Aetna, Inc.

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.

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 just finished explaining to my new bride that Aetna voided her insurance. And did it without telling us! I was not a pleasant conversation with the wife.

I spoke to two representatives of Aetna today (Jan 5th 2015) who both confirmed my wife's coverage was voided, and could not tell me anything more than that, and that the effective date of being voided was Sept 1 2014. They were[redacted] in website tech support and[redacted] in member services. [redacted] provided a reference number of[redacted].

My Insurance ID # is[redacted], my company [redacted] Inc

My date of employment is May 8 2013

I have had continuous coverage since I've been employed and with Aetna ever since my company switched to them. Prep for adding my wife started well ahead of our marriage. But adding my new wife took a couple attempts. After the 1st attempt, I was told she was covered. I later found out she was not! Then after the 2nd go around, finally, it was confirmed by the broker [redacted] Services and I was provide a temporary Insurance card for[redacted].

More recently, she had been trying to fill prescriptions and was of the assumption that these medications were not covered. Now after all the holiday hasles are over I was attempting to research the issue and this is what I came up with. Her insurance had been voided back to the day of initial coverage, and I was not even informed, totally Unacceptable.

I believe this is probably something Maryland should also investigate.

http://www.[redacted] Sorry for the frankness of the letter, but If I was to have an attorney write this, I'm sure it would sound less pleasant.

Thankyou in advance for your prompt attention to this matter.Desired Settlement: 1) I demand Aetna to quickly reestablish[redacted].

2) I expect Aetna to not cancel coverage without sufficient notice and per federal and state requirements of the Maryland [redacted] (for which I'll be investigating a parallel complaint)

3) I wish reimbursement to my company (and ultimately to me) charges I've paid to have coverage for my wife (listed as self + spouse) yet Aetna in their own admission has failed to provide.

Business

Response:

Please see our response to the complaint #[redacted] for [redacted] received on January 06, 2015.

Review: This complaint is in reference to a billing issue with Aetna

I called Aetna July 14, 2014 for pre certification for two scheduled procedures

I spoke with Roxanne exployee # [redacted]

the reference for my review with Roxanne is Ref [redacted]

I explained to Roxanne that my Doctor does the procedures not through her office, but through an outpatient center.

Roxanne confirmed the following regarding the procedure:

-no pre certification was required

-the procedure is 100% covered

-there is no deductible

-there will be a $50.00 copay

I recently spoke with my doctor's billing department and was told that Aetna has not paid them for the procedures. I called Aetna today and spoke with Amy employee [redacted] was told that they have not paid because I have not paid the copays. I said that I did not receive a bill for the copays. Amy says that there is a copay balances for $ 201.26 and $304.33 for the procedures.

I reviewed with Amy my notes from my discussion with Roxanne before the procedures. Amy says that Roxanne had given me incorrect information and that the copays are higher because my doctor does not perform the procedures in her office but through an outpatient facility. I explained to Amy that I gave the name and address of the facility to Roxanne during the call review.Desired Settlement: The desired outcome is that Aetna should stand by the information that was given to me before the procedure which is that there is a $50.00 copay for each procedure. Aetna should revise their billing and issue payment to my doctor for the services rendered.

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 have the call pulled to verify the information that was provided to the member. Our records indicate that the member advised the customer service representative that this procedure would take place in the provider’s own facility, with the doctor’s name and procedure code. Based upon that description the general benefits were provided to the member.

Information provided through member services is not a guarantee of benefits under the plan. The claim that was submitted to Aetna did not list the services rendered as being taken place in the office setting, instead in an ambulatory surgical center as outpatient surgery. Due to the way the claim was billed it triggered the deductible instead of an office visit copay. The claims in question were processed correctly in accordance to your plan benefits.

I realize that understanding your benefits can be challenging. It is our goal to be there for you when you need us, and I apologize that the assistance you received from our customer service representatives did not meet your needs.

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

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: 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 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: Aetna has confirmed on multiple dates per Aetna verification #[redacted] and reference #[redacted] that dental implants for my husband [redacted] would be covered under the Aetna Medical Coverage in the amount of $8,926 paid to in network provider Dr. [redacted] and a copayment of $40 from [redacted]. Numerous requests have been requested to place this in writing but have never been received. We have been promised this coverage on numerous occasions and need it in writing so that the surgery can be completed.

