Aetna, Inc.

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 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 am under doctors care for [redacted]. My physicians have prescribed a [redacted] and a [redacted] to support my recovery. To date, AETNA refuses to recognize the need for this equipment. AETNA has been given six letters of medical necessity over a period of six months from my physicians. The letters explain the need and urgency for AETNA to approve this request. AETNA will not pay for a [redacted] and a [redacted] because the Clinical Review Unit believes these items fall under the category of household equipment. They are incorrect with their identification of this need. Household equipment is defined as any item that is being used for personal comfort and convenience. In my circumstance, the [redacted] and [redacted] have been prescribed to treat [redacted] or an existing medical condition. It is for a mandated use. These items are not being prescribed for personal comfort and convenience. They are appropriate and consistent with the diagnosis in accordance with accepted medical standards. The [redacted] and a [redacted] are likely to produce a significant positive outcome if I am able to continue with the [redacted] They have suggested that I file an administrative appeal with the [redacted] if I disagree with their decision. However, my physical therapy benefits are about to conclude and my home therapy program is supposed to begin immediately following the conclusion of physical therapy. With the possibility that this process may take a substantial period of time, an extensive lapse in my treatment is possible. This situation has been handled very poorly and has been unnecessarily stretched out by them for a long period of time. I specifically submitted all of the requested documentation well in advance to avoid this situation. The communication with the representatives has proved to be difficult at times. They have been providing me with incorrect info.Desired Settlement: I want AETNA to approve and pay the claim for the [redacted] as a medical necessity. I also want AETNA to approve the pre-determination of benefits for the [redacted] as a medical necessity. They should send me the approval letters in writing immediately upon approval of this equipment. They need to go back and identify the distinct difference between equipment that is used to treat a medical condition and equipment that is used for personal comfort and convenience.

Business

Response:

Thank you for your inquiry received on July 29, 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 been receiving endless unsolicited phone calls from various medical equipment and pharmaceutical companies for someone whose name sounds like [redacted] or [redacted]. Most of the calls are typical telemarketers with no live person available. But, some were from Aetna Insurance. Recognizing Aetna as a theoretically reputable company, I returned their call today in order to stop the constant onslaught of solicitations. Because I work at night, these daytime calls are extremely disturbing. Because they come from a wide variety of numbers, I cannot block them all. And, because I am sole caretaker for my elderly mother, I cannot turn the ringer off while I sleep in case she needs assistance. On 8/22/14, I called Aetna after their last unsolicited call woke me up. The return number was ###-###-####. The customer service representative asked for my name and date of birth, which I refused for obvious security reasons. I explained the problem, believing initially that it was simply an error on their customer's file. The representative told me there was nothing they could do. She apologized, which obviously accomplishes absolutely nothing. I asked to speak to a supervisor, but the supervisor refused to speak with me. I asked that they escalate the matter to their Technology office in order to perform a data search for the name or number, and she also refused to do that. Aetna's official position is that they will continue with the harassing, unsolicited, and unwanted phone calls UNLESS I BECOME A CUSTOMER and provide personal identifying information. Their action in this matter has led me to further believe that they have sold my telephone number to unscrupulous medical telemarketers, which is why I am receiving constant calls from prescription companies, medical supply companies, medical counseling companies, medical finance companies, and other medical insurance companies.Desired Settlement: As a former IT professional, I know without question that a competent technology office can perform a data search for a phone number. All I asked was that Aetna request such a search and remove my phone number from any and all accounts used by them or by their affiliates. I resent that this company is attempting to manipulate me into becoming a customer in order to stop this harassment. It is their mistake, not mine. My phone number is ###-###-####.

Business

Response:

Thank you for your inquiry received on 08/25/14 regarding complaint #[redacted] for [redacted]. Our Executive [redacted] Team researched your concerns, and I would like to share the results of the review with you.

