Aetna, Inc.

Review: I have been a member of Aetna's Insurance for several years. When the Affordable Care Act began to take effect I was sent letters advising that if I wanted to continue with my current health coverage plan for the 2013 rate I would need to enroll in November, however if not I was to do nothing as I would be receiving the new rates for 2014. I have yet to receive information and have made several calls to Member Services as well as Sales with over an hour wait times and multiple transfers between departments. Today I was on the phone for over 4 hours transferred between Sales, Member Services, Billing, and Supervisors with still no resolution to their error. I was finally able to locate a number for [redacted]-Head of Florida's Corporate Office and I have left a message there in hopes that someone can finally provide an ounce of assistance. I am disgusted with the manner in which they do business and I am now going to be forced to have a gap in my coverage, which I have never had.Desired Settlement: I would like immediate resolution of the issue and for my coverage to continue 1/1/14 not 2/1/14. I still do not even know what the 2014 rates are so I feel it fair that I should be allowed to continue with my 2013 rate for January.

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.

We reached out to the Individual Billing and Enrollment department for assistance with the member’s concerns. They advised mailing a notification letter to the member on November 8, 2013, with her options. As an exception, they processed the repurchase of the member’s 2013 plan on December 31, 2013, and her new rate is $488. The member will be able to keep this plan for 12 months. They also advised voiding the February 1, 2014 plan and they processed a $528 credit card refund. The member will receive it in 3-5 business days.

Consumer

Response:

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

Review: I had Aetna as an insurance provider for only a few months. I went to only one doctor, two times. Aetna is refusing to pay for my doctor visits because they claim that I did not choose that doctor as my primary care physician. I told them that I did choose that doctor through their website, but for some reason, it is not showing up on their end. According to their records, I do not have a primary physician and therefor, they do not have to pay the doctor. I have filed two appeals with Aetna, but still they are refusing to pay for two measly visits. I am going to demand my money back, or file a lawsuit again Aetna. I paid for health insurance and I paid my co-pay, but they are crooks and they took my money for absolutely nothing. I got robbed. I paid for a service I did not receive and I will not go down without a fight. This is ridiculous.Desired Settlement: I would like Aetna to either pay me back the money that I paid them for health insurance that I did not receive, or I would like them to just pay the doctor. I will not pay them $250 a month for health insurance, just for myself and then have to go to the doctor to pay another $250 for just two visits. It is ridiculous and a scam.

Business

Response:

Thank you for your inquiry received on December 02, 2014, regarding complaint #[redacted] for [redacted]. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Review: Insurance ID: [redacted]DOB: [redacted]Group#: [redacted]My name is [redacted], my boy's name is [redacted], he is diagnosed on the [redacted], and we are using [redacted] for the ABA service to help him.I have medical insurance through my work - [redacted], it's a self insured plan and my firm provides ABA coverage as a employee benefits. And we obtained pre-authorization as required.However ALL the claims were wrongly denied AT FIRST based on the cited reason Charges for educational services and training are excluded from coverage under your planIt's like no Aetna representative even look at the system even through we are covered and obtained the pre-certification as required. After the denial, I have to contact Aetna each time asking for re-processing citing the pre-approval in the system, sometimes I get standard copy-paste answer it's under review and no results within 3 month.Have a child on [redacted] is hard and stressful enough, now I have spend significant time tracking and fighting the wrongly denied claims.Just please count how many emails I send this year 2015 so far alone for these wrongly denied claims in your system - 68.Specifically Part 1 of the claim # [redacted] ($587.89) is still wrongly rejected after at least 6 emails exchanges, the last one I sent to is Aetna [redacted] help account on 8/25/15, but still no results.And I see all the recent claims again are wrongly denied....Desired Settlement: Fix the wrongly denied claims immediatelyStart to process my claims correctly without my intervention

Business

Response:

Hello,

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

Upon receipt of the complaint we immediately reached out to have the member’s claims reprocessed per the approval on file. We were advised that all the claims have been reprocessed and are currently in the process of being paid to the provider. We have also placed a special handling on the policy so that future claims will drop to a claims specialist for handling.