We have also asked for transcriptions of the conversations re the above noted verification and reference #s but have yet to receive same.

Aetna ID [redacted] grp:[redacted]Desired Settlement: Confirmation that the payment of $8926 will be made to Dr. [redacted] and that our only out of pocket expense will be a $40 copayment.

Business

Response:

Thank you for your inquiry received on November 19, 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 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: [redacted], incurred a medical problem on November 2, 2012 in Germany.It required 2 physician visits with bills of 250 Euros and 230 Euros (total on credit card of $616.27. Medical coverage from the cruise company will not pay their share until I have documentation from the primary health insurer of what they will pay. I filled my claim with aetna on Dec. 10, 2012. I have followed up the written claim with 7 phone calls. The first two responses were that the claim was at the translation department. 3rd call they stated that a check had been sent and it had been cashed. I then requested a copy of the check which turned out to be a claim made for Feb.11,2012.The 4th call was made to explain to them the the check was for a claim 2/11/12 (Germans transpose the day and month so that the the doctor's bill was dated 2/11/12 which is 11/2/12 USA. I was promised a follow that up. No response so I again called explaining again the misconception.Ten days later I received a check for $209.09 dated for of Feb.11.2012. Today,6/18 I called again for an interpretation of all the codes on the statement accompanying the check. Again they told me the only claim they had was for Feb. 11,2012.and that had been paid.I cannot believe that Aetna with it's prestigious reputation has so many stupid people answering their phones. The last 3 calls I requested a supervisor and received no satisfaction. I have explained that I sent you the original doctor's bills but have copies and they replied that they did have the bills.I have explained that if Aetna will not pay the bill PLEASE send documentation of why so that I can collect from the cruise medical insurance. I am running out of time to file with them.Desired Settlement: My documentation for Aetna is that $300. I would like either a check for the $300.19 or documentation why for why they will not pay, so that I can file with the cruise medical insurance. I AM RUNNING OUT OF TIME, PLEASE RESPOND QUICKLY. Remember Aetna has the original bills

Business

Response:

Business Response /* (1000, 5, 2013/07/08) */

Thank you for your inquiry received on June 24, 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 for assistance. They advised the claim for February 11, 2012 were processed incorrectly with the incorrect dates of service and the claim for November 2, 2012, pended in error for a request for a Medicare EOB. We have reworked the claim and reprocessed to pay the additional $259.06 to the member on July 3, 2013, under payment number XXXXXXXXXXXXXX. We apologize for the errors, the delay and the inconveniences this member received.

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]@aetna.com.

Review: A recording from Aetna is calling my home phone on a frequent, recurring basis. Their call today (8/29/14) was shortly after 2pm. They are attempting to sell upgrades to "my" insurance policy, even though I have never been a customer of theirs. I have asked them to stop, but they say they are unable to remove my phone number from their system unless I am a customer. I believe they are attempting to use the continual harassment in order to scam me into purchasing insurance from them.I have verified the number (###-###-####) is a genuine Aetna phone number. At first I believed they were simply calling the wrong number since messages were left for someone named [redacted] or [redacted] or [redacted]. However, the unwillingness of Aetna representatives to even attempt to resolve this has led me to believe they are using a fictitious customer name in order to circumvent the Do Not Call list and pressure individuals with no business relationship to become customers. (This is my second complaint. I will continue to file complaints every time Aetna calls me until somebody in their office figures out a way to stop this.)Desired Settlement: They need to stop calling, stop selling my phone number to medical supply affiliates, and notify all of their affiliates who have already been provided with my phone number to remove me from their lists. Since these calls started, I have been inundated with medical-related recordings from dozens upon dozens of companies.

Business

Response:

Thank you for your inquiry received on 09/02/14 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: Aetna has sent me a bad check I have tried over the last two weeks to resolve it over several days worth of phone calls. To have it reissued. I have had several bank fees as a result of their bad check and they refuse to call me back and either direct deposit or even send out another one after theirs failed to be valid even after trying to deposit twice as they asked me too. The original check was for $440.00 and now I have two fees resulting in $10.00 more dollars and I am unable to pay several bills due to their lack of follow up. I have spent a total of at least 4 hours trying to get a email, call, etc back from the finance dept. AS I understand I am not alone in this problem, it was not just my check. I was just the first to notify them. I am a health practitioner (massage) and I am asking to be reissued the funds immediately. I would just like my due amount. The original bill was sent two months ago. This is bad business.Desired Settlement: I would like a direct deposit or check sent overnight immateriality so that I do not incur other problems and can deposit monies owed. A call back would be nice. Compensation for bank fees of $10.00 and a apology.

