ComplaintsforAetna Inc.

• Initial Complaint

  10/23/2024

  Complaint Type:

  Billing Issues

  Status:

  Answered

  More info

  I have been going to the same primary care doctor for about 17 years. They have an in house lab that does any bloodwork and xrays that is one floor down from my providers office in the same building. In the past, other insurance providers have recognized test that were ordered as part of an office visit, as covered under the office visit with primary care clause of their policy. Aetna choses to view them as hospital lab work because of how they are billed by ****** ******* ***** and require that our full deductible be paid prior to them covering anything. Nothing has changed with how they bill their tests since I had bloodwork done a few years ago. When I spoke to an Aetna Agent (Noah), their solution was that "next time" I should have my doctor send the tests to a lab that is cheaper for Aetna so I would pay less. As they have an in house lab, they do not send samples for basic blood work out at all. So in order for this to work I would have to drive to a ***** diagnostics testing center to have my blood work done. Costing me extra time and money, all while unwell. It seems that Aetna does everything they can to pass costs off to the consumer or the doctor. If they processed the tests I had on 9/10/24 as ordered as part of an office visit with my primary care provider, per a conversation between my husband and another Aetna agent, there would only be a $40 copay. I would like my bill to be adjusted to reflect that.

  Business response

  10/24/2024

  Dear *** ******* *********:
  
  Please see our response to complaint #******** for **** ************ that was received by us on October 23, 2024. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.
  
  Upon receipt of your request, we immediately reached out to our claims team, who reviewed Ms. ************’s concerns. Based on their review they confirmed that the claim from the date of service September 10, 2024, was processed correctly based on how it was submitted from the servicing provider. The billing office at ****** ******** was contacted and they have confirmed that the claim was submitted correctly and there were no errors found.
  
  We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms. ************’s  concerns.  If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at *****************.
  
  Sincerely,
  
  Marshell H.
  Analyst, Executive Resolution
  Executive Resolution Team

• Initial Complaint

  10/18/2024

  Complaint Type:

  Order Issues

  Status:

  Resolved

  More info

  I enrolled in coverage through the marketplace in July 2024 and paid several premiums, but Aetna never activated my coverage. Since my coverage was never activated, Aetna must return the premium payments I made to them. I am seeking a refund for the $1,073.03 I paid to Aetna in July and September 2024.

  Business response

  10/25/2024

  **** ******* **********

  Please see our response to complaint # ******** for ****** ****** that was received by us on October 18, 2024. 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 internally to further research the complainant’s concerns. We confirmed that, on July 1, 2024, *** ****** enrolled into a plan with a monthly premium of $682.42. She made a payment of $390.61 on July 7, 2024, but it was less than the monthly premium, therefore the plan did not go into effect. On September 9, 2024, *** ****** attempted to make a second payment of $682.42, but the account had terminated due to non-payment. Moreover, as of October 23, 2024, *** ******** account is voided, and the refunds ($682.42 and $390.61) will be applied back to the original form of payment within 5-7 business days. An outreach call was made to *** ****** on October 23, 2024, to review the resolution.

  We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address *** ******** concerns.  If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at *******************************. 

  Sincerely,
  
  Brittany F.
  Analyst, Executive Resolution
  Executive Resolution Team

  Customer response

  10/25/2024

  
  Better Business Bureau:
  
  I have reviewed the response made by the business in reference to complaint ID ********, and find that this resolution is satisfactory to me.
  
  Sincerely,
  
  ****** ******

• Initial Complaint

  10/17/2024

  Complaint Type:

  Product Issues

  Status:

  Resolved

  More info

  I purchased this Medicare Advantage policy with the understanding I had a fitness reimbursement value of $1200 for the year. Midway through the year I was advised the reimbursement was being significantly changed from what I had signed on for, eliminating many of the benefits I had anticipated. I have since called 4 times to ask for a list In writing of what is a reimbursable expense. (It is not published on their website or available to view on my account). I finally spoke with someone who promised to send it. 2 days later I receive by *** a form to use for claiming reimbursement- I have not yet received the list I requested. The year is running out and Aetna is stalling me out to be able to use some of any of this benefit. ( which they are discontinuing in the coming year),

  Business response

  10/22/2024

  **** *** ******* *********:
  
  Please see our response to complaint #******** for Ms. ***** ****** that was received by us on October 17, 2024. Our Executive Resolution Team researched the concerns, and I would like to share the results of the review with you.
  
