Aetna, Inc.

Review: I have called Aetna several times in attempt to process a medical claim from 6-18-14. At that time I had dual Aetna medical policies, a policy through myself and a policy through my husband ([redacted]). Every time I have called, Aetna continues to bill my husband's policy first which results in a denial of my claim and a $320.08 bill with my provider. I have spent several hours on the phone with customer service and have spoken with numerous representatives trying to resolve this issue. My provider has called multiple times on my behalf as well. It seems unreasonable that Aetna is still unable to process my claims with my dual coverage through them, billing my policy first and my husband's second. I'd like to have this issue resolved as soon as possible.

Product_Or_Service: medical claim

Account_Number: [redacted] id#[redacted]Desired Settlement: DesiredSettlementID: Other (requires explanation)

I'd like my claim from date of service 6-18-14 to be billed properly to my policy first and my husband's policy billed second.

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 contacted our Claims department regarding the claims from June 18, 2014. We confirmed the coordination of benefits for this member’s plan. The claims have been reprocessed for both health plans and payment will be made to Dr. [redacted] within 7 – 10 days. We apologize for the inconvenience this has caused. We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mrs. [redacted] concerns. If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted]. Thank you, [redacted] Executive Resolution Team[redacted]Complaints and Appeals ConsultantExecutive Resolution Team[redacted]

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 contacted our Claims department regarding the claims from June 18, 2014. We confirmed the coordination of benefits for this member’s plan. The claims have been reprocessed for both health plans and payment will be made to Dr. [redacted] within 7 – 10 days. We apologize for the inconvenience this has caused.

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

[redacted] Executive Resolution Team

Review: I currently have Aetna SRC insurance. I have had their insurance for six years out of the ten that I have been employed at my current job. The terms of their insurance plan state that if I see an in network doctor, they pay up to 100% with a $15.00 copay. I have visits from 9/6/12, 10/25/12, 1/31/13, and 2/21/13 that they are only paying at 50%, leaving a balance of $233.81. I have called them ten times since January to get them to fix my bills. Every time, they say that the bills have been forwarded to a manager for a review. The last time I spoke to a gentlemen named [redacted], who assured me they would be forwarded to the proper department for handling and that he would follow up with me in a week. He did follow up with me and left me a voicemail on my phone a week later stating that the bills were fixed and payment would be issued to [redacted] in [redacted] and that I was only responsible for my $15.00 copay. This was in February, Shortly after that I recieved Explanation of Benefit statements in February that showed the corrections and that I was only responsible for $15.00. My bills were still never paid. With the amount of calls that I have made and due to the fact the bills still have not been paid, it is clear that this company is a fraud and ripping off the consumer. They should be investigated. Is there anything that you can do to get them to follow my insurance policy and pay my bills. I have copies of everything, the corrected EOB's and their voicemail on my phone. My insurance is Aetna SRC GRP#[redacted]. ID#[redacted]. Aetna's phone number is [redacted]. Their Address is [redacted]. Upon looking up information about them, their are numerous complains online from other people not getting their bills paid. They should be held accountable. Thank you for your time.

Product_Or_Service: AETNA SRC

Account_Number: ID[redacted]

Desired Settlement: I want them to pay the $233.81 balance that they are responsible to pay. I have since paid my $15.00 deductable as they stated, in word and writing that I was responsible for paying. These bills have been left unpaid for months now. I have called them ten times and they are refusing to follow through and pay them.

Business

Response:

Business Response /* (1000, 5, 2013/04/25) */

Thank you for your inquiry received on April 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), an Aetna Company, for resolution of the member's concerns. The claims for dates of service, September 6, 2012, October 25, 2012, January 31, 2013 and February 21, 2013, have been reworked to show member responsibility as $15.00 copayment only. They advised they will contact the provider with this information. 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].com.

Review: Dear Mr. Bertolini,

I am writing to inquire of someone of authority with Aetna. I am POA for my mother who is a customer with Aetna though the [redacted] program. It appears that Aetna is using the old "smoke and mirrors." That is, my mother is in need of hospice and I contacted Aetna to locate preferred providers. The Aetna representative [redacted], walked me through the Aetna website to find providers for my mother's plan. I printed a list of 67 providers directly from the Aetna website that she directed me to on 1/27/2016. I asked her to review my mother's benefits with me for hospice and after a 5 minute hold I was told that Aetna does not cover hospice care. She was unable to explain why hospice providers were listed on the website. Incredulous, I requested a supervisor (I cannot find her name) who confirmed that Aetna does not cover hospice care.

I have already contacted my congressional representatives about Aetna's egregious breech of the public trust by this willful misrepresentation of healthcare services to customers who are sick.

Since Aetna appears quite organized when collecting funds from my mother's [redacted], I would expect a reasonable response as to why my mother cannot receive services. Further, in a separate conversation with an Aetna supervisor last month, I was told that my mother would not qualify for Home Health Services, yet she was unable to direct me to a written description of this policy or mail/email a copy of the Aetna policy or benefit description.

From my perspective, you have unknown Aetna Representatives on the telephone interpreting benefit policy information with no understanding of health care or medical issues.

The services I seek were recommended by a board certified neurologist as being medically necessary for my mother's medical condition and I respectfully request a response of why my mother's health insurance with is funded by the government is denying her coverage for medically necessary service.