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

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

Consumer

Response:

Review: [redacted]

I am rejecting this response because:

Review: I filed a reimbursement request for out of pocket expenses on 28 Sep which hasn't been processed yet. First, the customer service staff is very ill trained, they don't understand US rules and their own company policy. After several calls to understand the process, I finally submitted out of pocket reimbursement request from my HRA account. I was told everything is fine, they can see the documents and I shd expect the claim to be processed in 7 business days. After 10 days I called to see where we are on the process, and how can I see its progress on their website or anywhere, but seems like that's not an optional at all. Anyway I was told at that time, that it could take upto 4 weeks for this process. But even after 6 weeks, I haven't received any communication and of course there is nothing on their web site.

Business

Response:

Thank you for your inquiry received on November 10, 2014, regarding complaint # [redacted] for [redacted]. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Review: My complaint is that Aetna is not paying a claim I think they should. How is it that Aetna or any insurance company be able to self police claims. I pay for dental insurance and if a doctor says I need a valid procedure done, how can Aetna come back and say no! I have to pay for the procedure because they think it will heal on it's own or was not needed.My member ID is WXXXXXXXXX, procedure was performed 5/20/2013, procedure in question is a [redacted].I will also be taking this up with the company I work with

Product_Or_Service: Dental

Desired Settlement: Pay for the procedure, not place all cost on me just because they do not want to pay. No one else gets this option only insurance companies

Business

Response:

Business Response /* (1000, 5, 2013/09/03) */

Thank you for your inquiry received on August 20, 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 Dental department for assistance with the member's concerns. They advised that a pre-treatment estimate was submitted. They pended the $300.00 [redacted] procedure in the pre-treatment estimate that was issued on May 1 (before the services being performed) and requested x-rays and a narrative on the reason for the treatment. The benefit (for the other procedures submitted with the [redacted]) matched the amounts that were pre-approved. The provider and the patient both were sent a copy of the estimate.

The $300.00 fee for the[redacted] was reviewed by the Utilization Management (UM) staff and denied twice. Based on dental consultants' review of the diagnostics provided, they denied benefits on the [redacted] due to necessity as it appeared normal healing would have adequately eliminated the [redacted]. The diagnostics and information submitted thus far did show why the defect wouldn't have been able to adequately heal without the [redacted] being performed. They advised if the provider submits a narrative and/or diagnostics that shows why the defect wouldn't have normally healed without the [redacted], they can have this reviewed by their Dental Consultant to see if benefits can be allowed.

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 sent 4 claim forms for my daughter [redacted]'s orthodontic expenses to my Flexible Spending Account with Aetna Life Insurance Company in June 2015. I included a cover letter listing all claim forms included. The company returned an Explanation of Payment that only referenced the first claim, for January, had the wrong date of service (June 6 instead of Jan), and requested more information along with a return of the Explanation of Payment form.

In July, I returned the Explanation of Payment form as requested, supplied the information requested, and indicated that my other claim forms for orthodontic expenses for [redacted], for the months of February, March, and April, had not been referenced. I re-submitted these claim forms and copies of the insurance companies partial payments and my receipts.

As of August 10, I had received payment for the January claim form, but there was still no reference to the other orthodontic claim forms. On Aug. 10, I called and spoke to Jalisa, who said she would resubmit those months' forms and call me back. As she had not called back, I called again on Aug. 18, and spoke this time to [redacted] indicated that the case was "open" and that they would call me back. On Aug. 19, not having heard back, I called a third time, and spoke to Jilby. This time I asked for an email confirming the status of my claim submissions. I was told that I couldn't be given that. I asked to speak to the supervisor, whose name I was told is Leslie. I waited on the phone for 20 minutes, and finally spoke to Leslie who told me the check would be cut today, Aug. 19, but that she could not send me anything in writing such as email, to the effect. As Aetna recently sent me a letter indicating that they would be moving my balance to [redacted] soon and that [redacted] will be processing claims, I am eager to resolve this issue before that occurs on Sept. 1.Desired Settlement: I would like to be reimbursed the amount of the Feb., Mar. and April claims, which was $71.09, making a total of 123.27. I would like immediate written communication and apology from Aetna Life Insurance Company division for Flexible Spending Accounts.

