My employer changed to Aetna from Humana on Jan 1, 2016. Since then, 9 out of 10 claims are denied for various reasons: need more medical records, wrong codes, not a covered benefit (when it is), etc.
One denial for annual blood labs in Feb 2016 was denied as not a covered benefit. When calling in (17 phone conversations in total) I was usually told the charges were added to my deductible. They never were.
By August, I was able to show them the claim was never added to the deductible and that they should reprocess the claims. They did not stating I was beyond the 180 days to appeal. I was left with $700.00 of labls to pay for out of pocket.
It is not a lot of money except that I became permanently disabled in November 2016 with an incurable and untreatable condition in the United States. (Some foreign countries have approved treatment for my neurological progressive disease). Fortunately, I began receiving SSDI a few months ago.
Fast forward to Jan 2017 - Aetna is denying claims to manage my symptoms. They claim they never received my medical records even though my physician sent them with tracking. When I called in today, the representative said the records were not received. When I stated I had proof that they did receive the records, she said they weren't scanned into their system until 5 days later, 1 day after they closed the claim.
Instead of matching up the information and paying the claim, they did NOTHING until I called today 12 days since their receipt of the requested information. Concurrently, they have been reimbursing for my physical therapy (after many delays, denials, requests for more information) at 70% instead of 90%!
After requesting to re-process at least 20 claims at the higher rate, I asked what can be done to make sure the reimbursements going forward are corrected and was told by the member concierge, "I don't handle claims but they should pay it correctly next time." I let her know there is no logical reason to think they'll get it correct "next time" when they've had 20 PT visits to get it right so far.
I am so sick, live alone and resent having to spend hours on the phone each week to beg for services for which I pay (via my former employer as part of long term disability). Though I am dying a slow death, I am sure the emotional frustration and fatigue from Aetna is going to speed up my departure from this world.
Seriously, they are reprehensible!