Respectfully,

[redacted] for [redacted]

###-###-####Desired Settlement: 1. I would like a written description/definition of her benefit SPECIFICALLY pertaining to Home Health and Hospice care (not a 500 page book written by lawyers that contains more than a reasonable person can read).

2. I would like Aetna to approve payment for hospice service providers that were listed on the Aetna Website on 1/27/2016. In other words, honor what was described on their website

Business

Response:

Hello,

Thank you for your inquiry, regarding complaint #[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 [redacted] department to have the member’s concerns reviewed. We were advised by the [redacted] department, that The Annual Notice of Change (ANOC) and Explanation of Coverage (EOC) The Centers for [redacted] & [redacted] require us to send a combined ANOC and EOC mailing each year. The ANOC describes the changes to the members plan for the upcoming plan year. The EOC is the actual contract that provides the members plan benefits and guidelines. All of our booklets and mailings are approved by [redacted] and are written according to [redacted] guidelines.

We reviewed the members ANOC/EOC and found the following: Page 54 states: Hospice

The member may receive care from any [redacted]-certified hospice program. The member is eligible for the hospice benefit when their doctor and the hospice medical director have given the member a terminal prognosis certifying that the member is terminally ill and has 6 months or less to live if the members illness runs its normal course. The member's hospice doctor can be a network provider or an out-of-network provider.

Covered services include:

- Drugs for symptom control and pain relief

- Short-term respite care

- Home care

For hospice services and for services that are covered by [redacted] Part A or B and are related to the members terminal prognosis: Original [redacted] (rather than our plan) will pay for hospice services and any Part A and Part B services related to the terminal prognosis. While the member is in the hospice program, their hospice provider will bill Original [redacted] for the services that Original [redacted] pays for.

For services that are covered by [redacted] Part A or B and are not related to the terminal prognosis: If the member needs non-emergency, non-urgently needed services that are covered under [redacted] Part A or B and that are not related to the terminal prognosis, the cost for these services depends on whether the member uses a provider in our plan’s network:

-If the member obtains the covered services from a network provider, the member will only pay the plan cost-sharing amount for in-network services

-If the member obtains the covered services from an out-of-network provider, the member will pay the cost-sharing under Fee-for-Service [redacted] (Original [redacted])

When a member enrolls in a [redacted]-certified hospice program, their hospice services and their Part A and Part B services related to their terminal condition are paid for by Original [redacted], not Aetna [redacted] Select Plan (HMO).

Hospice consultations are included as part of Inpatient hospital care. Physician service cost sharing may apply for outpatient consultations.

Aetna Compassionate Care Program This program offers case management and services to members and their families who are managing the complex and emotional issues involved in advanced illnesses. A nurse case manager by the name of Sue L. will be in contact with you.

We strive to provide the best customer service experience possible and we expect that in all of our departments. We have reviewed your concerns and verified the calls made into our Member Services. We forwarded the issue to the representative’s direct supervisor for education and/or re-training.

Aetna strives to provide the highest level of service, quality, and satisfaction, and to continually improve our processes. I want you to know that we appreciate your feedback because it gives us the opportunity to listen to our customers and make any improvements to our processes and the service we provide. Your opinion is valued at Aetna, and I trust that you will not hesitate to contact us when you need assistance.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [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:

The response from Aetna does sound like a response from an attorney rather than anyone actually addressing my concerns. This is just a summary of the benefit that is so couched in "legalize" that I am not sure that my actual issue was addressed. That is, the response of the individuals, the representative and her supervisor, in addressing my concerns.

Since I did send an email to the company CEO, I did receive immediate feedback (within 1 1/2 hours) from someone with the corporate office who was able to answer my questions (that the initial Aetna representatives could not). It is a travesty that a paying customer should have to contact the CEO in order to obtain a response to a reasonable question about benefits.

Additionally, while I communicated my concerns in my complaint using my name as Power of Attorney for my mother, I notice that their response on this public website uses her full name and potential need for hospice services. Since this is protected health information I wonder if there has also been negligence in this.

It almost seems malicious unless the person writing the response is not familiar with HIPPA requirements.

Sincerely,

Business

Response:

Hello,

Thank you for your inquiry, regarding complaint #[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 back

out to our [redacted] department to have the POA’s concerns reviewed. We were

advised that they have sent the POA a new letter today, February 23, 2016, that

addresses all of her concerns.

Please know that all the information shared in our last

response is private and your complaint is not available for public view. All

member names, addresses, complaint numbers, Dr. names, claim IDs etc. are

starred out by the Revdex.com if they make it available for public view. They also

block complaint numbers from the public view. Only the analyst who is assigned

the complaint and the member or their representative can view the HIPAA

information provided in a resolution by clicking on the link supplied in an

email separately to Aetna and the member/representative with a log in and

password. We verified on the Aetna Revdex.com website that your complaint is not

available for any public view.

We sincerely apologize if you were not happy with our initial

response to you, as this was not our intent. We are here to assist our members

and if you have any further questions or concerns about the plan please feel

free to contact the number listed on the [redacted] resolution letter mailed

today, or you can email the address below.

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:

I have reviewed the response made by the business in reference to complaint ID [redacted] and find that this resolution is satisfactory to me.