Business

Response:

Thank you for your inquiry received on 07/22/14 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: Under my insurance coverage online it states prenatal is covered 100% no limitations and exceptions. When I call customer service I get a different response from every rep. Today I spoke to two different reps who stated my coverage covers prenatal except ultrasounds and pregnancy test among other prenatal related items. They are not providing the coverage I pay them for since it clearly states prenatal covered no limits and exceptions!Desired Settlement: DesiredSettlementID: Other (requires explanation)

ALL prenatal office visits and in office ultrasounds covered and any money I have paid refunded.

Business

Response:

Thank you for your inquiry received on 05/27/2015 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.

We reached out to Aetna’s Customer Service department, and were advised that Customer Service representative [redacted] contacted the member on multiple occasions to speak to her and go over any questions and concerns the member has regarding her benefits. On 06/03/2015, the member spoke to [redacted] and advised that it was not a good time to talk and requested that [redacted] call her back next week after 12:00pm. [redacted] advised she would call her back next week.

In regards to the member’s benefits, below is the information showing what is covered for pre-natal under the member’s plan.

· Prenatal and postnatal care - Prenatal: No charge. Postnatal: 10% coinsurance

· Delivery and all inpatient services: 10% coinsurance

· Limitations and Exceptions – None

This means there is no limits to the pre-natal visits she has (but the care has to fall within the pre-natal guidelines below ) and there are not exceptions to what is covered. Coverage for prenatal care is limited to pregnancy-related physician office visits, including the initial and subsequent history and physical exams of the pregnant woman (maternal weight, blood pressure, and fetal heart rate check).

Items not considered preventive include (but may not be limited to):

· Inpatient admissions

· High Risk Specialist Visits

· Ultrasounds

· Amniocentesis

· Fetal Stress Tests

· Certain Pregnancy diagnostic lab tests

· Delivery including Anesthesia

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].

Consumer

Response:

First it says my initial visit is covered which is not true I was charged a $50.00 copay. Second it says no limits but then in the next paragraph it states prenatal is limited to.... . They are contradicting themselves. Ultrasounds are routine to prenatal how can they not be covered? Meanwhile I have an email from another Aetna rep stating my ultrasounds are covered 100% and I am only responsible for a $50 copay.

Review: [redacted]

I am rejecting this response because:

Sincerely,

Review: Today, I was informed that my Aetna insurance account was termed in December. I was unaware of this until I checked my bank account and noticed that I was no longer being automatically debited for my premium since December. I had no reason to think my automatic payments had stopped. No changes to my policy were made to suggest this would happen. Not long ago, I was also informed by my pharmacist that Aetna had the wrong date of birth on my insurance account. I'm not sure if that's related to the cancellation. Im not sure what happened that my automatic payments stopped, but apparently the only correspondence I ever received to alert me of this was mailed. I recall getting, at most, two mailings from Aetna. Both inconspicuous and I threw them out as they looked like junk mail, and I was already enrolled with auto payment, and had no insurance claims outstanding. I was not contacted by email or phone to alert me of this situation AT ALL. To make matters worse, my insurance agent looked further into this and informed me that, according to Aetna, I had both written and called to cancel my insurance. I have had ZERO correspondence with Aetna since December, so this is simply impossible.Desired Settlement: At this point, I feel as if Im being treated very unfairly as a customer and would like my insurance reinstated retroactively. I am willing to pay all premiums back to December to get my insurance back.

Business

Response:

Thank you for your inquiry received on 07/11/14 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: Despite a phone transcript in which Aetna confirmed that [redacted] codes [redacted] and [redacted] are covered under my plan, Aetna has refused to honor their commitment to reimburse this submitted claims (see attached phone transcript), even though we have provided documentation to show they were medically necessary.Desired Settlement: A fair resolution to this problem is that Aetna pays the claim in accordance with the coverage statements made, which amounts to $1,437.80 (70% of eligible out of pocket expenses) for CPT Codes [redacted] and [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.