Review: Filed short term disability on September 6th, 2014. Contact and location information provided was confirmed via phone and fax with documents requested by Aetna. Currently October 21st and have to receive any disability checks. Spoke with a representative on October 11th and in question advised the incorrect address with zip code had been documented but would not interfere with me receiving disability check. Address that was documented was listed as a city in ** and zip code documented was for **. In speaking with a supervisor [redacted] at ###-###-####, explaining situation, supervisor response was " And you want me to do what about it". I called again on Saturday October 18th spoke with Claims manager supervisor [redacted] whom told me the incorrect address would prevent me of correctly receiving any checks. Check that was to be issued would have to be cancelled and reissued but would be sent over night Tuesday to be received Wednesday. On Monday October 20th received a letter in mail from Aetna that had incorrect address listed but I still received it. In the letter dated September 30th, 2014, stated I was qualified for short disability and would begin on September 15th, 2014 that I had to be out of work for 13 days in a row before benefits be released. Information I was never made or provided when filed my claim on September 6th, 2014. I called Tuesday October 21st, 2014 and advised that the original check has yet to be reissued and now would not be released until Wednesday October 22nd and received Thursday October 23rd. The 2nd check that was to be issued on Friday October 17th had to be cancelled as they had the incorrect address which the correct address was corrected on October 11th, 2014. The 3rd check scheduled for October 24th would be placed on hold as the original check being sent as an emergency check over night would show a negative in my disability account would have to be recovered by Aetna for them to correct their error and could not give me a date as to when the 3rd check would be issued.Desired Settlement: This is people lives Aetna is messing with. I have been on the phone with Aetna everyday. This is money my family depends on to survive while I am recovering. I have my car being ready to be reposed, household bills ready to be shut off. Aetna does not seem to take their error seriously. I would like this to be corrected without any delays in receiving scheduled payments or being held up as this is not our error it is Aetna.

Business

Response:

Thank you for your inquiry received on 10/22/2014 regarding short term disability payments for [redacted]. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

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: 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 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 called the benefits line to verify my coverage and I keep getting transfered. No one will provide me with coverage and benefits information. Three people at the doctor's office called to verify coverage for my child and he was unable to see the doctor because none of them could get through to someone in Aenta that could verify he has health insurance. I have called numerous times and on occasions the employee hangs up on me.Desired Settlement: I need my child to be seen by the doctor. All I need is for someone to verify his eligibility and explain his coverage to his doctor.

Business

Response:

Hello,

Review: Aetna advertising is misleading and states that they cover "everything" however they stuck me with an $800 dental bill. They refuse to pay their share of the dental claim. Although their ad shows they cover everything in or out of network. I find these practices to be fraudulent and misleading to customers. If you try to reach out to them, they hang up on you or reference a guideline as to why they will not speak to you, although the payment to them continues to get taken from my pay check.Desired Settlement: I want a full refund of all money that I've paid them (Aetna) for 2015 and I will credit them the $27 they paid for my $800 dental claim.

Business

Response:

Hello,

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: 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: On Nov 2012 I received claims that apparently belong to someone else with my same name and DOB. 6 months later & errors still in my account.

