Aetna, Inc.

Review: AETNA HAS BEEN JERKING ME AROUND FOR A WEEK PLAYING THE I DONT KNOW GAME IN EVERY PLACE THAT THEY TRANSFER ME TO I WAS TOLD THAT I HAD COUNTUINE OF COVARAGE FOR 90 DAYS TILL I COULD FIND ANOTHER THERPITS AND EVERY THERPIST I TRIED TO CONTAT THAT MET MY NEEDS EITHER ISNT TAKING NEW PATIENTS OR CALLING ME BACK I HAVE BEEN WELL ESTABLISED WITH MY CURRET THERPIST WHOM I TRUST AND THEY WILL NOT APPROVE FOR HER TO BE ON THERE PANEL NOW SHE HAS TRIED TO GET PAID FOR THE CONTUINE OF CARE SHE HAS PROVIED ME AND THEY ARE DENYING IT SAYING THAT I WAS TOLD I WOULD NOT BE APPROVED WHEN I WAS TOLD THE EXACT OPPISTE THEY EVEN MAILED ME THE FORMDesired Settlement: DesiredSettlementID: Other (requires explanation)

I WOULD LIKE FOR ALL THE RECORDINGS FROM MY CALLS PULLED AND TO BE REVIEWED WHERE THEY TOLD ME IT WOULD NOT BE APPROVED AND FOR THEM TO PAY THE OUTSTANDING BILLS

Business

Response:

Thank you for your inquiry received on 09/17/2014 regarding complaint #[redacted] for [redacted]. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Review: I have [redacted] medicine which I need to recieve monthly. Each month I order it to the day so I have enough and do not run out. If I do not have the medicine I will get very sick, [redacted] and end up in the hospital. I have been on hold with them for 50 minutes twice today. Each time they transfer me to a different department and cannot figure out why I cannot get the medicine. This has happened so many months in a row now, I am left with no choice but to file a complaint. I speak with people in every department. My doctor's office has to call and fax them several times. Sometimes they say they have a prior authorization sometimes they say they dont. Their files are not up to date or they say that they are switching me to another system. It should not be this much of a problem. It is frustrating to both myself and my doctor's office. It is also very dangerous because some of the times I have trusted them when they have said they will call me back with more information. No one does. Days lapse and that is more days that I do not have my medicine because they cannot get their systems right. Some people will do an over write but almost every time they have given me a hard time about it. If a perscription is given I am sure it is not legal to withold medicine from a patient because of your records not being correct or your people not following up. I am sure if this was a life or death situation, it would be taken more seriously. I have complained to them each time this has happened (at least 7 times in the year and a half) I have used them as my insurance. It has now been well over an hour that I have been on hold with no results. This time the name of the woman who said she would help me was [redacted]. She never returned my call even though she took down my phone number. Since this has happened so many times I followed up and after holding for 45 minutes with her she wound up transferring me back to the main number without telling me.

Product_Or_Service: [redacted]Desired Settlement: I want this matter resolved on my account. Each month I am supposed to get 24 [redacted]. 12 of the melting tabs and 12 of the pills. Each month it is a problem despite the perscription.

Business

Response:

Business Response /* (1000, 5, 2013/07/03) */

Thank you for your inquiry received on June 19, 2013. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

We reached out to the Pharmacy department for assistance. Since February 4, 2012, the member has been filling the [redacted], the generic for [redacted] 10 mg tab were filled and not (12 of the melting tabs and 12 of the pills) as the member indicated.

The meds were being processed on the same day, written by 2 different doctors, quantity of 12 as a 22-day supply by Dr. [redacted] and quantity of 12 as a 30-day supply by Dr. [redacted]. Because they are the same medication, the system rejects the second transaction as "refill too soon". If the doctors processed as quantity of 24 as what is allowed by the prior authorization on file as a 30-day supply, there should be no rejection. However, authorization overrides have now been placed to allow the member to fill the two different prescriptions that the member gets. We apologize for any confusion and delay this has caused the member.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the chance to address these concerns. If you have any more questions about this particular matter, please contact the Executive Resolution Team at [redacted].

Review: My wife and I are covered through my work with Aetna. My wife went to [redacted] with a referral because she had a scratchy throat. This is a routine type of exam yet Aetna refused to pay the bill and refuse to provide any reason or explanation. The claim number is [redacted]. I pay these guys thousands of dollars a month and they refuse to pay or even explain why they will not pay a routine throat check.