Sincerely,

Review: I have been taking various prescribed medications for [redacted] since march of 2013, the medications in question are [redacted]) and [redacted]). My coverage with Aetna began in May of 2014, and I was taking at the time 120mg daily of [redacted], and 100mg daily of [redacted]. My monthly premium was approximately $330, and being that I was 28 years old at the time, and very healthy other than my mental illness, the most important aspect of my coverage were these medications. After beginning coverage, I went to fill my prescription as I would do monthly and neither medication was covered, so I had to pay the full amount of around $270. When I inquired why this was the case, I was told that 120mgs of [redacted] Exceeded the recommended daily dosage according to Aetna. So I rectified the situation, consisting of numerous calls between myself, my doctor, and Aetna, and finally agreed that over a 3 month period I would ween myself down to an appropriate dosage, and Aetna sent me correspondence stating they would cover it in the meantime. The next month the medication was still not covered, costing me more than $250 once again, paying for the medication in it's entirety out of pockey. This happened a third time the following month before I called to see why I wasn't being covered. I was told by the representative that they would run my information again, because to them they couldn't see why my meds were not being covered. The following month I again paid the full price out of pocket. When I called again, I was now told that [redacted] was not covered under my "preferred generics" and that I needed to pay a deductible of $500 before it would be covered. Obviously I had already paid close to $1000 dollars at this point on the medication, but [redacted] (The pharmacy used in every instance), had not run my insurance everytime I filled my prescriptions, unbeknownst to me. I went to [redacted] and had them print out of detailed history of my prescriptions, and attempted to fax it numerous times to Aetna's pharmacy department, and the fax was either not received or it was returned to me saying I had inadequate information for them to process my request for reimbursement. Over the dozens of conversations I have had with dozens of Aetna's employees, and the HOURS I have spent on the phone trying to resolve this situation, Aetna has been EXTREMELY inconsistent and it almost appears as If they are trying to exhaust me to the point that I no longer pursue them for money that I feel I am entitled to. Had I been given the proper information initially, I perhaps could have gotten a policy that was more suited to my health needs. I also find it extremely unprofessional that it took months for them to figure out why my medication wasn't being covered.Desired Settlement: I would like a refund of the entire deductible ($500), and all money I spent on both medications that were not covered under any insurance policy. I would also like a refund on three months of my premium, seeing that it was essentially rendered useless, given that my sole need for the policy was to cover said medications. I have documents to prove what I have spent on the medications, and can produce contact numbers for my doctor, and any other information needed. I feel helpless against such a large company, and would appreciate somebody going to bat for me, seeing that the hours I have put into this have not produced any resolution, let alone a desired one. Finally I would like to add that dealing with a mental illness and having to deal with Aetna has been extremely taxing mentally and emotionally.

Business

Response:

Thank you for your inquiry received on 02/27/2015 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 canceled my AETNA policy, because I was enrolling in a different program. AETNA retroactively changed my cancellation date, to avoid paying claims.

On Thursday November the 13th, after 2:00 pm, I called Aetna customer service associates because I wanted to terminate my Aetna insurance and the reason why I wanted to end it is because I was just added to my husband's insurance. I told Aetna that I would like to have it terminated on Friday November the 14th and they accommodated me with that. Unfortunately, on Friday the 14th, I found out that the effective date of my husband's insurance actually starts on the 1st of January 2015. I called Aetna back on Friday to ask whether they could reinstate my insurance since I did not want to stay uninsured, but it was too late to call that day because it was after the working hours, so I decided to call back Aetna on Monday, November the 17th at 9:30am. I explained my situation to the Aetna associates and was told that the termination process will be cancelled because the process was not finished yet and that I would not have to worry about it. They asked me if I would like to have a new termination date on the 31th of December and I agreed. They also mentioned that they would send a letter stating this date. I had two doctors' appointments made that week and I told the AETNA representative in my Monday phone call about them. One on Monday the 17th (same day I wanted my insurance reinstated) and another one on Thursday the 20th with my primary Physician. I had to have my thyroid function checked which means I had to have some blood taken and have it sent to the lab.

Later, I received a letter that was sent out the same day I reinstated my insurance, November 17th, saying exactly what we agreed to: "You asked us to change the termination date of your Aetna plan. Your plan was cancelled on 11/14/2014. The new termination date is 12/31/2014. This is based on when you sent us your last premium payment."

However, several days later I received another letter that was sent out on the 21st of November, the day after my doctor's appointment, which stated: "You asked us to change the termination date of your Aetna plan. Your plan was cancelled on 12/31/2014. The new termination date is 11/14/2014. This is based on when you sent us your last premium payment." This is nonsensical.

I did not think much of the letter and thought it was sent to me by mistake. But at the beginning of December, I received a bill from [redacted] for $573.46 which was for the blood work I got done on 11/20/14 and found out it was not covered by the insurance and that I was not insured all this time. In addition to that, I got another "bill" from Aetna, dated for 11/24/14, in the amount of -$181.00, in an apparent attempt to refund my November payment for coverage through December.

It appears that Aetna was knowledgeable of my intention to have the policy extended through the end of the year, and decided to retroactively remove my policy after receiving a billing request from my doctor. I had multiple reasons to believe I would be covered for this doctor's visit per the conversation I had with the Aetna representative on November 17th, along with the letter detailing the termination date of 12/31/2014, also dated November 17th.

Use of the AETNA website to file a complaint resulted only in error messages, and an email to AETNA customer service has been unanswered.Desired Settlement: I want AETNA to honor its obligations under my insurance policy and assist in the compensation of my medical bills that I received while I was under the reasonable assumption that I was insured by AETNA.