Business

Response:

Thank you for your inquiry received on 08/21/15 regarding complaint #[redacted] for [redacted]. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Review: I have been in severe pain in my low back because of [redacted] in my [redacted] for over a year now. I went out of work on disability from 7/29/12 through 2/3/13 because I couldn't sit and/or stand for more than a few hours before my pain reached excruciating levels. My employer gets their disability insurance through Aetna. The contract states that if a medical professional deems you unable to do your job (sitting for 8-10 hours a day in a call center), that they have to pay the disability. They stated on numerous occasions that I didn't provide sufficient evidence of my problem even though my doctor sent them multiple documents, including MRI results that showed I have [redacted] in my [redacted]. I went back to work on 2/4/13, but the pain has persisted, so I am back out of work again as of 4/15/13. Aetna has again denied my disability claim stating that the documentation is insufficient to prove the claim. I have gotten an attorney to help with the first denial and am appealing their most recent decision to deny my disability again. This time they even denied my protected leave from my employer, so my job isn't even protected from this ongoing medical problem that I have.

Product_Or_Service: Disability Insurance

Desired Settlement: I would like Aetna to honor the contract they have with my employer and pay both of my disability claims.

Business

Response:

Business Response /* (1000, 5, 2013/06/18) */

Thank you for your inquiry received on June 4, 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 Disability department for resolution of the member's issues. They advised Ms. [redacted]s claim for the time period of July 29, 2012 to February 3, 2013 (claim number XXXXXXX) was denied because the medical information did not support functional impairment. It went through the appeal process and was reviewed by a peer physician specializing in Physical Medicine and Rehabilitation. The peer physician did try to speak to her providers, but was unsuccessful, so they faxed the peer physician's report to them with a request to review and respond. They did not receive a response and the appeal decision based on all the medical information on file was that the decision to deny benefits was correct. The medical information did not support functional impairment.

With respect to the time period of April 15, 2013 to the present (claim number XXXXXXX), benefits were denied because it was determined the medical information did not support her disability, the same reason her previous case was denied. They received her appeal on June 4, 2013 and it is currently in review with the Claims Operations Team.

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].

Consumer Response /* (3000, 7, 2013/06/20) */

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

My doctor did speak with Aetna's disability department. Also, the reason they gave my attorney that the claim was denied was that there was no diagnosis, which my MRI clearly stated that I have [redacted] in my [redacted]. This was caused by a car accident when I was 14 and the pain has gotten worse over the past 2 decades to the point where I have increased pain if I sit/stand for more than a few hours. I am having [redacted] tomorrow in the hopes that it stops the pain. Why would I go through that if it was just everyday aches and pains as Aetna claimed? Their resolution is unacceptable and they only want to deny the claim so they don't have to pay any money out.

Business Response /* (4000, 9, 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 again reached out to the Disability department for review of the member's issues. Unfortunately at this time, the denial stands. The [redacted] only has one level of appeal review. The only way we would do another review is if the employee had new medical for the time period in question, which dates back to July 29, 2012 to February 3, 2013. This information has to be new compelling information in order for them to consider another review. Also, to clarify, the short term disability monies come from [redacted] not Aetna as we are the administrator of their benefits only. It appears that she has had this condition for many years and worked with it. The employee would have to show what changed that now makes her completely disabled.

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].

Consumer Response /* (4200, 11, 2013/07/09) */

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

[redacted] pain gets worse over time, so even though I've had this problem for years, the pain has become unbearable. Obviously we are not going to resolve the issue through this outlet, so I will continue to pursue this through my attorney.

Aetna may not pay the disability benefits, but you do make the decision on whether or not [redacted] pays the benefits, so this is on you.

Review: This business is not PCI compliant according to the rules and regulations of the Card Associations.