Product_Or_Service: Medical insurance

Order_Number: [redacted]

Desired Settlement: I refuse to pay for this. I have been invoiced by [redacted] directly since Aetna refused to pay and I will NOT pay a dime more!! I want them to pay the invoice in full. I also want to FLUSH Aetna as our corporate insurance carrier and replace them with a "respectable" insurance carrier. They have done this on other claims of ours and I want to be reimbursed. I want to perform an audit on their claims because I believe they have created a denial system and made it impossible to fight denial

Business

Response:

Business Response /* (1000, 5, 2013/05/07) */

Thank you for your inquiry received on April 23, 2013. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

We received an appeal order on April 22, 2013 about this member's claim. The appeal is being handled on Case number [redacted], with a due date of May 22, 2013. The member will get a response from our Customer Resolution Team (CRT) under separate cover.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the chance to address these concerns. If you have any more questions about this particular matter, please contact the Executive Resolution Team at [redacted].com.

Consumer Response /* (3000, 7, 2013/05/08) */

(The consumer indicated he/she DID NOT ACCEPT the response from the business.)

They have not offered any resolution and there is no change to the status of the issue. All they have done here is acknowledge the complaint and offer nothing in return.

Review: We changed health insurance companies from Aetna to[redacted]. The effective date of our[redacted] policy is January 15, 2013. We did not pay our January Aetna bill expecting coverage to terminated within the terms written on our invoice which states, "Full payment of the amount due must be received within 30 days of your due date or your benefits will be terminated. Our deposit of late or partial payments does not constitute acceptance or continuation of coverage. This invoice may aloso refelect a prior balance from a previous invoice. Failure to pay this prior balance by the end of the current month may cause your coverage to be terminated." There is absolutely nothing on the bill that indicates that the policy must be terminated in writing. I did not pay the bill expecting to be terminated as the quote says. Aetna made no attempt to contact me and sent it to collections saying I owe them $1658.00. My monthly payment to them was $829.00. This is absurd as they are trying to get two months of payments from me. When I mentioned to the collections agent that I have not seen anywhere that my policy must be terminated in writing she laughed and said, "Yeah, that's what everyone says." There is a problem if that is what everyone says. We have been with Aetna since March of 2009 without ever a late fee or missing a payment. I do not feel I should be treated in this way. My husband called Aetna, only to be told that I would have to deal with the collection agency.

Desired Settlement: I am currently disputing the debt with the collection agency and will see what happens but want this to be filed with the Revdex.com in case we should need your assistance. We would like to have the bill nullified and not have a credit affected by a collection agency. We feel we do not owe this money. Our health insurance representative who helped us get our new insurance feels that Aetna is playing dirty and recommended we file a grievance.

Business

Response:

Business Response /* (1000, 5, 2013/03/27) */

Thank you for your inquiry received on March 19, 2013. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

We reached out to Individual Billing and Enrollment department for assistance. They advised they mailed the member a possible term letter on January 22, 2013 advising that if no payment was received the policy would terminate effective February 28, 2013 and that they would be financially responsible for the premium for that coverage. The possible term letter also directs them to send a written request to Aetna at [redacted] XXXXX, if they wanted to terminate the coverage.

The policy terminated for non-payment on March 1, 2013 effective February 28, 2013. We mailed a final termination letter advising that failure to pay the balance due may result in the account being escalated to a collection agency.

The account was referred to collections on March 7, 2013. We have received legal approval to change term dates for non-payment members under the following criteria:

* The member provides written proof of new coverage - OR -

* The member provides date/time stamped proof that the request was made prior to the termination.

Per the member's complaint they have new insurance with [redacted] effective January 15, 2013. Once they provide proof of the new insurance, including the effective date, we will be able to change the termination date and remove them from collections.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address these concerns. If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted]com.

Review: I believe Aetna Insurance misrepresented themselves and the coverage they would provide me. The initial term of my health insurance coverage was from January 1-December 31, 2015. I was paying $266.66 per month. On May 4th Aetna Insurance Company made an unauthorized debit transaction of $875.32 from my checking account. Om May 7th I called and asked why. They told me it was the tax credit I owed. I questioned this as my coverage was through December. They told me my coverage was only good for three months and that they couldn't assist me further. They went on to say if I had any further questions to call the Insurance Marketplace.Desired Settlement: I want the $875.32 returned to my checking account.

Business

Response:

Thank you for your inquiry received on 05/18/2015 regarding complaint #[redacted] for [redacted]. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Review: I have been waiting for a claim to be filled by Aetna since March 31, 2014. I have called on numerous occasions and have been told each time that "the claim was being processed." The next time I call, however, there is a reason why the claim hasn't even been processed.Desired Settlement: I would like the claim to be paid! The company told me that they would pay it fully when the service was done, but it hasn't been. I have probably spent 20 hours dealing with this. Now, my credit card has been charged and I am paying interest on the payment.