Business

Response:

Please see our response to the complaint # [redacted] for [redacted] received on January 02, 2015.

Review: I have a problem with Aetna and their billing/contract issues. I have health insurance with them. I called and spoke with [redacted] on 12/12/2013 and asked him if this particular service is covered by my insurance and if it needs precert. [redacted] stated it is a covered benefit and it does not need precert, so I proceeded to have my injection done with the doctor the next day due to my pain. I have [redacted], and I had a [redacted]. I have had this procedure done twice in 2010 and done in December of 2012, ALL times it was covered NO PROBLEM. Now I receive my EOB and a bill from my doctors office stating not a covered benefit and my EOB states the that the procedure is investigational/experimental. I asked them how that could be and still get the explanation of you will have to write an appeal so now I have asked to speak with a supervisor named [redacted] and to date she has not called me back. I have had insurance with Aetna for over 10 years and time and time again all I have are issues with NON payment and I am tired of this. They keep telling me to write an appeal and it takes them over 6 months to finally pay, while they are doing that I am off to collections with bill collectors hounding me for NON PAYMENT, so I am asking for your help, I am tired of all the running around they make me do, I shouldn't have to do this while they sit around and collect my dues every month they should pay for the services that are covered.Desired Settlement: I would like them to cover the service per their agreement with me

Business

Response:

Thank you for your inquiry received on December 31, 2013. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Review: I resigned from [redacted]. July 1st, 2014. Prior to putting in my resignation I spoke to multiple people from the HR help desk about my insurance and when it would expire. Per the people I spoke with as well as documentation that I have my benefits will end at the end of the month in which you left the company which would take me out to July 31st.I am to have a medical procedure on July 17th, 2014. I also have a pre op appointment schedule for July 14th, 2014. I received a call from my doctors office July 9th, advising me that my insurance was inactive effective June 30th. This is unacceptable. Someone has dropped the ball in this needs to be fixed immediately. My last working day at [redacted] was July 1st. I have called and verified with [redacted] of my last day. I also spoke with Aetna who stated that it showed my insurance went inactive on June 30th. June 30th was not my last working day. A representative was to expedite my issue but I cannot wait due to time and things that need to be done.Desired Settlement: My insurance needs to be activated ASAP. Both medical and dental. Extend it for additional month for the trouble that this has caused me.

Business

Response:

Thank you for your inquiry received on 07/10/14 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 am filing this complaint due to the poor service I have received from Aenta Student Health and its staff after being hospitalized in [redacted]. I am a graduating medical student at [redacted] and am a member of Aenta's student health insurance program. I was required to pay 100% of my medical bills up front (a ridiculous requirement in and of itself as my insurance covered me internationally) and told I would be reimbursed ASAP at 80% of the total cost. Aetna was prompt in reimbursing me for a large portion of the medical bills I submitted, with a balance of 242.83 needed to go through an appeals process due to the way a portion of the expenses were documented (the documentation process in [redacted] differs than what is typically seen in the United States). These were all submitted in late December 2013/early January 2014 and I have yet to receive any decision on the remaining balance despite my persistence. Worse yet, I have been given false promises on several occasions. I have been told I would receive a call on a specific date 3 times but received none, I have been told I would be updated within a week on multiple occasions but then receive no call or email. Not until I call or email do I get a response which typically contains an apology and another promise that goes unfulfilled. Now my past 3 attempts to contact Aetna have been unsuccessful (phone call, email, and phone call from our [redacted] Practice Manager). I am graduating and leaving the student health insurance plan and therefore need to get this outstanding claim resolved, and I have portrayed this information to Aenta to no avail. I have records of our email conversations and can supply them if necessary. My last email contact was with [redacted] (my main contact at Aetna) on 4/16/14 where I was told "we should have this wrapped up by the end of the week."Desired Settlement: I would like Aetna to reimburse 80% of the $242.83 in unsettled claims. I have submitted all documentation I obtained for the medical services I received, and have responded quickly to all of Aetna's requests, even when this included paying upfront to be reimbursed later, and obtaining paper copies of all services performed in a country where this is not always the norm.

Business

Response:

Hi [redacted],

We were unable to locate this member in our system. We’ve reached out to [redacted] on 06/02/14 for additional information. Once received, we can then review his complaint.

Thank you.

Sincerely,

Business

Response:

Thank you for your inquiry received on 06/02/2014 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: Dear Sir/Madam,I want to complain about Aetna Health Insurance regarding their policy and process of handling medical claims.I have Aetna Health Insurance since 2011 from my Employer [redacted]. I went for routine annual physical exam on 10/09/2013. Before the doctor visit, my physician verified the eligibility for routine physical visit and Customer service representative [redacted]. quoted that I am eligible for routine physical exam for the month of October 2013. The reference number for the quote is # 1[redacted].Now, Aetna declined claim from my physical service and I am stuck with the bill. I called Aetna customer service to resolve the issue and the customer service told me that my healthcare provider was quoted based on old policy by mistake. I was told that I was not eligible for annual physical exam on October and will be eligible only on December. The previously quoted eligibility was Aetnas mistake. And she was kind enough to file an Appeal stating the same.However, Aetna denied the appeal stating the same reason that I will be eligible for annual physical only on December. I have attached their denial letter at the end of the document and there are few points that I do not agree with the denial letter itself.1. In Denial Letter Page 1 of Aetnas denial letter, Aetna stated that I told them that provider told me that my plan covers physical exam without any age limit or frequency limit. I never said that. I told Aetna customer service that my provider verified my eligibility, told me that I was eligible and gave me reference number # [redacted]. 2.On Denial Letter Page 2 of the Aetna Denial letter, Aetna states that the call log shows that the provider was advised that I was eligible for annual physical exam every 12 month. But, it does not mention that they actually quoted that I was eligible for annual exam mistakenly based on some old account. Even when I called customer service after my claim got denied, the customer service representative admitted that they made mistake in quoting my eligibility by referring to my old account. However, there is no mention of that conversation either.3.Also, Aetnas denial letter states that benefit quoted via telephone are not guarantee of payment. So, basically even after quoting that I am eligible for certain service in phone, they can backtrack on their commitment? So, How am I supposed to verify my In Network Health Care Providers, if I cannot rely on customer service for quotes? Yes, I admit that I was not fully aware whether I am eligible to receive annual physical exam on October or not. Thats why I provided my full insurance information to the health service provide for verification. My provider contacted Aetna to make sure that I was eligible for the service. And Aetna quoted that I was eligible whether by mistake or not. Hence, I strongly believe that Aetna should honor their word. I have previous issues of medical claims incorrectly being processed by Aetna several times. For example, On 2012 Aetna denied claim for my wifes In-Network optometrist even after prior verification and had to go through customer service several times to correct their issue. They also incorrectly processed by lab claim on 2012 and I got billed for the lab services that were actually covered by the insurance. And again I had to call Aetna customer services to rectify their errors.Aetna quote benefits incorrectly then denies claims. Aetna also process claims incorrectly causing customers to pay for the claims even though it should have been responsibility of Aetna. It appears that Aetna does not have best interest of customers but wants to cheat customers from their benefits. My family health plan cost more than [redacted] annually ($750 per month from my pay check after employers contribution) and this is what I am getting from Aetna, lots of hassle on claim processing and wrong quotes. Dear Sir/Madam, I am fed up with the fine prints and long processes and technicality of larger corporations that is their just for the purpose of creating confusion and deception for the benefit of the larger corporations. I strongly believe that Aetna should honor their quotes and benefit promises. Aetna should approve my claim of annual physical exam.Thank youDesired Settlement: Approve claim.

Business

Response:

Thank you for your inquiry received on November 17, 2013. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Review: I had a procedure to remove a lump from my mouth on 9-8-2015 that was done in the dentist office o[redacted] hospital, I received 3 bills from the hospital from it with Aetna claiming I owe $28.46, $629.17, and $10.62 out of my pocket copays. According to the plan I was given, all office visit should only charged the $20 copay. According to Aetna, because the way the hospital coded the procedure, Aetna is considering it an outpatient surgery procedure of which non goes against my $250 deductible either and requires me to pay the above payments. I tried appealing it internally with Aetna but it was denied. I tried having the hospital re-code it but they claim that is the standard coding for this procedure. Prior to accepting Aetna as my health care provider, this "circumstance" where an in office visit procedure will be treated like an outpatient surgery was never stated anywhere I read at the time.Desired Settlement: I would like Aetna to do the right thing and accept paying the charges for this "In office visit procedure." If I had known this would be the outcome, I would have waited which was an option to see if the bump goes away in another month or two but I choice removal and biopsy to be safe. I should only be charged $20 since I never went to an surgical room, never went under anesthesia, never left the dentist office of which a dentist performed the procedure which is also not a surgeon!

I should be refunded $668.25.

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 Claims department to verify if the claims were processed correctly. We were advised that they were processed correctly according to the plan benefits. Unfortunately, we are unable to advise a provider how to bill the services that were rendered. Aetna would only be able to reprocess the services rendered if the provider wishes to rebill the services. Outpatient surgery can be completed in an office or a hospital. Your benefits state the following for outpatient surgery:

Outpatient Surgery [redacted]:

1. Performed at a Hospital Outpatient Facility:

a. IN- NETWORK: $200 per visit copay after Calendar Year deductible then the plan pays 90%

b. OUT-OF-NETWORK 60% per visit/surgical procedure after Calendar Year deductible

2. Performed at any other Facility:

a. IN- NETWORK: 90% per visit/surgical procedure after Calendar Year deductible

b. OUT-OF-NETWORK: 60% per visit/surgical procedure after Calendar Year deductible

While we understand your concerns and recognize this is not the resolution you sought, our decision remains unchanged as the claims are processed correctly. Our actions are solely guided by the plan guidelines in order to administer fairly and equitably to all participants.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr. [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:

Review: Aetna's Navigator website indicated that my health professional, [redacted], LCSW, was contracted as a licensed provider for health services for my particular health plan and group (note also that I was an [redacted] employee of the [redacted] office). Ms. [redacted] also verified this information prior to beginning treatment with me. In good faith, I began treatment for my condition with her, and she with me. She submitted bills to [redacted] requesting her negotiated rate for payment. She was notified that she was still contracted through [redacted] with her prior group in [redacted]. She has sent, and I have seen, no less than 3 requests with her [redacted] state tax ID number, and proof that she is a licensed health provider in [redacted]. She is told repeatedly that she is billing under her old [redacted] contract number, which is also untrue. I have seen not only copies of these bills, and the correct [redacted] tax ID number, but also confirmation of transmission where these items have successfully been faxed to Aetna. [redacted] is refusing to pay her bills, claiming that first she billed under her old [redacted] contract number, and then claiming that they never received the paperwork that she faxed them. I have met my $1700 in-network deductible through Aetna, and [redacted] now claims that since Ms. [redacted] submitted her bills under her [redacted] tax ID number, they have only filed these under out-of-network charges that count against my out-of-network deductible. Ms. [redacted] has stated that she will no longer be accepting [redacted] insurance, which halts my health treatments with her, and now I am facing having to pay for appointments that we both assumed in good faith that [redacted] would reimburse her for. I have established a long-term therapeutic relationship with Ms. [redacted], which is now in danger of being broken because of the billed charges that are unpaid by Aetna.Desired Settlement: Having seen the evidence that my healthcare professional is telling the truth, [redacted] needs to pay the contracted rate for these bills (12 appointments x $125.00 per appointment for a total of $1,500.00). I have also filed a complaint with the [redacted] State Department of Commerce and Insurance, and have filed an appeal with [redacted] to have these charges paid, to which they state that I will receive a response in 30-60 days. These bills need to be paid immediately as Ms. [redacted] will no longer accept my [redacted] insurance, and I am now looking at paying $125.00 per session out of pocket for my treatment.

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 Network department to request they reach out the provider and get the necessary network updates done for Dr. [redacted]. We were advised that the providers file has now been updated to reflect participating for the PIN/TIN and address combination. All the member’s claims have been reprocessed and allowed as in network. I have attached a word document of the reimbursement information.

Please accept my apology that we did not provide the level of service that the provider and member rightfully expect and deserve, and my assurance that their concerns are getting the highest level of attention at Aetna. I would also like to thank the member for sharing their experience with us. It is feedback like this that helps us address issues and prevent them 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,

Ashley S.

Complaint and Appeal Consultant

Executive Resolution Team

Review: In July, I was advised by my physician to undergo an scrotal ultrasound to detect any abnormalities. Aetna provides a "member cost estimation" tool via their website which allows the policy holder to choose both the specific provider and the procedure to get an estimation of the out of pocket cost. I've used this tool at least 4 times previously and it has been accurate to within $10-$20 of the cost that was billed. When I checked for this specific provider and procedure prior to rendering of the service, each ultrasound related procedure ranged between $150 at the lowest to $390 at the highest (this was for a complete abdominal, whereas my procedure was scrotal which covers a significantly smaller area).

After the procedure I was absolutely flabbergasted that my out of pocket cost was over $500, no where CLOSE to what the estimation was using Aetna's own cost estimation tool. I've already gone through two levels of appeals and still have not received an in depth explanation other than, "the out of pocket cost is accurate". When I specifically highlight that their estimation tool is showing a completely different price, they have no response other than, "I'm sorry".

This is simply unacceptable and and more importantly, unethical, to mislead customers by giving them a completely different estimate to procedural costs than what is eventually billed and not be able to provide a valid reason why.Desired Settlement: An out of pocket cost for this procedure in line with that Aetna's own member cost estimation tool reflects.

Business

Response:

Thank you for your inquiry received on November 01, 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: My ex wife was given a FSA card for our children to pay for medical expenses. She ended up using the card for her and her boyfriend. She said she would pay it back it has been almost eight months. Two months ago I opened a fraud claim with Aetna. The said they would send the paperwork which they did and I filled out and returned. They then told be I cannot dispute because the purchase happened in February, this was not a purchase for my children this was a purchase made for her and her boyfriend for medical goods and or services. This is Fraud.. Aetna swears they are against fraud but they will go ahead and let my card be used for just whomever chooses to use it. I tried to go through the correct lines of communication but just received refusal of assistance because they seem too lazy to open a fraud case and treat it as a lowly dispute. So why my children's money for medical expenses for the year are being taken they will sit on their laurels and just let it happen.Desired Settlement: I would like my children's money placed back on my card and a investigation opened. Or is it ok with this company to just let anyone use my money for their medical care?

Business

Response:

Thank you for your inquiry received on September 22, 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: Aetna has circular filed my application for coverage by an out of network provider due to a network deficiency in my area. This application is to try to get a prescription for a piece of durable medical equipment covered.Additionally, Aetna seems to have circular filed my complaint about the wrong out of pocket amounts being applied to my out of pocket limit.Desired Settlement: I would like my application for coverage of my durable medical equipment needs by [redacted] without further need to submit separate applications if I need additional equipment in the future.I would like my out of pocket amounts for 2013 and 2014 reviewed, audited, and corrected.Additionally, I would like an apology from either Aetna's CEO or Aetna's head of customer service for the way that I have been treated regarding these matters.

Business

Response:

Thank you for your inquiry received on July 21, 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.

We reached out to our Precertification department and the Claims department for assistance on the member’s requests. The member has been contacted with the following information. The precertification request for the 4-wheeled rolling walker was approved and the member can use the nonparticipating provider [redacted] Pharmacy. The member will receive a letter under separate cover advising of the durable medical equipment (DME) approval.