I received a bill in the mail of $107.34. I called the customer service number [redacted] on 7/14/15 to pay for Billing ID: [redacted]. Spoke with [redacted] and she refused to take my credit card payment over the phone. They require me to hand-write my complete credit card number on a piece of paper and mail it to them. Sending a credit card number or check by mail is the least secure method of payment possible. I wanted to pay my bill over the phone and was denied. This is not a PCI compliant practice according to the rules and regulations of the PCI Security Standards. Not only can my information be stolen by mail, it requires me to purchase stamps (which is rarely used in 2015).Desired Settlement: I want to pay my bill over the phone or online.

Business

Response:

Thank you for your inquiry received on 07/16/15 regarding complaint #[redacted] for [redacted]. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Review: I am reporting Aetna at this time due to misinformation given to me by a customer service rep. at Aetna, who does insure me. The telephone conversation was recorded and Aetna does not dispute that incorrect information was given to me regarding where I could obtain a booster shot. This information turned out to be incorrect and the service that I obtained at [redacted] is not covered under my policy. Because Aetna's representative made an error and they are not disputing this I would like this service reimbursed ..... I have been waiting since January of this year with countless calls and letters to Aetna. They must be held responsible for their staff.Desired Settlement: I would like Aetna to contact me and explain their position on this matter. I have been inundated with paper.....I realize now that this is not covered........I don't need more paper thrown at me.....just pay the charge from Walgreen's.

Business

Response:

Hello,

Review: A medical bill for a service from over a year ago was sent to a collection agency in my name due to negligence on Aetna's part in properly processing the claim. I received the bill the first time a few months after the service date and contacted Aetna and the biller to try to correctly resolve the issue. Aetna did not properly process the claim or communicate effectively with the biller to resolve the matter, so I continued to receive bills. Each time I received a bill, I contacted Aetna again who assured me that the bill was not my responsibility and that they would handle the matter. Finally the biller called telling me the bill had not been settled, and I contacted Aetna one last time. They told me to mail the bill to them, and they would take care of it. A few months after that, I started receiving correspondence from a collection agency claiming that I owed the full amount of the unpaid bill. Aetna's incompetence in handling this matter will have a detrimental effect on my credit due to no fault of mine.Desired Settlement: I want Aetna to pay or reimburse me in full for this claim

Business

Response:

Thank you for your inquiry received on 07/17/14 regarding complaint #[redacted]1 for [redacted] Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Review: Aetna will not pay bill of $880.00 because they claim I used a out of network provider, but I have proof to show that the provider that I used was in network.

Product_Or_Service: N/A

Order_Number: N/ADesired Settlement: DesiredSettlementID: Other (requires explanation)

Aetna to pay the bill of $880 plus any late fees to [redacted]

Business

Response:

Hello,

Review: I have been trying for a month to get a prescription filled via Aetna's [redacted]. I have spoken with various contact center reps ([redacted] - to name a few) and my doctor's office has spoken with several reps ([redacted], etc.). My doctor's office has completed the pre-authorization and called and faxed in my prescription several times. When I call inquiring about the status, Aetna keeps saying they don't have a prescription, which is a lie. I called Aetna's [redacted] (again) on Jan. 22 and asked to speak with a supervisor. I was transferred to [redacted] who was the rudest person I've ever spoken to over the phone. He tried to intimidate me and kept wanting to argue about the importance of my doctor's office telling me who they had spoken with previously, even though he said Aetna records their calls (so it should be easy enough for him to find out who my doctor's office spoke with at Aetna). Eventually he started to act like a human being and said he would call my doctor's office, get everything taken care of and call me that same day. He never called back nor did he speak with anyone at my doctor's office. My husband also has Aetna health insurance and went through this same thing last year when he needed a specialty prescription filled.It is obvious to me that Aetna practices stalling and intimidation techniques to avoid filling expensive prescriptions that their customers legally have a right to.Desired Settlement: I want Aetna to fill my prescription each and every month without going through this any more. I am paying my premiums each month and this is a service that Aetna CLAIMS to provide; therefore, they need to do their part. I want my medication and I want it now.

Business

Response:

Thank you for your inquiry received on January 23, 2014. Our [redacted] Team researched your concerns, and I would like to share the results of the review with you.