Business

Response:

Hello,

Review: I cannot believe that I was forced to spend $295 for my prescription that would normally be covered before Obamacare. 1/22/2014 I am told that a pre-authorization is needed from my doctor to refill the normal prescription that I have been getting for 1 year. I pay the full cost to the [redacted] pharmacy. I called Aetna customer service 14 times and every time I am told Pharmacy Management is handling it and the email had been sent to the specific computer database in January. Why am I lied to and why do I feel taken advantage of by a billion dollar company. This is why America has such a bad reputation when it comes to big business b/c no one is every held accountable for their actions. Please be advised that if this is not settled, I will take the next step and seek representation to settle this matter b/c it is a matter of principle and I will not go away. Please advise what are the next steps to ensure this type of ill-advised business practices do not happen to anyone else and the working class doesn't get screwed again.Regards,[redacted]Desired Settlement: Please ensure that I am refunded the full out of pocket cost for my prescription which was paid on 01/22/2014. I have receipts. Why was I not reimbursed.

Business

Response:

Thank you for your inquiry received on April 01, 2014. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Review: I have been attempting, since my first claim in June 2014, to be reimbursed for my prescription medications. In that time, several of my claims were lost and then magically found a few month later, and returned, one immediately after the other, all rejected for day supply, some to the wrong address. Every time I send the claim again with more prescriptions attached, it is ignored until I inquire multiple times, always going over the 30 day requested processing time. The last time I attempted, half of my claim magically disappeared, and the only half that appeared was rejected for being outside my dates of coverage, which was completely incorrect. When asking customer service what happened to it, I got no response except that the claim was sent again to the same place I always send them. The communication between departments and the competency of the pharmacy reimbursement department is clearly lacking. Also, there was apparently a policy change to my health insurance reimbursement that I was never even informed of until January 2015, long after it took affect in August 2014. This is the second Revdex.com complaint I have sent to this company for severely delayed reimbursement.Desired Settlement: I am owed, as per complete coverage of birth control and $10 billed for generic prescriptions, since 3/31/14 until November 2014, $1204.10. I would like this promptly paid, as in the interim of waiting for reimbursement I have gone completely broke.

Business

Response:

Hello,

Thank you for your inquiry, regarding complaint #[redacted] for [redacted]. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Upon receipt of the complaint we immediately reached out to our Aetna Pharmacy Management team (APM) to verify if they had any records of reimbursements that were sent to Ms. [redacted] and if we had received any reimbursement requests that had not been paid out yet. To prevent any private health information being released for public view I have attached the medications that have been reimbursed to Ms. [redacted], which includes claim numbers, paid amount and the paid date. If you do not receive these checks within 30 business days we will be able to place a stop pay on the checks and reissue them.

Please let us know if there are any other medications that you have submitted to us that are not listed so we may better assist you. Please provide us with a copy of the reimbursement request so that we may have that reprocessed as quickly as possible for you. I have also attached for reference, the claim form that needs to be mailed with reimbursement requests and the correct address that it should be mailed to. Please keep in mind to reimburse pharmacy claims we will need the attached form as well as the pharmacy receipt that is stapled to the top of your prescription when you pick up your medication. This shows Aetna how many are being filled, the refill amount left, and amount paid.

Please accept my apology for the delay in processing your claims correctly, and that it required multiple attempts on your part to resolve your issue. Unfortunately, in some instances, procedural errors do occur. When they do, we take them very seriously and do our best to understand how and why the errors occurred and determine what we can do to prevent a recurrence. We continually use feedback like yours to improve our service and prevent issues from reoccurring.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms. [redacted]’s concerns. If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted].

Thank you,

Complaint and Appeal Consultant

Executive Resolution Team

Consumer

Response:

Review: [redacted]

I am rejecting this response because:

I have already filled out multiple forms for the prescriptions listed and have already sent in many copies of the receipts for the prescriptions, I'm sure if you asked the pharmacy department and Aetna Student Health for those they would be able to find them. I guess for the sake of repetition, because this seems to be something Aetna loves to have me do over and over, I'll attach them all again. I was absolutely covered by Aetna Student Health insurance for the months of July and August last year, I know that because I was actively rotating as a full time student at [redacted] during that time, and if you do not forfeit the health insurance with proof of your own, which I did not, then it is automatically added to the tuition. This is a serious error, and if in fact I was not covered during that time, I would like to be reimbursed for that time that I absolutely paid for, and you will need to discuss this error with my school.

