Michael A. (Aetna)
Michael was admitted to a residential treatment facility for rehabilitative treatment of alcoholism. His entire stay at the facility was case-managed and approved in advance by Aetna, with written “certification notices” issued to the treatment facility. When a claim for reimbursement was submitted, Aetna requested that the facility send in a copy of the medical records, which it did. The claim was then denied for the stated reason, “Not eligible for coverage on date(s) services rendered.”
I contacted Aetna and spoke to person named Barbara, who explained that the denial was in error, because someone “got the groups mixed up”. The problem she said arose due to the fact that Michael had apparently switched groups after the claim was submitted and the claim was then apparently routed to the wrong group. When that occurred, the claim was denied because the charges were incurred prior to his effective date with the new group.
Barbara further explained that the claim was “still pending with the Review Department”, because that department was awaiting receipt of medical records. She assured me that no decision had been made on the claim, as it was “still in review”. But since Aetna had verified Michael’s coverage, pre-certified his admission and case-managed the entire course of treatment, I was at a complete loss to understand what kind of a legitimate “review” remained to be done. As far as I was concerned, all that remained for Aetna to do was to pay the claim.
So I asked for the name and a telephone number of a live person in the “Review Department” that I could correspond with and forward requested information to. Barbara said that she was unable to give me any such name or number of anyone in that department. She then said that Aetna's “Member Services Department”, where she worked, was located in the same building and that her department routinely took calls for the mysterious “Review Department”. Barbara said that I could forward the clinical and billing documents to her and that she would personally present them to the “Review Department”, which I did.
Several more months passed and still there was no payment. When contacted again, an Aetna representative explained that the claim had been “referred to Aetna’s legal area for review”. So I wrote a letter to Aetna pointing out that the federal regulations required payment or a timely notification of a denial of the claim and that Aetna was in clear violation of those regulations. The letter concluded, “Therefore, would you please contact your “legal area” and ascertain exactly what Aetna intends to do with regard to this claim, and precisely when it intends to do it; and then advise me accordingly.”
I was eventually able to effect full payment of the claim, but it took an additional four months to accomplish that feat.