Aetna Out of Network Reimbursement Issues

Tl;dr; If you suspect that you’re not getting the coverage (especially out of network) you deserve, you probably aren’t and you should annoy your health insurance company until you do. Check the Medicare Physician Fee schedule to see what you should be expecting to pay. I got the right coverage in the end.

I (26 M) recently decided to go to an out of network provider for regular treatment. I am on a high deductible plan and I have 70/30 coverage once I reach my deductible and $0 percent out of pocket once I reach my maximum.

Now I submitted the claim knowing that I potentially might not get full coverage, but a previous in network physician who had the same CPT code in the same zip code was covered within $10 of the billed amount. So I assumed I would end up having 95% of the bill apply to my deductible. Little did I know a month long saga would begin.

I submitted the claim and within a week, I received a notification that Aetna wasn’t covering anything because I didn’t submit the cpt and diagnosis codes (they were on the bill). I call them up and they reprocess the claim with the added information.

They reprocess the claim again this time marking the provider in network internally (while showing me online that’s he’s out of network) and covering only exactly half of what I was billed. This time I call them and they tell me that this is the “Reasonable and customary rate” for the provider and this amount is related to the Medicare reimbursement rate. She gives me no more details.

I spend the weekend fuming thinking I can’t imagine the government pays so little for this cpt code. I figure out that I can go see what the Medicare reimbursement rate is by looking up the cpt code I my area on the “Medicare Physician Fee Schedule” (https://www.cms.gov/medicare/physician-fee-schedule/search).

I plug in my cpt code in HCPCS and my area in see the non-facility price and it’s more than what I was billed for by my provider.

I contact aetna again, this time with this knowledge and just keep pressing the representative to reprocess the bill and figure out why it’s weird. They say that it should be out of network and they will reprocess the claim.

I call back when they me to call back and the representative has no idea what I’m talking about with the reprocessing until the deep dive in several systems. I finally have them look up what the “Reasonable and Customary Rate” is for my cpt code and give me a dollar amount. They finally do, and it turns out I should be covered for 97% of the billed amount instead of 50%. The representative submitted the claim for reprocessing again.

It took another call a week later when they told me to call to have the claims department on the line at the same time to make sure the correct amount was submitted and covered.

After 28 days and several hours on the phone I received the correct coverage for my claim.

I wanted to share this because I think it’s insane that they tried to make me pay everything, then half, then after much insistence give me the actual coverage for my claim. For reference, I never appealed the claim, they admitted it was their fault every time and reprocessed it.