In regards to the member’s request for a review of her out-of-pocket amounts for 2013 and 2014, an audit has been completed. Based on the 2013 claim audit, $6,000.00 was correctly applied toward the member’s out-of-pocket amount. For the 2014 claim audit, claims for January through April dates did not apply to the out-of-pocket amount, most of the claims where a deductible or copayment that was applied. For May through present dates of service, claims are applying correctly toward the out-of-pocket amounts. [redacted] out-of-pocket amount to date is $308.75. In addition to the above information, the member also requested a review regarding custom orthotics. Under the terms of the member’s plan benefits, orthotics is a non-covered service and was denied correctly.

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

Consumer

Response:

Review: [redacted]

I am rejecting this response because:

Review: Aetna and/or [redacted].com have failed to properly manage my health savings account.

I am a ** physician enrolled in a high-deductible health savings account ([redacted]) with Aetna since Jan 13. At that time, [redacted] was administered by [redacted]). Shortly after establishing [redacted], I was able to invest [redacted] funds into various mutual funds through [redacted].

In Feb 15, I was advised by Aetna that Aetna had made the decision to change the administrator of [redacted]s from [redacted] to [redacted]. I was not asked if I wanted to switch but told that I needed to liquidate investments with [redacted] and place the funds into a cash account so they could then be transferred over to [redacted]. I complied with Aetna's directions and liquidated my [redacted] investments on 26 Mar.

On 31 Mar, I received a letter from Aetna advising me of my new routing number ([redacted]) and 17-digit account number. I personally made changes with my human resources (HR) department that day and verified that both numbers were correct. I enrolled on-line with [redacted] also.

I then noticed that my contributions, which were each $252.00, were not being credited to my [redacted] account despite those contributions being deducted from my leave and earnings statement. Specifically, there were three contributions (27 Mar, 10 Apr, 24 Apr) missing. I began contacting [redacted] personnel [redacted]on 24 Apr inquiring about the missing funds. On that particular date I spoke with [redacted], supervisor, and expressed my concerns regarding the missing funds. He advised me he would find out what the problem was and call me within three business days. He did not call me.

On 27 Apr, I contacted my HR department ([redacted]) and verified that the routing and account numbers were correct. Mr. [redacted] subsequently submitted a ticket to Defense Finance and Accounting Service (DFAS) to track the funds to determine where they were.

On 28 Apr, I again called [redacted] and spoke with another supervisor ([redacted] - [redacted]). I again expressed my concerns and was assured she would research the problem and call me back. She did not call me and did not return my phone calls after two messages were left on separate days (01 May and 05 May).

On 05 May, I again contacted [redacted] and spoke with another supervisor (April). At this point I was basically told that I needed to contact my HR department to find out what to do. Later on this date I contacted Aetna and spoke with [redacted] to express my concerns (Ticket #[redacted]). He stated he would file a complaint against [redacted] on my behalf and that he would also send an email to his supervisor requesting further guidance.

On 08 May, I received communications from DFAS that the receiving bank (unspecified) had rejected my [redacted] contributions due to the account number being incorrect. These same routing and account numbers continue to be listed on [redacted]'s website. Mr. [redacted] advised that my lost [redacted] contributions would be returned to me.

On 08 May 15, I again contacted [redacted] to inquire if there had been a change to the routing/account numbers. At that time [redacted] staff advised me they would forward my concerns to their accounting department. Really?

I have multiple complaints. First, I am locked in to my current health insurance and unable to change until the open season returns in Nov. Aetna unilaterally made a decision to change administrators in the middle of the year requiring me, for all intents, to liquidate investments in profitable mutual funds to a cash account that receives a negligible interest rate. Second, on three separate occasions money was pulled from my paycheck to fund my [redacted] and the funds were not credited to my account despite using the routing and account numbers provided to me by Aetna and [redacted]. Third, I made multiple phone calls on multiple dates and spoke with multiple supervisors without any assistance. I would consider all of the above to be very poor management, organization, and customer service at best and possibly breach of contract or fraudulent activity at worst.Desired Settlement: First, I expect my [redacted] account to be managed in a professional, competent manner. I expect my routing and account numbers to work the first time, every time. Second, I expect supervisors in an organization to act like supervisors. Seek responsibility and take responsibility. At the minimum, I would expect my phone calls to be returned. Third, I have likely lost money based off Aetna's decision. I have definitely lost time, as I have spent hours and hours jacking around with Aetna and [redacted]. Aetna/[redacted] can't predict the market, nor can I. But, my time is valuable to me and I do expect to be compensated for it.

Business

Response:

Thank you for your inquiry received on 05/12/2015 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: AETNA WEBSITE SHOWED DOCTOR WAS "IN NETWORK " AND WE USED SAID DOCTOR AND NOW AETNA REFUSES TO PAYDesired Settlement: AETNA STOP FALSE INFORMATION ON THEIR WEBSITE AND PAY THE BILL , ALSO THEY SHOULD PAY ME FOR HARASSMENT AND MY TIME DEALING WITH THEIR MISTAKE

Business

Response:

Thank you for your inquiry received on 05/26/15 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: Hi I have had the worst experience ever dealing with Aetna and I'm sorry it had to be taken to Revdex.com but it has still not been solved. Through Aetna, my husband and I are able to get $150 given by Aetna for participating in a health assessment and tracker. My husband already received his with no issues, but I do not have access. It says cannot confirm my identity and this is the message I receive

"

We regret that we were unable to confirm your identity the last time you visited. In order for you to access your Personal Health Record, please call toll-free ###-###-#### (Monday through Friday, 7am to 9pm Eastern Time)

I've called this number 5 plus times and also called your help desk, who happens to be no HELP. I am so tired of dealing with this and that I've already wasted much more time than the $150 gift card. I can access everything else on AETNA.com other than this. I've also been called by a lady who said to try again and it should work, well it seems no one at Aetna can help and they make me call different numbers all the time. I've had my husband bring it up to his employer([redacted]) to take it further.