I need your assistance with removing erroneous claims from my online Insurance Claims History & Health History Record with Aetna(my old health insurance co. from my previous job).On Nov.2012 I received a claim from PALMS Emergency Services and another one from South Texas Health System for May 6,2012 emergency services in Texas. I have never been to Texas; never been to a TX ER; never been to a TX hospital. Immediately upon receipt of these erroneous claims I contacted Aetna in Nov. 2012. After speaking to numerous representatives from Aetna, PAMLS Emergency Services and South Texas Health System on numerous dates about the two erroneous claims being placed on my account and receiving no solution, I called Aetna once more and ask for a supervisor. I was transferred to Supervisor Megan Rogers (215-775-8933) on the week of Nov.12, 2012. I spoke with her several times, the last time being 12/10/2012. I mentioned to her that I was very concerned about being the victim of Identity and Health Insurance theft, but was assured by her that: Aetna received a paper claim from Texas; The claim's mailing address was "Aetna Global"; The person in the claim ironically has my same name and date of birth, but it was an "Aetna Global" (International) account.; She also stated that the address in the claim was from Texas and did not match mine. She also stated that the Insurance ID was not mine and that the individual had a different SSN than mine. She stated that it was clearly an Aetna input error. She also mentioned that she had spoken with the hospital and ER in Texas and that all parties were in agreement that it was a processing error on Aetna's part, a "manual keying error". Megan also stated that she had received faxes from Texas with the claim information. I mentioned to her that I needed all of this information in writing for my records and she agreed. I also mentioned that I wanted my insurance claims and health records cleaned of all of these errors. . I was told everything was going to be corrected. Nothing happened. She never returned my calls. I kept receiving the erroneous claims from TX up to Feb. of 2013. Since Aetna was not correcting the mistake, I placed a complaint to the PA Insurance Department. On April 23rd I received a letter from Ms. Debra Sweigard, PA Insurance Investigator Supervisor. She stated the following: That she had received verbal confirmation that the matter has been resolved; that it appears that the South Texas Health System and Palms Emergency Physicians billed for a patient with the same name and DOB as me; that the special investigations area of Aetna has completed an internal investigation and it was determined that the claims do not belong to me and will be removed from my record/history; that this process may take some time to correct on the online system; She gave me a contact at Aetna, Eileen Pierce (781-293-2370) for a status update on the correction process. It has been almost a month since then and still nothing has changed in my account and I have not received any letter from Aetna. I contacted Ms. Pierce on 3 occasions and on the last call she asked me to call customer service (in essence to go back to what I did in Nov 2012) to solve my situation. I have been waiting for 6 months and 13 days for Aetna to correct this issue. These errors need to be corrected. I am the victim here. I have waited enough. My health account must only show my information. This is especially important when Aetna claims it is the company's own internal billing mistake. I will not accept having the other member's claims and medical history information on my record. I need a written letter from Aetna explaining how my account was billed for these erroneous claims. This is allegedly a mistake on Aetna's part and they need to be held accountable. I need this in writing, guaranteeing that this indeed is an entry error on Aetna's part and in no way shape or form an act of Identity and/or Insurance theft. Desired Settlement: I need a timely correction of my Medical records and Claims history both internally at Aetna AND in my Online account.

I need a letter from Aetna's Headquarters explaining exactly what happened here. Guaranteeing that this indeed was an entry error on Aetna's part, and in no way shape or form, an act of Identity and/or Insurance theft.

I would also like a letter of apology from Aetna Headquarters for the company's lack of timely assistance, concern and communication in dealing with my situation. This is a very serious and personal issue. It is my personal health insurance history. This is not something I take lightly. I am not in the wrong here, I am the victim of incorrect information being placed on my account and will not accept it, especially when I have been waiting over 6 months.

Business

Response:

Business Response /* (1000, 5, 2013/06/05) */

Thank you for your inquiry received on May 22, 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 Claims department to assist with the member's concern. They advised it appears that the providers billed under the wrong patient identification number (ID). There was another patient with the same name and birth date and the providers billed under incorrect ID number for services on May 6, 2012 for the other person with the same name. We requested that all the claims from [redacted] Health System and[redacted] Emergency Physicians that was billed incorrectly with the member's ID be deleted out of Aetna's HMO claim system. We apologize for the inconvenience and the delay with the request.

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].

Consumer Response /* (3000, 7, 2013/06/07) */

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

The response from Aetna did not address my specific requests to resolve this complaint. Instead the response was the same generic response that I have been receiving from them since November of 2012.

To consider this complaint resolved I need:

A Immediate action from Aetna in removing all of the incorrectly billed information from my account with a clear stated timeline in writing of when the correction will happen.

B A letter from Aetna stating that they removed of all incorrect information that is not related to me and my healthcare from my Aetna HMO Claims History and Health History Report AND from my Aetna Navigator Claims History and Health History Report.