  Upon receipt of the complaint, we immediately reviewed the member’s account. We confirmed that Ms. ****** has called into the plan multiple times requesting a fitness benefit brochure to be sent to her. During our review we found errors made by our customer service representatives with the incorrect process they were using to send the request to have the fitness benefit brochure sent. We do apologize, and we have sent service improvement coaching’s to the customer service representatives’ direct supervisors, to allow for more training, and service improvement to better assist our members.
  
  We have attached a sample copy of the fitness brochure to this response that the member has been requesting to be sent to her. In addition, on October 21, 2024, we requested a fitness brochure to be sent to the member. We ask that she please allow 7-10 business days to receive the hard copy of the brochure via USPS mail.
  
  Please keep in mind, due to many consumer products available on the market today, there is no way to supply an exact list of approved and ineligible products to our members. This is why the plan supplies the general brochure and encourages our members to contact our customer service line when they question whether an item/product is approved, or not, for the fitness allowance benefit when they do not see the item listed in the plan documents provided to them.
  
  Our customer service representatives utilize a spreadsheet of facts and questions (FAQs), when answering our members questions when they call into our customer service line to inquire about the fitness allowance benefit and as to whether an item/product may or may not be covered under the benefit. The FAQ’s is updated often. We have attached the most recent Fitness item guidance list that is used by our claims department of the covered and non-covered fitness benefit allowance items, this list was last updated on October 15, 2024. Please beware this item list is continuously changing and updated often which is why it is not made available for our members to view.
  
  After further review of the members account, as the member has not submitted any claims into the plan requesting a fitness reimbursement for items purchased, we confirmed Ms. ****** has the full $1,200 fitness allowance to use until December 31, 2024. We also confirmed the current plan she is enrolled into is not offering a fitness reimbursement allowance for the 2025 calendar year.
  
  Keep in mind, for the fitness reimbursement to be approved, the items must be purchased and used within the current benefit year. The member must complete and submit the fitness direct member reimbursement (DMR) form within 60 days of the date of purchase along with any required receipts, either online, fax or via mail.
  
  The form can be found on ***************************, scroll down to "Get paid back for fitness items or services." Here the member can download, print, and complete the fitness reimbursement form. If the member does not have a printer, they can call our customers service line at the phone number on the back of their member ID card, and we can mail them the form. Once they have completed the form, gathered their itemized receipts and any supporting documentation, be sure to write their member ID on the top of each page being sent into the plan, they can mail the documents to the address on the back of their member ID card, or they can fax it to ###-###-####.
  
  Please know, once all of the required information is received by the plan, it may take up to 45 days for the member to receive payment from the plan.
  
  The member will receive a detailed Medicare Resolution Letter within 7-10 business days with this response.
  
  We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms. ***** ******’s concerns.
  
  Sincerely,
  Marilyn G.
  Analyst, Medicare Executive Resolution

  Business response

  10/22/2024

  **** *** ******* *********:
  
  Please see our response to complaint #******** for Ms. ***** ****** that was received by us on October 17, 2024. Our Executive Resolution Team researched the concerns, and I would like to share the results of the review with you.
  
  Upon receipt of the complaint, we immediately reviewed the member’s account. We confirmed that Ms. ****** has called into the plan multiple times requesting a fitness benefit brochure to be sent to her. During our review we found errors made by our customer service representatives with the incorrect process they were using to send the request to have the fitness benefit brochure sent. We do apologize, and we have sent service improvement coaching’s to the customer service representatives’ direct supervisors, to allow for more training, and service improvement to better assist our members.
  
  We have attached a sample copy of the fitness brochure to this response that the member has been requesting to be sent to her. In addition, on October 21, 2024, we requested a fitness brochure to be sent to the member. We ask that she please allow 7-10 business days to receive the hard copy of the brochure via USPS mail.
  
  Please keep in mind, due to many consumer products available on the market today, there is no way to supply an exact list of approved and ineligible products to our members. This is why the plan supplies the general brochure and encourages our members to contact our customer service line when they question whether an item/product is approved, or not, for the fitness allowance benefit when they do not see the item listed in the plan documents provided to them.
  