We reached out to Aetna’s [redacted] Account department for assistance with the member’s concerns. Based on our review [redacted] prescription for the [redacted] kit was approved and the precertification is effective for dates of service January 15, 2014 to July 15, 2014. Aetna’s [redacted] department processed the order of medication on January 22, 2014, applying a $70.00 copayment. The [redacted] kit was shipped on January 22, 2014, and was delivered on January 23, 2014.

Review: I am totally confused - RE: [redacted]10/16/13 To: [redacted]Edit profile detailsFrom: [redacted]) Sent: Wed 10/16/13 8:36 AM To: [redacted]) I received a letter regarding a non-authorized EFT payment for long term care and am unclear how to proceed. First, some background. Some months back (I am guessing 3-6 months ago) I requested to be set up on an automatic payment plan for the long term care insurance for myself and my wife. Last week, I had an EFT payment show up against my bank statement saying it was from Aetna. However:it was for a totally different amount than what I normally payI had received no notification that the automatic payment would startI had not received any invoicing to tell me a payment was due (as I received from every other automatic payment I have set up) So, I called Aetna and was informed that Aetna had not submitted any request to my bank for payment. As such, I assumed it was fraud and closed my bank account. Needless to say, this is a painful experience. I had to notify all organizations where I had direct payments (11 of them) and re-file paperwork to shift to my new checking account. I had to tear up all my checks (for which I had paid for printing). I had to request new checks (for which I had to pay for printing). And then I get a notification per the letter from Aetna complaining that I had denied authorization of the payment that Aetna tells me they didn't submit. Now, where do I go from here? I have had this policy in force for approximately 10 years, but if this is the way Aetna does business I have no confidence that they will pay if I ever file a claim (and based on this experience, filing a claim is likely to be very painful). I called your Customer Service line (what a misnomer) and was told:I cannot get invoices for this policy while I have automatic paymentsIf I want to return to paper billing, I will not only have to send in a letter authorizing this change, but you will charge me $2 every time I pay my bill - which is now harder for me to do since I have to manually do this OK - now back to my initial quandary. If I have to send in a letter authorizing return to paper billing, why does the letter you sent me say that "If payment is not received within 30 days... your billing method will be changed to direct bill..." NOTE: If it took 3-6 months to convert to automatic billing in the first place how can I pay this in 30 days? The checking account we set up for automatic billing is now closed - yeah - thanks for that. And, since I have no paper invoice, I am unable to send a check for the premium.If it is this hard to work with Aetna, why would I want to continue sending you money? Since this letter is dated October 7th, the time clock is ticking (we are down to 21 days). My recommendation?Offer to send me electronic invoices for automatic payments (my preferred choice) or cancel the $2 charge for paper billingLook at your internal procedures - obviously, this is not the way to run a customer service businessConvince me that Aetna would pay a claim without making it VERY painful for me to do so Your advice? [redacted]Desired Settlement: See complaint description (per e-mail sent. Note: No reply was received from the e-mail.

Business

Response:

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

Review: In December, 2013, I successfully enrolled in an Aetna health insurance policy (#[redacted]) via the [redacted] website. I paid the first month's premium, received my policy package and health insurance cards. I was content that I had a good policy. Then, on January 14, 2014, I received correspondence from Aetna stating in bold type, large font: "The Aetna plan you enrolled in is only available in [redacted] counties." Having all medical treatment I might receive in [redacted], where I reside, being treated as "out of network" would cost me exponentially more. There was obviously no meeting of the minds in this contract - as I was not informed of this contractual condition prior to making payment. Thus it is my contention that said contract was, and is, null and void.I was acrimonious, contacted Aetna immediately, and spoke with a supervisor ([redacted], I.D. # [redacted]) at 2:30 p.m. on January 14, 2014. I requested that the policy be immediately cancelled and the $523.00 I had paid for the flawed policy be reimbursed to me. At that time he told me, in no uncertain terms mind you, that the policy had been cancelled and I would soon receive full reimbursement. I took him at his word, and I was never informed that I was required to cancel the policy via the [redacted].The following day I also spoke with a representative from the [redacted]. I explained the situation and, once again, was never informed that I was required to cancel the policy via the [redacted]. I was told that the case would be assigned a caseworker and someone would contact me. I never heard anything back from them.On February 6, 2014, I was surprised to receive a bill from Aetna for the next payment on this policy. I contacted Aetna customer service and spoke with a representative ([redacted], I.D. # [redacted]) who informed me at that time that I needed to cancel via the [redacted], and put me in contact with a [redacted] representative.Effective February 7, 2014, I have confirmed with [redacted] representing the [redacted] that I have officially been disenrolled. I respectfully request immediate reimbursement of the $523.00 I paid to Aetna for the flawed policy, or I will seek a legal remedy.Desired Settlement: I respectfully request immediate reimbursement of the $523.00 I paid to Aetna for the flawed policy, number [redacted], with an effective date of January 1, 2014.