C A letter from Aetna's Headquarters explaining exactly what happened, not what "Appears to have happened".

D A letter of apology from Aetna Headquarters for the company's lack of timely assistance, concern and communication in dealing with my situation.

I have attached more details of this situation, including all of my personal efforts in trying to get this situation corrected, along with more information regarding why Aetna's response is unacceptable.

Sincerely,

Consumer Response /* (-5, 8, 2013/06/07) */

Brief Summary of actions I have taken.Immediately upon receipt of these erroneous claims I contacted Aetna in November of 2012. After speaking to numerous reps from Aetna,[redacted] Emerg.Serv.and [redacted] Health Sys.on numerous dates about the two erroneous claims being placed on my account and receiving no solution, I called Aetna once more and ask for a supervisor. I was transferred to Supervisor [redacted] (XXX-XXX-XXXX) on the week of November 12th,12. I spoke with her several times, the last time being 12/10/12. Detailed actions taken on my part to correct the situation:11/06/12 Called Aetna and spoke to several reps about false/incorrect claim on my account/Called PEBTF ([redacted]) and spoke with [redacted] in benefits (XXXX-XXX-XXXX)/ Called [redacted] and spoke with several representatives.11/07/12 Called the hospital in TX (XXXX-XXX-XXXX)and spoke with [redacted] in Billing/Called [redacted] (XXX-XXX-XXXX) and spoke with Supervisor [redacted] (X5315).Called Aetna again and spoke with [redacted] He stated that it was not possible for Aetna to just send payment. Stated that someone in TX must have billed Aetna using my information. [redacted] advised me that if I believed this was a case of ID theft and possible Medical insurance fraud I should place a Police report. I called the [redacted] County Police Headquarters ([redacted]), [redacted], ** XXXXX and asked to have a Police report issued. Received a call from Officer Connor (XXX XXX-XXXX) and placed my Report with her. Called [redacted] from PEBTF.11/08/12Called Aetna and spoke with [redacted] again and gave him the Police Report number.11/09/12 Placed a complaint with the Federal Trade Commission.11/11/12-Sent formal complaint letter to Aetna.12/7/12 Spoke with Customer Supervisor [redacted] (XXX-XXX-XXXX). Claims kept appearing in my account; on 1/10/13 Called [redacted] left message.1/21/13. Spoke with [redacted] Hospital billing department and was informed that Aetna was working with the other insurance company to get this resolved. They did not know why Aetna was still billing my account.Called again later in the day and spoke with [redacted]1/25/13.Called AETNA. Spoke with [redacted].1/28/13 Spoke with [redacted], Aetna Senior rep. 2/1/13left voice mail for [redacted] complaint w/PA Ins.Commissioner. I contacted Ms. [redacted] from Aetna 3 times (4/29/13; 5/6/13 and 5/13/13). 5/21/13 Revdex.com received my complaint.

Business Response /* (4000, 17, 2013/07/16) */

Thank you for your inquiry received on June 10, 2013. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

We again reached out to the Claims department to help with the member's concern. The providers billed under the wrong patient identification number (ID). There was another patient with the same name and birth date and the providers incorrectly billed under incorrect ID number for services on May 6, 2012 for the other person with the same name. All the claims from [redacted] that was billed incorrectly with the member's ID were deleted out of Aetna's HMO claim system, Aetna Navigator and Aetna claims history. We apologize for the delay due to applying the necessary changes to the account within our systems and apologize for the inconvenience experienced by 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: I received a [redacted] in January of 2013, which is preventative care and should be fully reimbursed by Aetna, my health insurance company at the time. Since then, I've been trying to get reimbursement, with no success. Although from their website it clearly appears that the pharmacy where I received the [redacted] is in network for Aetna, and the customer service representatives I have pointed this out to acknowledge the fact, they continue to tell me either that the pharmacy tax ID number shows up as out of network in their system, that the system is being updated, or that my claim is being reprocessed.Desired Settlement: I would like a complete refund.

