The Games Aetna Plays

I'm going to start by saying what I have to be thankful for. Thanks to the much-vilified ACA, my annual mammogram and my post-50 colonoscopy are provided at no cost to me, even if my spouse and I have not met his employer-provided insurance coverage deductible. Who knows how long that will last, thanks to the GOP-controlled Congress working day and night to repeal everything President Obama touched. But lucky for me I got to use these wonderful preventive care benefits as long as I did. My first colonoscopy found a few polyps, so I thank all who brought me the ACA, and all who have brought attention to the need for colon cancer screening, for possibly preventing and/or delaying the day when I may have ended up with colon cancer.

In the crazy world that is the U.S. health insurance system, I am probably better off than most people. Our employer-provided health insurance is a high deductible plan, but, oh well, chronic migraines go a long way in a short time to helping one meet that deductible. We are fortunate to be able to pay the deductible, so we can actually afford health care itself, beyond paying the premiums for health insurance. We have an HSA through Mr. Z's employer and that helps a bit as well - again, because we have enough money to spare to put into the HSA to begin with.

So I feel grateful for these things.

I also feel grateful for the Mental Health Parity and Addiction Equity Act provisions, which means that treatment for mental health has been covered the same as medical and surgical treatment. This is still not perfect, because most mental health providers one wants to see are not "in network" with any insurance company. So one must pay upfront, out of pocket, and submit a claim for reimbursement.

The parity provision has meant, in theory, that instead of being assessed a variety of coinsurances and copays separate from my regular coverage and then offered a reimbursement rate that works out to something like 15% of what I paid out of pocket, I get reimbursed for everything, if I have met my deductible.

In practice - only if I'm paying attention.

Because I receive SSDI, I am also automatically enrolled in Medicare Part A, which provides only hospitalization coverage. When I submit a claim to Aetna for out-of-network provider reimbursement, Aetna wants to know if I am covered by any other insurance. I always fill in the information on the form - Medicare Part A only. I always include a cover letter, stating that while I have Medicare, it is Part A only, and does not provide any coverage or reimbursement for the claims submitted.

Nine times out of ten, Aetna either refuses to process the claim because they are "waiting for [my] Medicare EOB" or because "member did not supply information on Medicare portion of this claim". I then call Aetna and say "see that form I sent with the claim? and the cover letter? where it says I have Medicare Part A only? so there is no Medicare portion of this claim?" And they say, oh, yes, just a processing mistake, we'll send this back for reprocessing, it will just be two to four weeks to reprocess.

Sometimes Aetna just flat out refuses to deal with it. I submitted one claim and heard nothing for weeks. I called Aetna: no, they never received it! Why did I submit the claim through the mail? Nobody sends claims through the mail! (Instructions on the form and on the back of the member card tell you to send the claim by mail, and give you the address where to send it.) I should have faxed my claim! Fax it to this number! I faxed it. Which cost me money, because I don't have a fax machine at home. And got...crickets. Called again. No, they never received anything. They don't know who gave me that fax number but it's not the right one to use. I should have submitted it online. I balked. They allowed as how maybe it could be mailed in, and promised to process it in two to four weeks... I said I felt harassed. I mailed it in again. This time miraculously it was received and processed.

Earlier this year, I submitted a claim in the usual way. Aetna received it - somehow, the mailroom does work! And they processed it, really rapidly, and sent me a check right quick. I was so happy I didn't realize the check was only 60% of what it should be. Today I was going over my records and trying to reconcile the check received with the documents I had submitted. (Pro-tip: keep copies of everything you ever send to a health insurance company, and keep an organized file system.) I studied the EOB for the claim, a multi-columned table studded with footnotes.

Here's the trick Aetna pulled. They separated the multiple dates of service, all submitted in one claim, into two groups, and listed them as two separate claims on one EOB. Then they sent me a check for one of the "two claims". They flagged the other as "member did not submit Medicare EOB information for this claim" and dumped it in the "do not pay" file.