Review: I am primary subscriber of AETNA health insurance. My husband is covered under same insurance. AETNA keeps harassing me on my cell phone about service they want to offer to my husband. I told them multiple times that this is not his phone number and asked to take my phone number of the call list but they refuse to do so and for the last few monts they call me at least once a week. Last night they called again, they said that if I put my husband on the phone and he himself asks to take MY phone number of the caller list they will honor the request. My husband asked them to take the name of the list, but the associate on the phone kept talking ignoring the request to stop talking and stop calling. At this point this is plain harasment by AETNA.Desired Settlement: I would like them to stop harasing me and my husband and stop any non claim related communication imediately.

Business

Response:

Thank you for your inquiry received on 03/19/2015 regarding complaint #[redacted] for [redacted]. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Review: Failure to process the most expensive claim in a group received by them in the same envelope on 10-29-14 and delay practices in paying claims

As an out of network provider who works as a solo practitioner, I have submitted my own claims for several patients for the past year. I have had problems getting claims paid.

Patient 1 - With each claim submission, I have had to call repeatedly to get the claims reprocessed for payment, though I have authorization and, at this point a precedent of payment for the services.

Patient 2 - I submitted a group of claims in the same envelope, sent via [redacted]. I have verified that all of the claims in the envelope were received on October 29, 2014 with the exception of the largest claim submitted for a child. The parent and I are incensed. I have resubmitted the claim via fax today (fax number ###-###-####). However, my experience, particularly with large claims is that they are not paid unless I waste time pushing the company to do the right thing. All services for this patient were pre-authorized (a copy of the authorization was attached to the claim) and a case manager was assigned due to the significance of the issues. Payment for claims for his brother were also difficult to get processed, but were eventually paid in full. I do not have time to press nor do I feel I should have to waste time with making Aetna do their job. During phone calls I am asked to send information such as copies of authorizations to company reps. Don't they have access? If not, why? Are authorizations updated regularly? Company reps indicate that they are not. All seem to be delay tactics.Desired Settlement: I do not want a settlement. I want someone at a high enough level to cut through the poor business practices, at best, or systematic strategies to deny payment and get these claims processed efficiently.

Consumer

Response:

Review: [redacted]

I am rejecting this response because: I do not wish to share patient data with Revdex.com. I would prefer to be contacted by someone with authority who will give me a working fax number to share the pertinent forms. I was given a bogus fax number by claims last week. I realized that it was not workable after the Revdex.com complaint was filed. I had a fax number that worked when I sought authorization, so I faxed the information there and requested that they get it to claims. I checked and one of the claims I submitted was still indicated to be missing from the batch mailed. I mailed it again Friday with the authorization attached and made a video of myself mailing it to serve as evidence.

Review: I was put out on short term disability because I was having issues with my heart. I was out a month and a half and Aetna called me and said THEY DENIED MY CLAIM! So I didn't get paid for that month and a half that I was out. Mind you my doctor sent everything they needed and still they denied me.Desired Settlement: I want to be paid for the month and a half that I was out of work

Business

Response:

Hello,

Thank you for your inquiry, regarding complaint #[redacted] for [redacted]. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Upon receipt of the complaint we immediately reached out to the Disability department to review the member’s request. We were advised that the claim was denied as the medical information did not support the member’s disability. A letter was mailed to the member on December 11, 2015, that explains the decision in detail. At this time the disability claim is denied. The member may submit additional information for review and may also file an appeal by following the instructions in the decision letter. The letter states to appeal within 180 days and send the appeal to:

Aetna Life Insurance Company

Fax: ###-###-####

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms. [redacted] concerns. If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted].

Thank you,

Ashley S.

Complaint and Appeal Consultant

Executive Resolution Team

Consumer

Response:

Review: [redacted]

I am rejecting this response because: I tried calling Aetna for a month and a half trying to get everything they needed for my claim. Every time I called they needed new documents which I provided. My doctor even sent everything they needed. Also when I called they kept telling me different things. So I went without pay for a month and a half because of this which also means my bills didn't get paid, myself and my daughter barely had food to eat. I did everything I was suppose to and also my doctor. The denial I feel isn't accurate.

Sincerely,

Business

Response:

Dear Ms. Shea,

Please see our response to complaint [redacted] that was received by us on January 11, 2016.