Business

Response:

Thank you for your inquiry received on September 10, 2013. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Review: On Jan. 27, 2014, I sent Aetna a very detailed letter describing a billing discrepancy I experienced after an appointment on 11/1/2013. Due to incorrect info that I was given by Aetna representatives, I saw a doctor who was not within my plan network -- though I did so specifically on the recommendation of an Aetna representative. After receiving bills throughout December and January, being unable to resolve the issue by phone, and being unable to get information through Aetna's website because part of it was nonfunctional for over 2 weeks in January, I received a letter dated 3/5/14 stating that Aetna had reprocessed my claim and paid the hospital in question ([redacted]) on 2/5/14. However, according to my account with [redacted], they have received no such payment as of 3/16/14 and are still holding me liable for over $200 in services that should be covered by Aetna. Aetna's conduct towards me during the past months as I tried to resolve this issue has been completely unacceptable. I have called and emailed and sent letters and faxes, and only received a response in a timely fashion from them when I took to [redacted] and publicly described the issues I was having, which of course made them look bad (and were deleted). Even then, my emails were ignored for weeks on end, or I was sent encrypted messages that wouldn't open properly. Just getting through to anybody at this company requires monumental follow-through on the customer's part.Desired Settlement: I want Aetna to pay the remainder of the bill to [redacted] from my appointment on 11/1/13, for which I've already paid a co-pay. I want documentation from them, in writing, acknowledging what caused my problem to begin with (bad information from their representatives and website) and confirming that I am not liable for any further charges stemming from this 11/1/13 appointment. Further, I want Aetna to acknowledge how terrible their customer service practices are!

Business

Response:

Thank you for your inquiry received on March 17, 2014. 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 Claims department for assistance with the member’s concerns. The claim for date of service November 1, 2013, has been paid in full leaving a copay balance of $30.00. The original claim was processed applying the entire negotiated rate of $206.84 toward the in-network deductible on November 21, 2013. An appeal was received under case number [redacted], and it was determined that the claim will be paid and no deductible will apply. The claim was reprocessed and a check was issued for $156.84 and cashed on January 31, 2014. This claim applied the specialist copay of $50.00. After another review of the claim it was determined that the Primary Care Physician (PCP) copay of $30.00 should apply and not the $50.00 specialist copay. Therefore, the claim was reprocessed and a check was issued for $20.00 and cashed on March 18, 2014. The member’s responsibility is only the $30.00 copay.

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: 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 started with Aetna RX Pharmacy in 2013. I require medications that are made by a certain manufacturer because of a severe allergy I have to a binder/filler. I received a medication in early April that I was unable to take because it contained this filler. I promptly called them & they said they would send me a return back package to send the medicine back and they would send me a replacement with the proper drug. They even did an over ride so that I could get a 2 week supply from a local pharmacy to make sure I had enough. I even talked with a pharmacist at Aetna who said she marked my records stating that I could only take medicine from a certain manufacturer and also added in my allergy to the filler. On 5-02-13 I received another of my medication (90 day supply) made by a manufacturer I could not take. I called them and they said they would sent return package for me to send back medicine and they would sent me the brand that I could take. 2 weeks went by and I got nothing. I called back again to see when to expect it. This time I was met with bad customer service saying they could not accept medications back as it was against company policy. Saying it was a manufacturer issue. I replied it is not a manufacturer issue it is Aetnas issue for sending me the wrong medicine with the filler I am allergic to when it was clearly marked in my records I couldn't take it. I have tried calling over and over only to be met with the same excuse. I asked why they allowed it for the other medicine and not this one. They said that who did the one before "apparently wasn't doing her job right." No I am forced to go to my local pharmacy to get the medication since they have the one I require & pay out of pocket simply because Aetna is unwilling to work with me. This error is not my fault and it is due to lack of customer service and the person that filled my medicine without regard to my allergy. I am stuck with medicine I cannot take and having to pay a larger amount out of pocket. Warning to others!