Business

Response:

Thank you for your inquiry received on 02/07/2014 regarding complaint#[redacted] for [redacted]. Our [redacted] Team researched your concerns, and I would like to share the results of the review with you.

Review: I am so disappointed in [redacted] for so many reasons. I have called and called almost every day requesting status of my appeal for a preauthorization for surgery and [redacted] keeps pushing me away.

I called a few weeks ago, and was told I would get a call no later than 11/24/15 of course I never got that call. I then called back and was told I would get a call by 11/30/15 and I never got that call as well. I then called back and requested to speak with a supervisor and was told a supervisor by the name of Lori would call me. I kept my phone on me for an entire day expecting a call on the status of this appeal and never received a call.

Every time I call [redacted] I am being given the run around and I am simply tired of it. I will be filing a complaint with my employer along with the Revdex.com. My doctor has also put calls in as well and is being told the same story. I have given [redacted] enough time to respond to me and [redacted] has simply not done so.

This has been going on since the end of August, and I have still yet to receive a response to the appeal for my preauthorization. I even sent a prior message to this very same database on [redacted].com and received a response that you did not see an appeal for me in the system. I called in a day later and of course there was.

I am at my wits end. I am trying to have this surgery before the end of the year. My doctor has even noticed that your company keeps delaying my appeal. My doctors assistant also seems to think your company does this so that I will have to pay more out of pocket next month if it is approved since my out of pocket max will start over. I consider this a violation of claims practices.

I have no choice but to believe this because when I call literally every representative cannot see a reason why my appeal keeps getting pushed back.

I also attempted to submit this letter under your complaint/appeal topic but of course I receive a message stating my information cannot be submitted. As an executive at Progressive Insurance, I will be making sure to voice my opinion of your company with my hr department in hopes of switching administrators as well as reporting this to the department of insurance. I cannot be the only client this is being done to.

[redacted]Desired Settlement: I am requesting my appeal to be resolved today. It is bad business and unethical to keep pushing back a decision so that my out of pocket maximum will roll over in 2016.

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 reviewed the prior authorization request and the appeal request. According to our records our pre-certification department was contacted by the provider on September 14, 2015, and the medical records were received by [redacted] on September 22, 2015. Our medical director reviewed the pre-certification request on September 22, 2015 and a determination was made that same day. We mailed a letter to both the member and the provider advising of the resolution on September 22, 2015, and we verified that the address on file for the member was the address the letter was mailed to.

The appeal request was made on November 27, 2015 by the provider on the member’s behalf. The first page of the appeal request included the pre-certification denial letter dated September 22, 2015, and at the top of the page the provider wrote received on September 30, 2015. The provider’s office was waited almost a month to request the first level appeal. The appeal was closed on December 07, 2015, in a timely manner and a resolution letter was mailed to the facility on the same day.

The member was advised of the resolution by a representative of [redacted] on December 10, 2015, and she also emailed the resolution letter. I understand your concerns and recognize this is not the outcome you desired. However, we must make coverage decisions in accordance with your plan of benefits and our medical necessity guidelines. The member and/or the provider can request another level of appeal by contacting our customer service department or sending a request in writing within 60 calendar days.