During our review, we reached out to our Disability department to address Ms. [redacted] concerns. It was determined the denial was accurate. The Disability department sent Ms. [redacted] a letter dated December 11, 2015.

The letter has the appeal instructions Ms. [redacted] can follow if she does not agree with the determination and explains the decision in detail. The letter states Ms. [redacted] may appeal within 180 days and send the appeal in writing to:

Aetna Life Insurance Company

TriNet Group, Inc. Appeals

PO Box 14578

Lexington, KY 40512-4578

Fax: ###-###-####

I apologize for any difficulties or confusion this may have caused Ms. [redacted] We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms. [redacted] concerns. If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team [redacted].

Regards,

Julian C[redacted]

Executive Resolution Team

Review: I was admitted to [redacted] hospital after a fall where I sustained two fractures of my back. I am unable to stand or get out of bed without the assistance of two hospital staff. The Physician responsible for my care recommended transfer to a rehabilitation facility for physical therapy and rehab (previously, I was totally independent and capable of walking 3 miles without difficulty; now I cannot get out of bed and even walk 3 steps). Aetna, without examining me, without reviewing the hospital records, arbitrarily decided that rehab was not indicated and refused transfer. They subsequently refused any communication with the 2 physicians managing my care at the hospital or with the case manager working on my transfer. Aetna refused to send the necessary forms for expedited appeal to me, the case worker, my attending physicians, or my son who has power of attorney, even after repeated calls and written requests for these forms. Aetna will not allow anyone to get past a screening secretary and will not allow us to talk to a reviewing physician. I am not physically capable of returning to my assisted care facility. I remain in the hospital with no solution and no means of obtaining a solution. Aetna told my son the case is closed and not open to appeal, but refused to provide the necessary documents to remedy the problem. They made apparently false statements to the case worker and my son about attempted communication that cannot be substantiated in their phone logs. I am bringing this to your attention, because this has been an extraordinarily frustrating predicament that is exposing me to unnecessary risk of physical harm and is causing unnecessary pain and suffering. I request your prompt assistance in this matter, not only to assist me, but also to attempt to prevent other patients in the future suffering similar predicaments.Desired Settlement: Aetna needs to honor their contract with me to provide necessary medical care.

Business

Response:

Hello,

Review: This is my second complaint about this company. I have been insured by the SRC Group of Aetna since October 2012. I could not receive my perscriptions from them or my family until the last time I contacted Revdex.com. So in like Feb. Everything was good until May. I receive a prescription on May 9 and two weeks later when I went to get one it was denide because it said incorrect member ID number. After many calls to member services on my card they said yes it was correct by the pharmacy part of the insurance said no I was terminated in Dec 2012 and they have never paid a claim of mine. Well the pharmacy said who has then because its right in front of me that the claims went through. The lady argued with my pharmacy NO. This is what happened until I contacted Revdex.com the last time. The pharmacy says this is the worst insurance they have EVER SEEN. I am laid off now and need to pay my own premiums until Sept. If this doesn't get taken care of NOW. I WILL BE NOT PAYING FOR THIS POLICY NO MORE. Someone needs to get this straight and call me with the answers. Disscussed with this company and would not recommend it to ANYONE!!!!!!!!!!!!

Product_Or_Service: health benifits

Desired Settlement: I believe with all the headaches my pharmacy and I have gone through on MULTIPLE OCCACIANS. Months of calling and getting NoWHERE. I should be refunded any portion I have paid towards prescription coverage with this policy. I am just descusted at how this company works and would not recommend it to anyone!!!!!!!!!!!!!

Business

Response:

Business Response /* (1000, 5, 2013/07/03) */

Thank you for your inquiry received on June 19, 2013. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

We reached out to Strategic Resource Company (SRC) for assistance with the member's concerns. They advised when the member was being added to a plan in one of Aetna's systems, an error was received stating the plan was cancelled. When they tried to correct the error, it was showing that the plan was still showing active on another system. The Enrollment department contacted Aetna help desk to report the problem, that the plan was active in one system and showing cancelled in another. The help desk contacted the correct department and advised that to resolve this problem between our systems all affected plans would have to be purged then

re-added. It seems once the error was corrected, the Eligibility Team was not notified to add the member back. They have advised they will make sure this step is added to the workflow to avoid any recurrence and apologize to the member for the error and inconveniences this has caused.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the chance to address these concerns. If you have any more questions about this particular matter, please contact the Executive Resolution Team at [redacted].