Product_Or_Service: [redacted] 90 days supply

Account_Number: [redacted]Desired Settlement: I would like for them to send me a return package so I may send back the medicine I cannot take. At this point I feel more comfortable getting this certain medicine from my local pharmacy. I feel they should refund the copay of $1.15 I paid for the orginial 90 days supply of the medicine I could not take. As well as cover the correct mediciation I just bought from out of pocket for the amount of $66.53. They can reimburse me for the difference after my copay is taken. I think this is only fair.

Business

Response:

Thank you for your inquiry received on June 6, 2013. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

We have forwarded the member's concerns to our Medicare Resolution Team to begin a grievance review on their behalf. The member will also get a response from our Medicare Resolution Team shortly 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:

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

I was contacted by the Aetna Medicare Resolution Rep on June 20. I was unable to take the call as I was at a doctors appt. She said she would call me back on June 21st. I called her back the next day to the phone number that was in my phone call log. I got a voice mail saying I would be contacted back within 24 hours. Since then I have called and left 3 other messages trying to receive a call back. I have not received a call back to try to rectify this matter. I am not satisfied at all with this how this matter has been handled. Which is has not been handled at all. I still seek a refund on the medicine that I had to purchase out of pocket the 3rd of June. As I am having to once again purchase the medicine out of pocked on July 3rd because the company will not accept back the medicine I have received that I was unable to take due to allergic reactions. As I said before the prescription sent to Aetna had specific orders to send me the [redacted] brand and Aeta had all my allergies noted in the files. Stating I was allergic to [redacted] which was in the medicine they sent me. I have since cancelled my prescription with Aeta and I am having to get it through a local pharmacy that has no problem getting me the correct medicine. At this time I can't request that this claim be closed until I am contacted and a resolution is met to my satisfaction.

Business

Response:

Thank you for your inquiry received on July 2, 2013. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

We resent the member's concerns to our Medicare Resolution Team to review. They contacted Ms. [redacted] by phone on July 8, 2013 and the member is aware that in order to request reimbursement, she must send in certain forms that was sent out to her. The Medicare Team advised the member was satisfied with the response and she was also advised about the "stop and see" that was placed on her account.

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:

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

At this time I am unable to accept the proposed solution to this issue. I have received the paperwork to fill out and send back in with my receipts for the cost of the prescription for the month of June and July. I have questions about the form and have left a message and waiting on a return call. I am satisfied that they are making steps to help resolve this matter but I was told on the phone that the paperwork is going to be looked over as it doesn't mean that I will get the resolution I am seeking to be reimbursed for my charges. They claim not to have my allergies listed prior to this issue with this medication. But in fact it should be list in their computer from another medication I had this issue with. At this time I am unable to say that I am satisfied with the outcome. Not sure if they will be autorizing coverage for my medication supply in the month of August which is one thing I am seeking along with a refund for the 2 months out of pocket prescription that was due to their error.

Consumer

Response:

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

I received a letter today from Aetna saying they are unable to process my request for reimbursment do to issues with the receipts and form I mailed to them. I went over the form with the Medicare Grievance representative to make sure it was correct. They are saying I can't send a copy of the receipts that I received from buying both months our of pocket and I cannot send in a copy of the information regarding the purchase from the pharmacy themselves. I am tired of them running me around in cirlces after all these months. I need someone to actually return my call within 24 hours as promised via voicemail instead of a week or more for the return call. I am very unsatisfied that this company would still try to resolve this claim as nothing has been done to futher it on their end. I will not accept a resolution until the money is returned to me that I paid out of pocket due to their error.

Consumer

Response:

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

I received a call that my request for reimbursement was being looked at and they said I would receive a call back LAST week letting me know whether or not it has been accepted. I have yet to receive a call back and have received no reimbursement at this time. I will not close the case until reimbursement has been received.