We show that this complaint was already reviewed and responded to under previous Revdex.com case [redacted]. We had the complaint reviewed again to make sure the original determination was correct. We verified that our previous response was correct regarding the coverage for codes [redacted] and [redacted]. We mailed a check to the member on October 08, 2014 for $1,227.80 for code [redacted]. The procedure code [redacted] is not being denied at this point for medical necessity, the procedure is being considered incidental to code [redacted] so an additional payment of $210.00 will not be allowed. We have had this reviewed under appeal case [redacted], where a medical director agreed with this determination. When a code is incidental the charge for the service ([redacted]) is not payable because it is considered part of another procedure ([redacted]) performed on the same date and is included in that payment of [redacted].

While we understand your concerns and recognize this is not the resolution you sought, our decision remains unchanged. 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,

Complaint and Appeal Consultant

Executive Resolution Team

Consumer

Response:

Review: [redacted]

I am rejecting this response because:

Review: My daughter is insured with Aetna Better Health.I contacted the company for an Oral Surgeon to have her wisdom teeth extracted because she is in pain and they are becoming infected.She can not eat or swallow.Her surgury was set up for 6/3/2014.The Surgeon called me and informed me Aetnea Better Health/ [redacted] is not paying for the surgey.Three different dentists told us they must be removed or she will become very ill.Desired Settlement: My daughter is in pain ,her wisdom teeth are now infected.Her mouth is swollen.She lost 6 pounds and can not eat or swallow.She has been in bed with ice on her face drinking ony fluids.I am a single father on SSD.The doctors told me if Aetna better health/[redacted] does not approve payment she will be hospitalized.The surgeon and dentist sent in all the proper forms and begged Aetna/[redacted]t to approve the surgery.Please help my daughter !

Business

Response:

Hi [redacted],

We are unable to locate [redacted] information in our system. We reached out to [redacted] via email today 06/01/2014 requesting additional information.

Once received, we will advise you so you can update the case.

Thank you.

Sincerely,

Business

Response:

Thank you for your inquiry received on 06/02/14 regarding complaint #10072554 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 requested a refund because my insurance was cancelled on the same day issued on the phone..recorded call, with rep that signed me up. She told me the premium was $416.73 and I thought she said 16.73....misunderstanding on amount. I ask her on the phone when she took the application to cancel it because I misunderstood amount she said. She said it was too late because she has already sent it to my bank, but someone would call me before drafting my account and not to worry. She said she had cancelled, but I called back and it was never cancelled. [redacted] drafted my account after cancellation 2 different times caused an overdraft fee of $35.00 and again another overdraft fee of $35.00 totaling $70.00. I had to eventually call 2 times after the first cancellation with the rep on the phone that took the application. [redacted] asked that I faxed proof of overdraft fees to them at fax # ###-###-#### with case# [redacted] which [redacted] & [redacted] bank managers at ###-###-#### did send 4 different times. [redacted] said they never received. After the first 2 faxes sent, they said they had received and to wait about 10 days for refund that I never got in Feb 2014. I then called back about refund and they said never got fax. So I called the corporate office and spoke to [redacted] at ###-###-####, she told me she would handle it, took all the information and my email of the fax that my bank finally email to me. She finally called me back and said that they need additional information showing my balance prior to overdraft which I didn't understand because it should have never gone through my account in the first place. Now it is April 2014 and I still don't have my refund. I was told many times that a supervisor would call me back and on several calls to them no one never called me back and gotten many hangup calls from the call center. I could never speak to a supervisor and have been getting the run around. [redacted] have all the documentation needed to get my refund. Help. ThanksDesired Settlement: Refund of $70.00 overdraft fees only. Mailed or put in my bank account.