Just like that, they wrote off 40% of a bill they owed me. Let us say there were ten dates of service from the same provider submitted together in one claim. Aetna grouped the first six dates of service together and said "these, we will pay". Aetna grouped the last four and said "these, identical services from same provider that we should also pay, tick this flag and don't pay."

I have to give them credit. It took me awhile to notice what they did and if I didn't keep good records and obsessively look them over every so often I might not have noticed it. If I were sicker, or more preoccupied with other things in life right now (like elder care) it might have slipped by me. And Aetna would have saved 40% of a bill they legit owed me with a simple trick that on the surface looks like human error. "Well, she does have Medicare, so one of our employees was just overcautious in not processing those claims in case the Medicare was outstanding." Never mind the six other identical services that went through just fine, and never mind they were all submitted on the same form.

After I called Aetna to "correct" this "processing error" (15 minutes on the phone, and was told "two to four weeks to reprocess") I said I wanted to submit a complaint. I got sent to a voice menu that asked me a bunch of questions about the person I interacted with, who was perfectly nice and helpful. At the end I was asked if I wanted to leave a comment. Did I ever.

I said that my spouse pays good money for our insurance premiums, that these premiums are supposed to purchase coverage for us; that every time I submit claims from this out of network provider, I get the same run around about "waiting for Medicare EOB" information, even though I have informed them there is no Medicare coverage; that I feel harassed by my insurance provider; that having to deal with this red tape and stalling and refusal to pay makes me sicker; that my health insurance company should be helping me with my health, not making me feel worse; that if we pay for coverage we should expect that it should be there when we use it.

I am grateful to the ACA for my having access to coverage for mental health providers at all, and I am aware that this coverage is precarious and about to be taken away from me and others. I am grateful that I have the resources to expend for mental health care while waiting months for my health insurance company to get around to deciding to pay what they owe me for coverage my spouse and his employer have already purchased. I am aware this is probably the best coverage for mental health care I've ever had in my life. With all its problems, my situation is no doubt enviable to many.

I grieve thinking that the GOP-controlled Congress doesn't see what I have as just barely adequate, as something worth building on, making better. I grieve that they don't see the problem as lying with insurance companies who use accounting tricks to withhold 40% on the dollar from disabled, chronically ill customers who paid for coverage. I grieve that they think the solution is just to take away what little we do have and give us "access" to high-risk pools. If insurance companies are playing dirty tricks to get out of providing coverage to people like me now, what will they do when unfettered by the ACA?

2 responses so far

  • potnia theron says:

    I think that if a child or a parent of a congress critter had to go through what we do, they would reconsider. If Insurance executives actually saw how it worked, they might rethink the process and situation. But, I suspect they all, deep somewhere in the pumping organ that passes for a heart, think that people are trying to steal from them, take money and things they don't deserve. That the reason they (and their beloved children, of course, who have done nothing to earn what they get) don't have these problems is because they are so much better, and deserve the privileges they get.

  • Jaws says:

    Hmm. Sounds to me like a pattern or policy of failing to accommodate administrative standards to a recognized disability under the Americans With Disabilities Act's various requirements. Perhaps a lawyer letter (from SpousalEmployer's legal department, or even privately) to Aetna's legal department is called for... and if the reply is nasty or dismissive, a follow-up copied to the state health department and state insurance commissioner may be appropriate. You're not being confrontational if you choose to have that letter sent: Aetna has already started the confrontation. As it almost always does, consistent with industry custom.

    Notice that I didn't say "file a lawsuit." That would just harden Aetna's position if it's not offered at least two opportunities to correct (long, boring exposition on why insurance companies "deserve" more opportunities to correct policy-and-procedure problems — at least according to the courts — omitted). Appealing to "insurance executives" by requiring them to go through the same process won't work, because most executives actually in a position to do anything about it have People to do their own claims work for them and thus have no conception of the actual claims process (and think it doesn't apply to them anyway).

Leave a Reply