Review: I paid for insurance and they can't figure out why I am not covered!

I don't think I have ever had a good experience with Aetna. Just another way students this generation are getting screwed. Aside from having to waive in and out every single semester (even though insurance is supposed to be automatic, since it is MANDATORY if you are a registered student), I even pay the extra premiums for extra summer coverage (which are not automatic). Well it was impossible to waive into summer coverage- and you have to wait for someone to actually contact you and fax you the form. When it finally does happen, it ends on Aug. 14- where your fall coverage should theoretically pick up with your semester.

Well, in America, the motto is "just don't get sick." I had to go to urgent care. I was hit with the surprise that I didn't have insurance upon checkout? That's $105 out of pocket. When I went home to call the Aetna hotline, they had no idea why I was not covered since I did not waive out and had just come out of extra summer coverage. Not only could they not solve the problem before I had to pick up my Rx, but I was told they had to submit a request just to FIGURE OUT what the [redacted] was wrong with my coverage! I was told someone would call me back. Days later, that NEVER happened- per usual. Not only could I not be covered for insurance that I paid for, but I was told that I should just wait "1-2biz days" to get my [redacted] and healthcare. They couldn't care less it was a time-sensitive health situation. So I also had to pay for my [redacted] out of pocket. This is the state of students and healthcare everyone. Even those that pay for the privatized version.Desired Settlement: I just want insurance coverage.

Business

Response:

Thank you for your inquiry received on August 27, 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 Aetna Student Health (ASH) for assistance with the member's concerns. They advised a manual enrollment error was made which resulted in two different ID's. They voided the duplicate account and the correct ID for the member is [redacted], which will remain active.

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.

Consumer

Response:

Review: [redacted]

I am rejecting this response because:

There is no text in the message? Furthermore, it has been over 3 weeks since I talked to Aetna. It is ipso facto at this point, because I still had to pay for all my healthcare out of pocket, while nobody called me back when they said they would.

Sincerely,

Business

Response:

Thank you for your inquiry received on August 27, 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 Aetna Student Health (ASH) for assistance with the member’s concerns. They advised a manual enrollment error was made which resulted in two different ID’s. They voided the duplicate account and the correct ID for the member is W187814290, which will remain active.

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 [email protected].

Review: My company recently switched to Aetna health insurance. Prior to switching we had to fill out detailed (exhaustive) forms outlining all of the medications and medical issues that we are on/have. We were told that the change in insurance would not impact the meds we were currently taking. Unfortunately one of my wife's medications was rejected the first time we tried to fill it with Aetna. She has complex medical issues and it has taken us 7 years to get her rare [redacted] disease under control. I have no desire to watch my wife deteriorate. In an effort to fix this problem I have now called Aetna multiple times and spent over 4 hours on the phone with various people at the company. I have been told multiple various excuses including: no diagnosis code (ICD9)was given (untrue and I provided them with one anyway), the medication is not indicated for the pathology (not true, it is a second line agent, but there is published evidence supporting its use), therapeutic alternative exist (true, but my wife is already on them or has failed on them) and the drug is not listed on their pathway for the specific pathology (fine, then put me in touch with someone who can override this pathway...). When I asked them for the name and number of someone who can make these decisions, I have been told by the people helping me that they don't know of anyone who can make that decision. I then asked to speak to a medical director and was told that they don't have the number of any medical directors. I then asked to speak to Dr. [redacted] who signed my denial letter (with the title "Medical Director")and was told that there is no number for him at Aetna, and no way for me to reach him. It amazes me that Aetna will not take responsibility for their decisions... Where is the accountability?Desired Settlement: I want Aetna to be true to their word and refill my wife's meds. It amazes me that someone at Aetna thinks that they can do better than the specialists currently treating my wife without ever reading her chart or examining her.

Business

Response:

Thank you for your inquiry received on November 6, 2013. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.