Review: AETNA, my health insurance company thru my employer, has prevented me from getting my prescribed medication ([redacted]) for over 3 days now. They require, understandably, that I get doctor authorization for this prescription, which I accomplished successfully over 2 months ago. Now, after only that short time, they are requesting a second duplicate authorization. The authorization is a process which takes anywhere from 2-4 days, but, since I have already completed this process successfully, this wait time is unnacceptable. I have already been approved for all of my prescriptions and I have followed every instruction given to me by AETNA. After recieving this latest request for authorization, I had my doctor call in. This was this past Wednesday and now it is Friday. I have double-checked with my doctor who has filed all of the required paperwork, but, still, AETNA claims (fraudulently) that they have not recieved the authorization.Their policy, that they only cover medications taken once a day, is ridiculous, detrimental to my own mental health, and discriminatory against members who are prescribed certain medications. Adderal in particular is a medicatino that is never only taken once a day. So, anyone prescribed this medicaiton is constantly harassed and prevented from getting their needed medication.

Product_Or_Service: Health Insurance

Desired Settlement: For my needs, at least, this policy is completely unreasonable. Getting authorizatino should at least last for 1 year. Asking that I go out of my way every month and are prevented from getting my needed medicaiton for days on end without anything as much as a phone call from AETNA is tatamount to criminal negligence and actively preventing me from getting my prescribed, needed medication. AETNA should be prevented from getting any favorable rating from the Revdex.com until this policy is changed. Most medications are used more than once a day, so this policy unduly and unreasonably prevents patients from getting their needed medications. Thus, the damages resulting from this policy are a direct result of AETNA's unwillingness to help its members.

Business

Response:

Business Response /* (1000, 5, 2013/07/09) */

Thank you for your inquiry received on June 25, 2013. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

We reached out to the Pharmacy department for resolution of the member's concerns. They advised the member is on two strengths of [redacted]. The prior authorization from Pharmacy department is for [redacted] XR Capsules 15MG and the prior authorization from Aetna Precert is for [redacted] 10MG Tablets. Each strength of medication requires a separate authorization for quantity. Each override is on file properly and according to the approval letter. Approval letter, case number XXXXXXXX is for [redacted] XR 15MG is approved for 3 months, June 7, 2013 to September 7, 2013. Second approval letter, case number XXXXXXXX, is for [redacted] 10MG quantity 90/30, approval from March 4, 2013 to March 5, 2014. The member filled [redacted] 10mg on May 10, 2013 and July 3, 2013. The member filled [redacted] 15mg on June 7, 2013 and no other claims were submitted prior or since.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the chance to address these concerns. If you have any more questions about this particular matter, please contact the Executive Resolution Team at [redacted].

I called Aetna for a doctor in the network for my annual exams. I was given a doctor's name/number in my network and area. The rep then told me the Dr. would give me a referral for the other part of my exam. Since she said this and nothing else, I figured all was covered under my insurance as preventative care. After the fact, I find out it was not. I get a bill, so I send in my appeal to Aetna. They told me to wait 30 days. I called back after 30 days; the appeal never made it to the appeals dept! It was just sitting there. INCOMPETENCE. Aetna gives you inaccurate info and then doesn't pay the bill.

