbursed if you do. I would do everything I could to get it worked out, but I would not pay the bill. If your credit is good, one $500 charge that you can dispute wont do much damage at all. Ive done this twice (let an erroneous medical charge go to collections) and my credit score is over 800.
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Old 06-19-2015, 10:09 AM   #6
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There's no way I would pay the bill. I wouldn't hold your breathe waiting to get reimbursed if you do. I would do everything I could to get it worked out, but I would not pay the bill. If your credit is good, one $500 charge that you can dispute wont do much damage at all. Ive done this twice (let an erroneous medical charge go to collections) and my credit score is over 800.
utrecht, what did you do when the collectors started hounding you for payment? I do have a good credit score, and I'm not intensely worried about a ding to my credit since I never take out loans or do anything that requires excellent credit (other than occasionally getting a new credit card for the frequent flier miles bonus). But I definitely don't want to be hounded for months (if not years) by collectors or be threatened with legal action, all over a $500 bill that I most likely would be reimbursed for if I paid it.
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Old 06-19-2015, 10:19 AM   #7
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You should be able to speak to the billing department or the office manager without that much difficulty. The office manager should be at the office virtually every day the doctor's office is open. Sometimes the offices are hard to get through on the phone. Calling in the late morning is usually the best time to get through, and avoid Monday mornings and Friday afternoons. I have actually gone to the doctor's office to get a problem resolved, as sometimes phone access can be difficult.

Also, you should be also have a record of your EOBs sent to you from Aetna, can you forward that to the practice manager? Do you have online access to your account? If you don't, you can register and get access. Most insurance companies now prefer online communications. You should be able to get the EOB yourself that way as well as all the information on your account, and bring it to the office or email it to the practice manager.

I recently had a payment screw up and the mistake was DH's handling of the bill with online banking. It was our fault.
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Old 06-19-2015, 10:40 AM   #8
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Also, you should be also have a record of your EOBs sent to you from Aetna, can you forward that to the practice manager? Do you have online access to your account? If you don't, you can register and get access. Most insurance companies now prefer online communications. You should be able to get the EOB yourself that way as well as all the information on your account, and bring it to the office or email it to the practice manager.
EastWestGal, thank you so much for this suggestion. I do have access to my EOBs through the Aetna member portal, and I just logged in and saw that they have finally posted my updated EOB that shows I do not owe any payment for this bill! Amazing... it has been so long in coming that I assumed it was still not done, but finally... it is!

Thanks to everyone for their input and advice.
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Old 06-19-2015, 11:52 AM   #9
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I have a bronze-level health plan with Aetna and have been having all sorts of problems
Well if it helps you feel any better, based on my experience, they won't treat you any better even if you have platinum coverage.
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Old 06-19-2015, 12:18 PM   #10
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utrecht, what did you do when the collectors started hounding you for payment? I do have a good credit score, and I'm not intensely worried about a ding to my credit since I never take out loans or do anything that requires excellent credit (other than occasionally getting a new credit card for the frequent flier miles bonus). But I definitely don't want to be hounded for months (if not years) by collectors or be threatened with legal action, all over a $500 bill that I most likely would be reimbursed for if I paid it.
The doctors office forgot to file the claim with the insurance company. When they finally filed it like 9 months later it was denied because there was a 6 month deadline. The doctors office then billed me and of course I refused to pay it. After several phone calls with the billing manager at the docs office, she agreed that it was their fault and said they would write it off. I think it was for something like $750.

About 2 months later I got a call from a bill collector. I told them the story of why I didnt owe any money and told them that no matter what they did I would never pay one red cent to a bill that both the doctors office and I know full well is not my responsibility. I told them to do whatever they needed to do but not to waste their time or my time. I never heard from them again.
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Old 06-19-2015, 04:41 PM   #11
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Print the EOB and fax it to the provider.
If that does not solve the problem then (if the provider is an in network provider for Aetna) contact network contracting at Aetna and file a complaint. There is language in the provider contracts that addresses sending or threatening to send members to collections. It's a no no unless the member legitimately owes and a long period of time has passed without the member trying to pay at least a portion of the bill.


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Old 06-19-2015, 04:45 PM   #12
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I'm glad that it sounds like this issue is resolved with the corrected EOB.

The one issue I was concerned with when considering whether or not to pay the bill was that usually the provider's office will not schedule any further appointments if the client refuses to pay an outstanding bill. If you don't care if you see that provider again, then it's fine. In my case, the provider was the surgeon who repaired my detached retina, and I did want to continue using his services.

Just one more thing to consider when deciding what to do.
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Old 06-19-2015, 04:56 PM   #13
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In my experience, Aetna is just incompetent. And that's when they actually want to pay a claim. When they don't want to pay, forget about it.
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Old 06-19-2015, 05:30 PM   #14
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I'm glad that it sounds like this issue is resolved with the corrected EOB.

The one issue I was concerned with when considering whether or not to pay the bill was that usually the provider's office will not schedule any further appointments if the client refuses to pay an outstanding bill. If you don't care if you see that provider again, then it's fine. In my case, the provider was the surgeon who repaired my detached retina, and I did want to continue using his services.

Just one more thing to consider when deciding what to do.
Why would you want to go back to a doctor whose office cant get billing right? Was he the only eye surgeon near you?
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Old 06-19-2015, 06:41 PM   #15
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1) have the claim rep email you an explanation and forward it to the doctor; or
2) depending on your state, file a complaint with the Dept of Insurance or Dept of Managed Care for the delay in claim handling; or
3) pay the doctor and sue Aetna in small claims court for reimbursement and your costs.
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Old 06-19-2015, 07:05 PM   #16
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Why would you want to go back to a doctor whose office cant get billing right? Was he the only eye surgeon near you?
Similar to the OP's situation it was an issue with my insurance....not the provider. In my experience, getting a refund from any medical provider for over payment requires extensive follow-up and persistence.
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Old 06-20-2015, 12:51 PM   #17
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I had a payment issue with Aetna and a lab where I had some blood work done but it was for a much smaller amount. The blood work was part of my annual physical but Aetna initially coded it wrong and refused to reimburse the cost. I got hounded by the lab for the payment so decided to pay it while working with Aetna to get it recoded correctly. In the end Aenta corrected it and sent the payment to the lab. I had no problem getting my payment back from the lab, just took one phone call.
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