I've also sent 8+ messages through the secure website and every time, I get automated message saying to call the same number I've been calling, like they don't read the message.

I'm tired of calling numbers, so can you please just get this $150 gift card sent instead of making me go through more hoops and wasting time. I've also been told I'd receive something in the mail to confirm my identity, but again another lie, didn't receive anything.

You can email me and I can supply you with any info you need to confirm identity. I've completed the "health assessment" but the health activity tracker is inaccessible for me.

my user ID is [redacted] . I don't want to share social on here.

Thanks,

[redacted]Desired Settlement: Please just send the $150 gift card as this seems to be the easiest way since I've tried countless times.

Consumer

Response:

this issue has been resolved. please close thx

Review: I have been in the process of Aetna's medically supervised weight loss provision as to gain approval for weight loss surgery.My medical team called me to inform me that during my last month, I gained 4 pounds during the last month of supervised weight loss and I am no longer eligible for my surgery that is scheduled for this coming Monday. It had been well documented that I was power lifting during this duration (4 months).My medical team has been over their criteria for the supervised weight loss numerous times and they said that there was no stipulation to how much weight I could or could not gain.My medical is set to change at the beginning of next year and I will be required to pay more for the operation than I would now and there's also a deductible that will also have to be paid.Now that I have been denied, my surgery is now expected to not happen.Desired Settlement: Allow the surgery to go through (likely not possible now that they've waited until only 4 days to deny the operation). If my surgery does not happen as scheduled, I would like them to keep the original claim with my current medical contract through my employer.

Business

Response:

Thank you for your inquiry received on December 16, 2013. Authorization number [redacted] remains denied; however, there is an appeal under Case number [redacted] for clinical review. Once a decision is made they will get a response from our Provider Resolution Team under separate cover with a decision.

Consumer

Response:

Review: [redacted]

I am rejecting this response because:

Review: I repeatedly requested an Explanation of Benefits statement from Aetna Global Benefits for a portion of an emergency room bill not paid by Aetna. After more than 4 months the hospital had threatened credit bureau action so I was compelled to pay the disputed portion of the bill. To this day, I have yet to receive the EOB from Aetna Global Benefits or any letter or explanation despite numerous requests and assurances from Aetna that the EOB was on its way.Desired Settlement: The disputed bill is for a total of $306.40 I request full reimbursement for that amount.

Business

Response:

Thank you for your inquiry received on 06/30/2014 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: on December 2, 2015 I contacted Aetna regarding my new Aetna Leap plan for 2016. I noticed the rate that they were billing me ($437.07) was different from the quote I received on Aetna.com (397.34). I addressed this issue with several departments and kept getting the same thing. No one would notate the system so I would have to explain the situation over and over again. I even had a license sales rep quote the premium for me and she was also coming up with the same rate I was of $397.34. I specifically asked her if they could be rating my husband and I as smokers and she told me no that they do not charge more for smokers. This was a lie as I went back on Aetna.com and did a quote for the smoker and non smoker rate and sure enough they are charging my husband and I as smokers which we are not and never have been, As I pursued this issue I was then sent over to the billing and enrollment department who I spoke with a rep that had her manager Toni change us to non smokers bt the rate still had not changed. I have been calling Aetna almost every other day and they still have not corrected the premium to the non smoker rate. Every time I'm told they sent in a request to fix the rate I'm told it will be 24 to 48 hours. I had the manager Toni approve me to pay the non smoker rate of $397.34 and now I am getting emails and letters in the mail threatening that they will terminate my policy for non payment all of this after I had sent in an attestation form stating my husband and I are non smokers and was reassured by some one named Silvio that since this was their mistake they cant cancel my coverage. After further research it turns out that When Aetna automatically enrolled me in their 2015 plan they rated us as smokers then as well. They told my husband that there is nothing they can do on the 2015 plan because the policy is now terminated even though we contacted them when the policy was still in force and sent over the documents they asked of us. They are thieves and it is not legal for them to charge a smoker rate to non smokers. They lie every time I call in and never once have called me back even thought I have been promised several times a call back.Desired Settlement: I would like the money I over paid for 2015 returned to me and I would like my 2016 plan to be rated correctly and the premium to reflect the non smoker rate of $397.34 and not to have my coverage terminated because I didn't pay the smoker premium because I am a non smoker.

Business

Response:

Hello,

Thank you for your inquiry, regarding complaint [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 Premium Accounting department to have the member’s concerns addressed. We were advised there was a system error that was causing the incorrect premium rate to be reflected on the invoices. It was confirmed that we have updated the member’s premium, in all of our systems, to reflect the non-smoker premium.

Aetna strives to provide the highest level of service, quality, and satisfaction, and to continually improve our processes. I want you to know that we appreciate your feedback because it gives us the opportunity to listen to our customers and make any improvements to our processes and the service we provide. Your opinion is valued at Aetna, and I trust that you will not hesitate to contact us when you need assistance.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted]s 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