Review: This is a customer service issue and delivery of monthly refills for a critical, health essential medication for a toddler.I have been unable to get a refill for my son's prescription of [redacted] since May 2014. I have contacted Aetna Specialty Pharmacy each week in June and was told on July 3 that the Prior Authorization that my son's Endocrinologist completed would be marked as urgent and processed as soon as possible. I just got off the phone with Aetna and still [redacted] is pending and the only thing that can be done is rush it through which is not reassuring since I have been told that at least four times in the past two weeks. I explained my frustration and my concern since it has been almost two months and my son has no medication. My son does not produce any growth hormone, so his daily injection of [redacted] is extremely important. He is 4 years of age and started taking [redacted] before he was 1 year old. My doctor has done everything to ensure Aetna had all information needed to process the Prior Authorization and yet Aetna still has not done it. Aetna does not have anyone or department that advocates for its patients, so for a mother this is very disheartening and troubling. Every time I called, I spent an hour to two hours on the phone holding and waiting only to hear the same information again. I need resolution and decided to attempt to reach Aetna this way before I take this to court. Below is a summary of struggle I have endured over the past few weeks. ________________________________________I contacted Rx Member Services on Friday 6/27 after trying again to refill my sons prescription with the Specialty Pharmacy, still an issue.wish to file a complaint once I get a response from my sons Endocrinologist. 6/13 prior authorization pending, no informationThe representative placed me on hold and followed up with Specialty Pharmacy Prior Authorizaton and was told that they received a second prior authorization request for [redacted] on Friday 6/20 and it is being processed now. They will expedite it but it could take another week. The representative recommendation was to wait for the decision. If it is denied then call Member Services to file an Appeal.Complaints, Grievances, Appeals must be in writing Aetna[redacted] (fax)[redacted] from the Endocrinologists office returned my call at 10:58am stating the Prior Authorization request made last week was for [redacted] not [redacted] reviewed the file and confirmed. She fought tooth and nail to get the [redacted] approved. [redacted] said Aetna contacted the Endocrinologists office after I tried to refill the prescription at 10:00am. Aetna Specialty Pharmacy was confused because two prescriptions are on file, so the doctor clarified that the prior authorization request and the prescription is for [redacted] not [redacted] recommended I make another attempt to refill the [redacted]. I tried to get a refill at 11:30am, but it still would not process. The verbal approval that was given to the doctor has not been finalized yet. I will try again next week.Monday, June 30, 201411:30 amUnable to refill [redacted] prescription/refill still on hold due to no prior authorization on file.No notation of prior authorization receiving/processing. Follow up by Specialty Rx, put on hold to research issue.12:05 pmWhile on hold, I contact Medical Member Services to file a complaint/appeal. Member Services called Rx Mgmt. Representative ([redacted]???) was very helpful she explained situation and why I am frustrated. [redacted] in Rx Mgmt said she understood but was only triage and would have to transfer us to a Prior Authorization Agent. Member Services Representative was advocating for me and asked if [redacted] could relay background info to Agent and/or Supervisor. She said it would be better for me to do it so nothing is lost in translation. She would immediately request a supervisor so I would not have to repeat several times. [redacted] put us on hold while waiting to be transferred to a Prior Authorization Agent, the call was disconnected at 12:30pm. Waited 10 minutes, but did not receive a call back, so I called back.12:40 pmCall Medical Member Services again to file a complaint/appeal. Members Services called Prior Authorization Department. Provided details. Prior Authorization explained that there are three separate Precert Departments which may be the reason for the run around. She suspected in the past, the wrong Precert Department may have been contacted which prolongs the process. She put us on hold to transfer to Rx Precertification. Call disconnected 1:06 pm. Aetna Prior Authorization Representative called back and said we were disconnected. She had spoken to Aetna Specialty Precert Representative and was told: The prior authorization form was received from the doctor on 6/27. After she reported my son had no medication on hand, the Precert Representative said the Prior Authorization will be expedited and rushed through today. It is expected to process and be approved by end of day. Just in case there are issues, she gave me the direct line for the Specialty Rx Precert Dept (###-###-####). I will try again either Tuesday or Wednesday of this week. Wednesday, July 2, 2014Called to refill and was told by [redacted] that [redacted] was pending. I expressed my frustration since I was told on Monday that the Prior Authorization was being expedited. She did not understand and put me on hold. [redacted] contacted [redacted] and [redacted] did understand and remained on the phone. [redacted] contacted several departments trying to find assistance. [redacted] finally reached Nina, emp id [redacted] at ###-###-####. Nina would not speak with me, so [redacted] put me on hold and talked to [redacted]. Per [redacted] explained that they got the prior authorization form on 6/19 but medical did not start to process it until 6/27. They will mark this as urgent and process it asDesired Settlement: I want the Prior Authorization for [redacted] approved and the prescription filled immediately. I also want a case review of the issues that Aetna seemed to have with my son's diagnosis and medication. This is a horrible situation that I do not want to happen to me or any other family.If this is not possible, then I need a denial decision in writing so I can proceed with legal proceedings to get the medication my son needs.

Business

Response:

Thank you for your inquiry received on 07/09/14 regarding complaint #[redacted] for [redacted]. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Review: I had surgery to perform a Mastectomy in August of 2014. Prior to the surgery, I confirmed with both my doctor and the insurance company in regards preauthorization from my doctor. I was told it was not needed by insurance, but if it was, doctor would provide. My husband and I relocated out west after my surgery. In March of 2015, I was sent a bill from the hospital for just under $4400 dollars. I immediately called and was told insurance denied my claim because no preauthorization was given. When I contacted insurance, I was told I now had to appeal the process. I was now notified my appeal was denied because I had 120 days from time of surgery to appeal. However, I was notified of the bill in March of 2015, after the 120 days was up. I should not have to pay for the balance when I was given authorization by my doctor and not given enough notification to provide to the insurance companyDesired Settlement: I would like insurance to honor what was stated prior to my surgery as I was following there instruction and gave me no outcome to resolve since the bill was furnished well outside there 120 day process. 0 balance to my account

Business

Response:

Hello,

Thank you for your inquiry, regarding complaint # [redacted] received on 09/22/15 for [redacted]. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Upon receipt of the complaint, we contacted our Claims department and confirmed that the claim from Dr. [redacted] was denied correctly. The authorization on file was for [redacted] Hospital and Dr. [redacted]. Dr. [redacted] was not included in the authorization. Unfortunately, we would not be able to make an exception to allow this claim without an authorization.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms. [redacted]’s concerns. If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted].

