Aetna Denying a Provider They Show as ‘In Network’

Hi All – looking for some advice / alternative escalation paths for an issue with a claim denial under Aetna insurance. Here's the situation:

Received a surprising bill from a UCHealth provider today for over $800 for an appointment earlier this month. The appointment consisted of an annual physical and a simple, very common vaccine. I called UCHealth and they simply said my insurer (Aetna) had denied it. I called Aetna and she confirmed the entire claim had been denied because the provider was 'Out of Network'.

I have been to this provider for a physical before under Aetna, and they covered the appointment. Prior to this most recent appointment, I did my due diligence and verified in myAetna app (while logged into my account) that he still showed as 'In Network'. The support person also noticed he showed as 'In Network', and she spent over 20 mins escalating to a claims specialist.

She finally came back with this: "This issue is that this provider is in network, BUT, he's not in network for your ID." She couldn't explain how this made any sense at all.

I'm baffled and pissed. So in summary:

The app, the browser, and the support person all show he was in network (and while I was logged in, so it had my plan details loaded). It took a whole 30 minute call to figure out some obscure reason this guy is no longer a provider. Obviously not easy for me as a customer to figure that out prior to booking a doctor. The provider never told me my insurance wouldn't work (not really their fault I guess since they don't always pre-run – I think I'll make that a habit from now on). I never, ever would've gone to that doctor for these simple items if I'd had any idea of the above.

…and yet they think I should be charged over $800 for this misunderstanding they 100% caused.

The phone support woman was unable to offer any escalation routes herself. The only advice she had was to file an appeal to Aetna, which is via snail mail (of course, can't make it easy to complain). I'm doing that today.

Does anyone have any insight or advice on other paths I might follow here to get this covered? I already feel hopeless at the possibility of avoiding this bill in the face of the powerful, uncaring machine that is US insurance.

Thanks,
Mike

submitted by /u/MichaelSurgesREALTOR
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