  Our customer service representatives utilize a spreadsheet of facts and questions (FAQs), when answering our members questions when they call into our customer service line to inquire about the fitness allowance benefit and as to whether an item/product may or may not be covered under the benefit. The FAQ’s is updated often. We have attached the most recent Fitness item guidance list that is used by our claims department of the covered and non-covered fitness benefit allowance items, this list was last updated on October 15, 2024. Please beware this item list is continuously changing and updated often which is why it is not made available for our members to view.
  
  After further review of the members account, as the member has not submitted any claims into the plan requesting a fitness reimbursement for items purchased, we confirmed Ms. ****** has the full $1,200 fitness allowance to use until December 31, 2024. We also confirmed the current plan she is enrolled into is not offering a fitness reimbursement allowance for the 2025 calendar year.
  
  Keep in mind, for the fitness reimbursement to be approved, the items must be purchased and used within the current benefit year. The member must complete and submit the fitness direct member reimbursement (DMR) form within 60 days of the date of purchase along with any required receipts, either online, fax or via mail.
  
  The form can be found on ***************************, scroll down to "Get paid back for fitness items or services." Here the member can download, print, and complete the fitness reimbursement form. If the member does not have a printer, they can call our customers service line at the phone number on the back of their member ID card, and we can mail them the form. Once they have completed the form, gathered their itemized receipts and any supporting documentation, be sure to write their member ID on the top of each page being sent into the plan, they can mail the documents to the address on the back of their member ID card, or they can fax it to ###-###-####.
  
  Please know, once all of the required information is received by the plan, it may take up to 45 days for the member to receive payment from the plan.
  
  The member will receive a detailed Medicare Resolution Letter within 7-10 business days with this response.
  
  We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms. ***** ******’s concerns.
  
  Sincerely,
  Marilyn G.
  Analyst, Medicare Executive Resolution

  Customer response

  10/22/2024

  
  Better Business Bureau:
  
  I have reviewed the response made by the business in reference to complaint ID ********, and find that this resolution is satisfactory to me.
  
  Sincerely,
  
  ***** ******

  Customer response

  10/22/2024

  
  Better Business Bureau:
  
  I have reviewed the response made by the business in reference to complaint ID ********, and find that this resolution is satisfactory to me.
  
  Sincerely,
  
  ***** ******

• Initial Complaint

  10/17/2024

  Complaint Type:

  Billing Issues

  Status:

  Answered

  More info

  Twice I have encountered payment issues from providers. 1. ********** ** ******* ********** ****** **** ** *** **** *** **** **** *** **** **** ****** **** ** ***** seeking payment and I had insurance.

  Business response

  10/22/2024

  **** ******* *********:
  
  Please see our response to complaint #******** for ******* ***** that was received by us on October 17, 2024. Our Executive Resolution Team researched the concerns, and I would like to share the results of the review with you.
  
  Upon receipt of the complaint, we immediately reached out internally to further research the member’s concerns. We have reviewed the member’s claim history and confirmed that the processed claims were applied towards her $3,500 deductible. However, for the denied claims, we show that *** ***** may have other insurance. Therefore, she must contact Member Services by dialing the number on the back of her member identification card, to update her coordination of benefits (COB). If the COB is not updated, the claims will remain denied and per the explanation of benefits (EOB), the member is responsible for the denied charges.
  
  We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address *** *****’s concerns. If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at ********************************
  Sincerely,
  
  Shay G.
  Analyst, Executive Resolution
  Executive Resolution Team
  

• Initial Complaint

  10/16/2024

  Complaint Type:

  Order Issues

  Status:

  Answered

  More info

  I left my previous employer on 08/07/2024, at which time I activated COBRA to cover my wife ********* **** *****. I made my Cobra payment to *** which started on 09/01/2024, which was received and activated at by ***. On September 4th, *** notified Aetna that of the Cobra coverage. However, Aetna failed to activate the coverage. On September 13th I called Aetna, and they said that they did not receive the information from *** to activate the coverage. On a joint line, Aetna called *** at which point *** confirmed the information was sent to Aetna. Aetna said the policy would become active in 7-10 business days. On September 27th I called Aetna again and was told that Aetna had not received the information from ***. We once again held a joint call with *** and they once again sent the necessary information to Aetna. On 10/2/2024 Aetna confirmed receipt of the necessary information from *** in writing (ticket number ************ and the subsequent email was provided to me from ***). On October 16th, the policy still did not show as active. I called Aetna and they once again said they had not received the information from *** even though I have their written confirmation of receipt. Their complete and utter failure in this matter has had direct and serious consequences for my wife's health as she is disabled without her treatment. I have diligently paid necessary premiums to ***, and *** has submitted the necessary paperwork to Aetna several times, yet Aetna still refuses to activate the policy that is paid in full. The case number that Aetna has provided me is *********