Concerning the customer service you experienced, our goal is to provide exceptional service to our customers, and immediately resolve issues when they do occur. I sincerely apologize for the frustrations and difficulties you experienced and that we did not provide the level of service that you rightfully expect and deserve. These actions are not consistent with [redacted]’s service standards and we appreciate you notifying us of your experience. We have addressed your customer service concerns directly with the representatives and supervisors who were involved.

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].com.

Thank you,

Ashley S.

Complaint and Appeal Consultant

Executive Resolution Team

Review: Since November 2013 I have made four separate attempts to file a claim to receive reimbursement for medical services per the regulations of my health plan. Aetna has either misplaced the claim, demonstrated sheer ignorance about what services are covered, or instructed me to resend or refax the claim multiple times. As of today, 12/26/2013, I have not received payment for expenses incurred for medical services. I have filed two grievances with Aetna and have not received a response. This is appallingly poor service and something that feels like deliberate mistreatment or intentional delays. It has contributed to sheer distress and anxiety on my part. I have notified my employer of Aetna's repeated failure to satisfy its obligations as an insurer.Desired Settlement: I request immediate reimbursement of my expenses. I also request that Aetna provide me with an alternate form of communication to ensure timely and complete processing of my claims.

Business

Response:

Thank you for your inquiry received on December 30, 2013. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Review: On July 21, 2013, I submitted four claims for the reimbursement of pharmacy expenses that I paid out of pocket during a period when my new (COBRA) card had not yet been delivered. I've been trying to get a status update from AETNA since a week after that. Each time I call they pass me around to several departments and basically tell me that the issue is that "AETNA is not contracted with [redacted] pharmacy". They always admit that this status is invalid, yet they don't address it. This has been the status for 1.5 months. Each time I call, it is a 45 minute investment, with me being on hold 90% of that time, and no progress. On my latest call (8/28), [redacted] (Cust Care Mail order team) finally transferred me to [redacted] (senior team) who told that they will need to send the documents back to the original (claims) department for re-processing. When I asked for an escalation, she transferred me to [redacted] (her manager) who took my number and said he'd look into this. Its not the first time I've been told that someone will look into this and call me back. At this point I have to assume that they are hoping I will give up and go away. Please assist me in getting AETNA to take action on this issue. Claim details:[redacted] 11/6/12 $ 507.99 paid to [redacted] pharmacy[redacted] 12/4/12 $ 253.99 paid to [redacted] pharmacy[redacted] 11/7/12 $ 183.99 paid to [redacted] pharmacy [redacted] 12/5/12 $ 14.29 paid to [redacted] pharmacy --------Total: 960.26

Account_Number: [redacted]Desired Settlement: pay me the money I am owed

Business

Response:

Thank you for your inquiry received on August 30, 2013. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Review: It takes me several attempts to get every claim paid by Aetna. They usually deny the claim asking for more information, when the information is provided, they claim that the medical services are too expensive and pay only a small part of these.

I have 2 specific claims where it took 3 months to even get them to consider a claim, and then they provided an explanation of benefits where the services were above "market rate". The latter is a complete misstatement as I received 3 quotes from different doctors, all in excess of the doctor I used. This is a systemic issue with this insurance company. I have not been able to get any rightly qualified claim paid without a lot of hassle.Desired Settlement: adjust the payment on the claims in question

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 had the claims for the [redacted] family reviewed. We were able to verify that there were a few claims on file that were delayed in processing due to not have diagnosis codes submitted with the claim. Once we received the diagnosis codes we were able to process the claims in a timely manner. At this time all claims on file have been processed and finalized.

Most of the family’s claims on file were processed and finalized within 10-15 business days of receipt. If the member sees an out of network provider the payment of the claim is going to be based upon a reasonable and customary rate, not determine by Aetna, and will pay the percentage of the allowable. If there is a particular date of service that the member feel was not processed correctly or disagrees with the payment, the member may file an appeal with our Customer Resolution Team.

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

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

Thank you,

Ashley S.

