Aetna: It's War

I am trying very hard to remain calm and rational. This is WAY beyond my usual Wendy's fiasco. This is going to be war.

Remember the Aetna saga? They have neither approved nor denied three separate claims (for $800+, $123, and $300+) pertaining to a pulmonology appointment and a pulmonology workup I received while I was pregnant in October 2003. They keep insisting upon "more information" from myself and various doctors to confirm this was NOT a preexisting condition.

The only helpful person so far has been the office manager of the pulmonologist I saw. She has been going to bat for me-- and trying to get these claims paid out.

Today I got a letter from her. (Note: the pulmonologist will be "Dr. M." herein.)

Dear Ms. Clarke:

I am writing to you to keep you up to date on the pending claim that is still unpaid by Chickering [underwritten by Aetna.] The date of service was 10/22/03.

I spoke with a Chickering representative named Betty today, and was told this claim will remain unpaid and pended because of several reasons. Chickering needs operative notes [note: operative? Needless to say, I did not undergo any operation] from Dr. M., which I will obtain and send to them. They sent 2 letters asking for these notes, but they put the patient's name as Jared. Dr. M. sent back both letters, marked "not my patient." They send a 3rd corrected letter on 2/14/05.

Betty stated that Chickering also needs notes from [the hospital where I had the pulmonology workup and gave birth], a hospital in California, and a Dr. G. in California. She said that letters went out to these entities as well several times.

Lastly, Betty said that the form that you sent to them was incomplete, and that they need a completed form from you. She suggested that you call them to get this claim payment expedited.

I have little hope that this claim will be paid, but I thought that I would let you know the status. If you could please call Chickering, it would be appreciated. I have done all that I can do to get it paid. I have called them several times, and talked to supervisors, and representatives. Their stall tactics are frustrating, and I don't have any other recourse than to ask for your assistance. I will send them the notes from your chart after I receive them from Dr. M.

Thank you in advance for your attention to this matter. I may be reached during normal business hours at [number.]

Sincerely,
[name]
Billing Adminstrator

So, to recap: 17 months after the fact, Aetna has neither approved nor denied 3 separate claims pertaining to the same issue (namely, pregnancy-indued asthma.) Because the claim is perpetually "pending" I cannot appeal it, since there is no ruling. When I have called Aetna, I have been told that they "need more information" from "two doctors." I was told that due to privacy laws, they could not TELL me who those doctors are.

However, they evidently have no qualm telling the billing administrator of the pulmonologist's office who those doctors are. They are: the ob/gyn I saw in California before we moved, a hospital in California where I went with an asthma attack before we moved, and the hospital where I had the pulmonology tests (and also delivered my daughter.) Side note: we had different insurance when we lived in California; Aetna is not being asked to pay for those claims, they apparently just want the records to see if my story is consistent-- namely, that I had no history of asthma before pregnancy.

Additionally, Aetna has sent out letters to these entities "several times"-- but considering they were requesting the records of the completely wrong person from the pulmonologist (Jared instead of Megan), it is not unrealistic to speculate that perhaps the hospitals and CA ob/gyn were also receiving requests for the records of my husband, who, I am fairly sure, has never had pregnancy-induced asthma. (How confused that ob/gyn's office must be . . .)

So. This is war. I don't know whom to call or what to do, but this is ridiculous. When a seasoned insurance billing administrator is expressing frustration with Aetna's "stall tactics," something is rotten in the state of Maryland.

If you are reading this and have any idea of where I should turn next, please PLEASE e-mail me. Because I can't even find solace in a cheeseburger. Wendy's still gets it wrong.