Business

Response:

Thank you for your inquiry received on 04/26/2014 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 currently have Aetna health insurance. My son has a prescription for medication that he takes 3x/day which is necessary for his condition. The dosage is prescribed so that he can receive the full benefit of the medication and is considered titration. Our health plan does not cover this dosage unless it meets one of three criteria, with titration being one of the criteria. In July 2013, Aetna denied coverage for my son and I filed an expedited appeal (Case #[redacted]). Upon review of all applicable information, Aetna reversed this decision in our favor and issued a letter dated July 18, 2013 approving the dosage. Aetna honored their decision for the next several months until March 2014 when we refilled the prescription. Again, Aetna denied the coverage based on the quantity. On March 22, I received a letter from Aetna denying coverage. I called Aetna to remind them that this dosage is covered as titration. I waited on hold for over 30 minutes before getting a customer service representative. [redacted] (who was extremely helpful and patient) transferred me to the pharmacy department. [redacted] (#[redacted]) was rude and said there was nothing she could do because the pre-cert department was closed until Monday. I indicated that I have a letter with the approval and if she could just look it up in her system, she would be able to see that the dosage is approved. I impressed upon her that this does not require pre-cert - that the claim was denied not due to pre-cert requirement, but due to coverage. She was short and rude. I requested to speak to her manager. We waited on hold until [redacted] from Pharmacy Mgt picked up the call. [redacted] gave her the case number and DCN number but [redacted] insisted that she could not override a quantity denial without authorization. I told her that the authorization was in the letter. They told me to call back on Monday. I called on Monday and was told to call later since their system was down.Desired Settlement: Aetna needs to ensure that communication regarding coverage extends to all appropriate departments and ensure swift and simple communication when there is a denial. It is causing serious distress for my family and if it is not resolved, we will have no other choice but to take legal action. It is quite simple. Improve communication between internal depts. and with your customer (us).

Business

Response:

Thank you for your inquiry received on March 31, 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 Aetna Pharmacy department for assistance with the member’s concern. They advised the drug allowed 3 per day was approved only from July 17, 2013 to October 17, 2013. The member was still able to fill for 3 per day beyond that date by an override that was placed on the account in error. We received an approval for a one-time exception to allow the member to get 1 more fill of the [redacted] at 3 per day. They contacted the Pharmacy and they have processed the claim; however, the member must go through the Precertification process to have the medication approved for future fills.

Review: My recently passed mother has aetna life policy, no named beneficiary. I as court appointed executor of her estate was told by aetna, to send certified death and legal executor documents. Aetna acknowledged receipt of all required documents 12-23-2013 was told 4-6 wks to receive estate check.going on 8 wks called customer service numerous times which is in india by the way.all I get is run around.Desired Settlement: Request penalty for late charge and interest for far exceeding 4-6 week period.

Business

Response:

Thank you for your inquiry received on 02/19/2014, 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 for assistance to Aetna's Life Insurance department, and they were unable to locate Mr. [redacted]'s mother, [redacted] in their system. We contacted Mr. [redacted] for additional information to assist us in our review, such as, the phone number of the Life Insurance department at Aetna he's been contacting and/or who he's been dealing with, as well as, additional information on his mother's life insurance policy. Unfortunately, no response was received. This information is still required for Aetna to review further.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr. [redacted]'s 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: life insurance check was finally received on feb28 2014 for estate of [redacted] my mother. Aetna claims they had no files of her was totally untrue . They had already acknowledged her policy and receiving all required documents of her death and my certification as executor of her estate on dec23 2013. As far as my communication with there customer service reps, there was only 1 service # given to call on there policy statements and given they had all required info to send check , they knew the customer service department I communicated with. Which by the way was in INdia, until complaint was filed with Revdex.comc I was given run around and ignored. Once Revdex.comc got involved issues were quickly addressed by aetna, without them I sincerely think I would still be getting the run around. Thank you Revdex.comc.

Review: Patient was seen, benefits were obtained prior to any office visits, or surgeries. The benefits given were incorrect. Specific questions were asked concerning a surgery, and the limitations and coverage for that particular procedure was not divulged. Now after the patient has had their surgery, the patient is financially responsible for more than what was quoted prior to the surgery. Upon speaking to a customer representative, the reason given was coverage for that particular service was different than what we were quoted. I explained I had a reference number and name of the person that had given us original benefits, if she would direct this back for an investigation, but I was told it was too late being I had previously called regarding the patient's bill. I explained, even when I inquired back then, no-one told me of the benefits I was being quoted now. She would not transfer me to her supervisor because the supervisor would just relay everything she had already told me.

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

The claim should be paid according to the original benefits given. That is what was told to the patient and facility, and that is what needs to be honored. The patient was only $2,032.02 from meeting his out of pocket, then the insurance would cover 100%. Now he is faced with $18,855.08 in medical bills that the insurance should pay.

Business

Response:

Hello,