  Business response

  10/23/2024

  Dear ******* *********:

  Please see our response to complaint # ******** for ****** Addu that was received by us on October 16, 2024. 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 internally to further research the member’s concerns. We confirmed that the Consolidated Omnibus Budget Reconciliation Act (COBRA) plan is a spouse only plan and has an effective date of September 1, 2024. Since we do not have a signed authorization form on file for the member’s spouse, we cannot provide plan details. However, should *** **** have any questions regarding the plan, he can call the Member Services number on the back of his member identification card. In addition, we have reviewed the member’s call history, and the necessary feedback was provided to the representatives.

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

  Sincerely,
  
  Brittany F.
  Analyst, Executive Resolution
  Executive Resolution Team

• Initial Complaint

  10/16/2024

  Complaint Type:

  Billing Issues

  Status:

  Answered

  More info

  Dear Aetna Appeals Department, I am writing to formally appeal the recent decision to process the claim for my wisdom teeth extraction under my health insurance instead of my dental insurance, which has resulted in an unexpected charge of $1,197. This decision was made without any prior notification to me or my oral surgeon, despite the initial claim being submitted under my dental insurance. The procedure in question is a dental procedure by nature, and both my surgeon and we understood it would be processed as such. It is unjust for me to be billed such a significant amount without any notification or explanation of this change beforehand. This unexpected financial burden is something I cannot afford, and I was not given the opportunity to make provisions or discuss alternatives prior to receiving this bill. sy I respectfully request that you reconsider this decision and reprocess the claim under my dental insurance, as initially intended. Please consider the impact of this decision on my financial situation and the lack of communication that led to this oversight. I appreciate your prompt attention to this matter and kindly request that you review the claim as well as the circumstances that led to this billing issue. I have attached paperwork showing that claim #***** was initially processed under my dental insurance without any issues. However, claim #***** was later created under my healthcare plan. Why was this claim not processed under the same plan? It seems unreasonable to mix and match policies, switching to the healthcare plan at the last minute, leaving a portion uncovered. As someone who processes claims for a living, I would never handle a claim in this manner. It would be like diagnosing a vehicle issue under one contract, then switching to another contract for the repair and telling the customer, "Sorry, it's not covered on this contract—you have to pay." This approach is unethical and needs to be corrected. Sincerely, **** *** ****

  Business response

  10/23/2024

  **** ******* **********
  
  Please see our response to complaint #******** for **** *** **** that was received by us on October 16, 2024.  Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.
  
  Upon receipt of the member’s concerns we immediately reached out to investigate. We found that the member’s dental plan covers oral surgery when it’s not covered, in whole or in part, under the member’s medical plan. The medical plan covers oral surgery that is medical and dental in nature. Current Dental Terminology (CDT) codes that are defined as surgical are labeled as medical-in-nature or dental-in-nature by the ******** ****** ***********, and are not subject to review or redefinition by the member’s plan(s).
  
  The member’s initial consultation was not surgical and was therefore not considered under the medical plan and simply covered by dental when it was submitted. Aetna policy does indicate that when the consultation is submitted with surgery, and the surgery is covered under medical, that the consultation and related services would also be covered under the member’s medical plan. However, we will not reprocess the member’s consultation claim to pay under medical at this time.
  
  We reviewed the member’s contact history. We did not find a call or email from the member or the provider inquiring about the coverage for the service before it was rendered. We did not find a predetermination request for these services. Our plan documents, provided to the member when they enroll in the plan and available on the Aetna Member website, disclose the coverage that applies to the relevant plan.
  
  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 there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at *****************.
  
  Sincerely,
  
  William B.
  Analyst, Executive Resolution
  Executive Resolution Team

• Initial Complaint

  10/15/2024

  Complaint Type:

  Order Issues

  Status:

  Answered

  More info

  I am a small business owner and, as such, have a health insurance plan through the marketplace. in August I updated my estimated income through the marketplace to accurately determine my federal subsidy. When my updated enrollment was sent to Aetna on 8/16, it was mislabeled and misrouted. This resulted in the termination of my coverage, effective 8/31. Aetna acknowledged their error, but my coverage has not been reinstated. I just got off the phone with both the marketplace and Aetna. They are now saying it will be two more weeks before they can even begin reinstating my coverage. I have been without coverage for almost two months now. I am a single-income, self-employed woman with multiple medical conditions requiring specialty care and maintenance medications. I am a mental health professional and find myself on the precipice of a mental health crisis of my own. I have filed a grievance with Aetna, along with a complaint to the ********* ********** (case ******). Nothing has changed.

  Business response

  10/22/2024

  **** *** ******* **********
  
  Please see our response to complaint #********for *** ***** ********* that was received us on October 15, 2024.  Our Executive Resolution Team researched the concerns, and I would like to share the results of the review with you.
  
  Upon receipt of the complaint, we immediately reached out internally to further research the consumer’s concerns. Our Enrollment, Eligibility, and Billing (EEB) team previously submitted a service request to release the complainants file and correct the enrollment. This service request was escalated and the enrollment now reflects as active.
  
  Due to the complainant not having access to her plan for the month of September the premium has been written off. The October premium has also been prorated for the days that the complainant did not have access to the plan. The plan is currently in good standing and paid through October 31, 2024.
  
  We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address *** *********** concerns. 
  
  Sincerely,
  
  Phalyn C. |Analyst, Executive Resolution
  Executive Resolution Team
  
  

• Initial Complaint

  10/15/2024

  Complaint Type:

  Customer Service Issues

  Status:

  Resolved

  More info

  Aetna Claim ID: ********* On June 4th I had bloodwork drawn for hereditary cancer screening. Prior to the bloodwork being drawn I spoke with an Aetna care advocate 3 separate times to figure out what my out of pocket costs would be (if any). I spoke with Nicole 3 times, she advised me which CPT codes to use to ensure the testing would be covered & there would be no out of pocket costs as the testing was deemed medically necessary. I followed up with her several times to ensure the information she was telling me was accurate & there would be no billing surprise. The medical claim has since been denied as "no prior authorization form" was completed, however, when I spoke with Nicole, never once did she mention that I needed this form. I filed a 1st level appeal (#*************) which was denied. I have filed a 2nd level appeal & am pending a decision. However, I am absolutely appalled by the support I have received as I cannot rely on my insurance to advise me with correct information on my benefits. I spoke with another Aetna advisor, Kevin, and he said they could not provide me proof of my prior conversations with Nicole. He also said that there is "no allowance for incorrect information." I find this completely unacceptable because if I can't trust an advisor to give me correct information on my medical benefits before a service then who am I supposed to trust. I went above & beyond trying to take the necessary steps before getting my service (which I'm sure not all people will do) & I am still the one who gets stuck fighting with my insurance company 4 months after my date of service because I was told incorrect information. How am I, the policy holder, supposed to know what's needed beforehand, that was the reason I called in the first place, to make sure any pre-requisites were completed BEFORE the date of service. I should not have to pay anything as I did everything I was supposed to ahead of time and was still told incorrect information.

  Business response

  10/18/2024

  Dear Mr. *********:

  Please see our response to complaint #******** for ***** ******* that was received by us on October 15, 2024. 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 reached out internally to have the member's concerns reviewed. Based on the review, we confirmed that the member's provider is in-network with their plan. Based on the providers contractual agreement with Aetna, they should not be billing the member. We confirmed that a representative from both Aetna's Member Advocate Team and the Account Team are working directly with the member and their provider to resolve the situation.
  
  We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms. *******’s concerns. If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at *******************************.
  
  Sincerely,
  
  Lisa B | Analyst, Executive Resolution
  Executive Resolution Team

  Customer response

  10/24/2024

  
  Better Business Bureau:
  
  I have reviewed the response made by the business in reference to complaint ID ********, and find that this resolution is satisfactory to me.
  
  Sincerely,
  
  ***** *******

• Initial Complaint

  10/14/2024

  Complaint Type:

  Product Issues

  Status:

  Answered

  More info

  Bought hearing aids through them and had to get my hearing aids through ******* ******* Januray 24th I picked up the aids. They told me I had 30 days to pick them up. I did so at the end of February and sent out the paper work to Aetna. I got mail back stating they no longer would be paying for it since they are no longer partnered. I then called ******** ******* and they wouldn't be paying it, and had to follow up with Aetna. Now I am stuck between them giving me back and forth, but in the Medicare booklet, Aetna would be the ones responsible for helping me. 1 says they wont pay because they are no longer a provider, the other says they won't pay because the paper work showed up too late.

  Business response

  10/25/2024

  Dear *** ******* *********: 
  
  Please see our response to complaint # ******** for Mr. ******* *****, which we received on October 15, 2024. Our Executive Resolution Team researched the concerns, and I would like to share the results of the review with you.
  
  Upon receipt of the concern, we immediately reviewed the member's claim history. We found the member’s reimbursement claim for date of service, March 24, 2024. The claim denied because the provider, ************ ******* *** *******, is no longer an in-network provider with ******* *******. We understand that the member contacted the plan to verify the network status of ************ ******* *** ******* on, November 13, 2023. According to ******* *******, the provider became out-of-network on, March 19, 2024. The member’s concerns about this claim were previously addressed under grievance ID, ************. We understand that this has been a frustrating situation. We are truly sorry for any inconveniences encountered. We encourage our members to always confirm the provider network status on the date of service. The provider directory is subject to change at any time during the plan year. The member has the right to appeal the claim decision made by the plan. 
  
  We found that the member has an open appeal on file. We received the appeal request on, September 23, 2024. The Appeals team has 60 days from the receipt date to decide on the claim reconsideration. The Executive Response Team has contacted the Appeals team directly to request haste completion of the member’s appeal. The current due date on the appeal is, November 22, 22024. However, the Appeals team has advised that they will decide in an expedited manner. I will contact the member by phone upon the completion of your appeal. We cannot make any changes to the claim decision outside of the appeal process. 
  
  We partner with ******* ******* to provide member hearing aids. The member’s hearing aid benefit amount can only be used to purchase hearing aids through a ******* ******* network provider. The benefit amount is applied to the hearing aids at the time of purchase. If the cost is more than the benefit amount, members pay the difference. 
  
  The member will receive a written resolution letter within 7-10 business days.
  
  We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr. ******* concerns.
  
  Sincerely,
  Jasmine W.
  Analyst
  Medicare Enterprise Resolution
  
  

  Customer response

  11/04/2024

  I did not receive any response from you previously.

  The information you show is not the complete story.

  i would like to give you a written response showing a timeline and what I was being told.

  i Was told over the phone originally they had all the information w needed.

  This is not the half of it.

   

• Initial Complaint

  10/14/2024

  Complaint Type:

  Billing Issues

  Status:

  Answered

  More info

  I purchased an Aca healthcare plan from Aetna, according to my plan, blood work is a covered item subject to deductible, in network discounts and out of packet. On 09/27/2024 I went to ***** **********, an in-network lab facility to get my blood tests done that were ordered by my PCP after my annual wellness visit. I received my EOB from Aetna, showing the full amount for the blood work classified as “pending or not payable” with a denial code M15 (Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed). When I called Aetna’s customer service, I was first told that they already paid my PCP for the blood work and when I asked will my PCP reimburse the lab their answer was yes, later I was told by another agent that they will reprocess the claim. I have not received any new EOB. My PCP did not collect my blood samples, she did not perform the labs. My blood work was a separate procedure completed by ***** ********** ( a separate provider) on a different day of service than my PCP visit and within a different place of service so I don’t understand as to why my laboratory appointment would be bundled with my annual wellness visit resulting in denial code M15, subjecting me to full, out of network charges of $587.41 unpaid to ***** **********.

  Business response

  10/16/2024

  Dear ******* *********:
  

  Please see our response to complaint # ******** for ****** ********* that was received by us on October 14, 2024. Our Executive Resolution Team researched the concerns, and I would like to share the results of the review with you.
  

  Upon receipt of your request, we immediately reached out internally to further research the concerns. After further review it was determined that outreach was made to ***** billing, a representative named Hava J verified that the member has a $0 balance on this claim, it was paid under capitation. Several outreach attempts were made to discuss the findings with the member were unsuccessful. A detailed voicemail left that if the member had any further questions or concerns, that the member can reach out directly to **** * at the number she provided. An email was also sent to the member on October 16, 2024, the member can reach out to the email address provided as well.
  

  We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address *** *********** concerns. If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at *******************************.
  

  Sincerely,
  ShaCarra B.
  Executive Analyst, Executive Resolution Team

*Some consumers may elect to not publish the details of their complaints, some complaints may not meet BBB's standards for publication, or BBB may display a portion of complaints when a high volume is received for a particular business. ↩