Thank you, LaShonda C. Executive Resolution Team

Consumer

Response:

Review: [redacted]

I am rejecting this response because:We are not contesting the bill from Dr. F[redacted]. We paid him out of pocket. The [redacted] Hospital sent us the bill for Dr. [redacted], who was told I didn't need precertification. And when I appealed the bill, the insurance said I was denied because it was after 180 days past the date of service. There was no mention of Dr. [redacted] at all. He was paid separately and in entirety prior to the procedure.

Sincerely,

Review: On 3 separate doctors office visits Aenta has forced me to pay deductible charges for visits that should have been covered under the co-pay only.

Two eye doctor's visits for my daughter [redacted] on 7/22/14 and 9/23/14 the doctor's office has coded something as diagnostics but I was with my daughter and all the examines were routine and done in office with no special equipment, blood drawn etc. Aenta is interpreting the code incorrectly and I should only be charged the co-pay but after several attempts to have them correct them Aenta is stuck on it's policy.

Separately on an ER visit I had myself [redacted] on 2/12/15, a blood test of $320 was done during the ER visit but because how it's coded, Aenta says it goes against the deductible which it's supposed to be only a 10% for me to directly pay. Again I've complained numerous times but Aenta cannot fix the issue internally.Desired Settlement: For the ER visit on 2/12/15 the Aenta says owe $168.01 but I should only be paying $16.80

For my daughter's visits Aenta says I owe on 9/23/14 $70.50 and 7/22/14 $213.13 but I should be paying $0

Please note both 9/23 and 7/22 the total doctor's fees was $924 each but somehow Aenta disagrees on how much I owe on both which where the exact same type of visit. Clearly internally Aenta cannot agree on their evaluation on what is deductible and how much.

Business

Response:

Thank you for your inquiry received on 04/14/2015 regarding complaint #[redacted] for [redacted]. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Review: I've been the victim of a bait and switch by Aetna. In December 2014, I was sold a health insurance policy by Aetna (Aetna Silver $20 Copay EPO Signature) with the assurance that my current healthcare provider was in network with this particular plan, and found out in January that my physician was never in the Aetna network -- not in December 2014 and not in January 2015. (Note, my doctor was listed as in network when I chose the Aetna plan in December, I have this information from the Aetna website.)

When I learned in Jan 2015 that my doctor was not in network with Aetna, I called my doctor's office to see if a simple error had been made on their part. That is when I learned they were not in the Aetna program, and had not been in it in December 2014, and that many other patients had been duped in a similar way.

The Aetna insurance was significantly more expensive than competing plans, and I chose to spend the additional money for it based on the assurance I could continue with my current physician. Upon learning that my physician was not in the Aetna network (and never was), I cancelled the policy and had to move quickly to find alternative coverage. Having been burnt once by Aetna, I had no desire to continue to work with them.

I wrote to Aetna to complain, and they responded that I was informed in January that my doctor was not in their network. That's correct, but Aetna fails to mention that I was informed incorrectly that my doctor was in network just one month earlier.

I think ultimately that Aetna needs to be censured and fined for this type of behavior. In the interim, for my situation, I'd like a refund for my payment for January coverage ($632.97)Desired Settlement: I think ultimately that Aetna needs to be censured and fined for this type of behavior. In the interim, for my situation, I'd like a refund for my payment for January coverage ($632.97)

Business

Response:

Thank you for your inquiry received on 04/10/2015 regarding complaint #[redacted] for [redacted]. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Review: Claim filed 2/5/14, Since that time repeated information has been sent, numerous phone calls made, and claim has not been approved. Aetna customer service does not return phone calls as promised,and continues to delay. I am a [redacted] who has been out of work for over 6 weeks, and am struggling with daily activities. I have been told by 2 [redacted] that I am unable to work, and this information has been given to aetna.Desired Settlement: Claim approved in a timely manner

Business

Response:

Thank you for your inquiry received on March 6, 2014. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.