Complaint and Appeal Consultant

Executive Resolution Team

Consumer

Response:

Review: [redacted]

I am rejecting this response because:

Review: Aetna uses [redacted] systems to manage our company's flexible spending accounts for both healthcare and dependent care accounts.This is the second instance where [redacted] has mismanaged funds and refuses to provide a solution for receiving reimbursement for deposited funds.Dependent care deposits are made to the [redacted] employee account every pay period. In my specific instance, this is every two weeks. If there are eligible claims, [redacted] issues payment each time funds are available.In my case, there are eligble claims exceeding the balance in my account, so each time a deposit is made, a check is sent to reimburse me for the claim.Until August 2013, the process was working appropriately, and I would receive reimbursement checks each pay period. As of the first August pay period, reimbursement checks for deposits made into my account have not been received for two claim periods/payments.After not receiving payment for the 8/8 - 8/9/13 payment, I called in to customer service and was told that the check would be voided and reissued. It appears that the check was voided but never reissued, as I have never received payment.After not receiving another payment for the 8/23-8/24/13 payment, I called in to customer service again - noting that two checks have not been received. I was told that a request would be made to have the checks cut again. There is no record that this request was ever made.After receiving payment for the first Sept pay period 9/6/13, I called again to find out the status of the two missing checks. The customer service agent Ursula could not tell what was going on with my account, didn't appear to understand the process and told me that all supervisors were in a meeting and I would need to get a call back. At this point, [redacted] has retained two payments totaling $153.84 of my funds and does not appear to be doing anything for a resolution.Desired Settlement: Make payment of reimbusement deposits in a timely manner.

Business

Response:

Thank you for your inquiry received on September 17, 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 Flexible Spending Account (FSA) department for assistance with the member’s concerns. They advised check number [redacted] was voided on August 8, 2013 and reissued August 26, 2013. The replacement check has not been cashed by the member. Check number [redacted] has also not been cashed. They attempted to reach the member on September 30, 2013 and October 1, 2013 at the phone number on file but got the member’s voicemail. They left call back information and the member does have the direct number to contact the [redacted] representative to help resolve her issue.

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:

Review: [redacted]

I did receive a call and voicemail from a customer service Supervisor. I called her back 3 times on different days & times and received her voicemail each time. I left messages each time and never received a call back.

Review: I have Aetna Health Insurance through my employer, [redacted], **. I have medical coverage for myself, spouse, and my two children. Last year alone, [redacted] paid OVER $11,000 in premiums to cover us. Last November 3rd, 2013, my son was hit in the face, at school, by an object. Since it was a facial injury, we took him to our dentist. The bill was $154. The school refused to pay the bill, their insurance refused to pay, and our Aetna insurance refused to pay. The school's insurance carrier contacted both us and Aetna stating that they spoke with Aetna and that Aetna agreed to pay because the dentist was treating an INJURY, not a regular dental issue. Aetna still never paid. Come July of 2014, the initial injury finally caused an absess to develop, and once again, the complications from this INJURY was treated by our dentist. This time the bill is a $1,188...for complications from an INJURY. INJURIES and COMPLICATIONS are covered by my medical policy! Aetna still refuses to pay. I have appealed BOTH bills now and still they refuse. Why would they tell the school's insurance carrier that they would cover the bill, and then refuseIESDesired Settlement: My policy covers injuries and complications. IT should not matter if the injury was treated by a doctor or dentist. These two bills should be paid, period.

Business

Response:

Thank you for your inquiry received on 11/06/2014 regarding the claims for date(s) of service 11/04/2013 and 07/22/2014 to 07/31/2014 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 your complaint, we reviewed your policy and benefits regarding these services. We are showing that both claims and the codes billed by Dr. [redacted], would fall under dental coverage and not under the current medical policy through [redacted]. The policy only covers Oral Surgery that is medical and dental in nature and none of the billed codes for these dates of service fall under Oral Surgery. Dental coverage is not administered by Aetna for [redacted]; please contact [redacted] at ###-###-####; this dental coverage is an optional plan provided by your employer.

I regret that my response cannot be more favorable and apologize for any difficulties this situation has caused you. 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].

Consumer

Response:

Review: [redacted]

I am rejecting this response because: