ins. admits their mistake, but still won't pay??

[sisymay]

What is the name of your state? GEORGIA

My ins. co. is AETNA HMO.
My daughter was going to a general practice doctor who was not on the ins. companies list of providers for their HMO plan.
The reason for this is because there were NO doctors in our area who WAS in the HMO network.
We called ins. about this and they told us we could go to out of network dr. and pay extra $10.00 above regular PCP (primary care physician) cost.

So, my daughter went to this dr. many times. Insurance co. did pay for this doctor every time. Dr. sent us a bill for every visit showing we had to pay the extra $10.00 that the ins. did not pay, and this bill showed that the ins. co DID pay the rest of the visit.
And we paid the $10.00 each time.

This doctor wanted my daughter to go to hospital for tests and ultrasound.
Then ins. co sent letter to us saying they would not cover this hospital bill because the doctor who ordered this is not in their HMO network.

I called ins. about this. The person I talked to told me that the doctor bills should not have been paid at all. I told her that someone there told me it was ok to go to this dr. and that I would have to pay $10.00 over regular payment.

She said she dont' know why anyone at the ins. co. told me that. I said well, the ins company paid for all these doctor bills anyway except for the $10.00, just like they told me.

She said yes, but they were not suppose to. Our ins. co was suppose to deny all these claims. Since this is a mistake of this company, you will not have to pay for this hospital bill.

The hospital is working with someone from our ins. co. in getting this worked out.
Hospital said there has not been a settlement made yet, even though ins. keeps telling me they are not going to pay. I am not sure if they have told the hospital they are not going to pay. I assume they have not told hospital this, since it has not been settled yet.

I called ins. today to find out who is working with hospital and to talk to them. Ins. co. told me there is no record of anyone there working with the hospital. They also said there is no record of the call where the person told me I would not have to pay for the hosp. bill since it is their fault for paying the dr. to start with.
They said again that these claims should have been denied but were paid for anyway.

I am going to call hospital and find out the name of the person from ins. co. who is working with them.

My daughter has since been going to a dr. that IS on their list of HMO network providers.

 

[lealea1005]

I have to deal with insurance companies every day and I totally understand your frustration. They never seem to have a record of telephone calls. I swear they fall into a black hole somewhere! It is very rare to speak to a representative who actually knows what they're talking about. It isn't unusual to get conflicting information from different representatives.

In any event, in the future put everything in writing and send it return receipt requested to your insurance company....get the first and last names of people you speak to but don't be surprised if, on a subsequent call, you are told there is no one ther by that name.

It is true that a non-par Physician's referral will not be recognized by Aetna. Keep all of your EOB's (explanation of benefits) Aetna sent you. They will show that they paid the claims regardless of the Physician's participation status. Provide the sequence of events as you have in this post to Aetna and the hospital and try to remember as acurately as possible the dates, time, and people you spoke with. Send copies of all your correspondence with Aetna to the hospital. Keep copies of all of your correspondence and receipts.

hope this helps.....good luck

 

[moburkes]

What is the name of your state? GEORGIA

My ins. co. is AETNA HMO.
My daughter was going to a general practice doctor who was not on the ins. companies list of providers for their HMO plan.
The reason for this is because there were NO doctors in our area who WAS in the HMO network.
We called ins. about this and they told us we could go to out of network dr. and pay extra $10.00 above regular PCP (primary care physician) cost.

So, my daughter went to this dr. many times. Insurance co. did pay for this doctor every time. Dr. sent us a bill for every visit showing we had to pay the extra $10.00 that the ins. did not pay, and this bill showed that the ins. co DID pay the rest of the visit.
And we paid the $10.00 each time.

This doctor wanted my daughter to go to hospital for tests and ultrasound.
Then ins. co sent letter to us saying they would not cover this hospital bill because the doctor who ordered this is not in their HMO network.

I called ins. about this. The person I talked to told me that the doctor bills should not have been paid at all. I told her that someone there told me it was ok to go to this dr. and that I would have to pay $10.00 over regular payment.

She said she dont' know why anyone at the ins. co. told me that. I said well, the ins company paid for all these doctor bills anyway except for the $10.00, just like they told me.

She said yes, but they were not suppose to. Our ins. co was suppose to deny all these claims. Since this is a mistake of this company, you will not have to pay for this hospital bill.

The hospital is working with someone from our ins. co. in getting this worked out.
Hospital said there has not been a settlement made yet, even though ins. keeps telling me they are not going to pay. I am not sure if they have told the hospital they are not going to pay. I assume they have not told hospital this, since it has not been settled yet.

I called ins. today to find out who is working with hospital and to talk to them. Ins. co. told me there is no record of anyone there working with the hospital. They also said there is no record of the call where the person told me I would not have to pay for the hosp. bill since it is their fault for paying the dr. to start with.
They said again that these claims should have been denied but were paid for anyway.

I am going to call hospital and find out the name of the person from ins. co. who is working with them.

My daughter has since been going to a dr. that IS on their list of HMO network providers.

What is your legal question?

 

[sisymay]

Is the insurance company legally required to pay this hospital bill because it was their mistake for paying for the out of network doctor that they were not suppose to pay?
Wouldn't this be considered a violation of their own policy that I could make a complaint to the insurance commisioner about?

 

[moburkes]

No. According to your original posts, they only stated that they would pay the doctor's bills. You even stated that you were okayed to go to that particular doctor. You were never told that they would pay for the hospital visits. You can try to appeal the decision. You should, though, look in your booklet that you received when you signed up with your insurance company, and read what it says about referrals from out of network doctors.

 

[lealea1005]

No, they are not required to pay the hospital if it is an out of network hospital.....regardless of whether the referring Physician was participating or non-par.

As I suggested above....get your paperwork together and write the letters with the EOB's attached..

Read the fine print of the policy. It may state whether or not Aetna is liable to payment if it is their error....but don't hold your breath!

You can go ahead and file a complaint with the insurance commission in your state. You will need all your paperwork copied and attached to the complaint.

 

[sisymay]

The hospital has just told me the insurance did pay them.
So now, does the ins. co. have to send me some form of documentation proving they paid? I don't just have to take their word for it, do I?
It hasn't done any good to do that so far....

 

[moburkes]

Any time an insurance company pays a claim, you should receive an explanation of benefits.
Please do not send your daughter anywhere else UNLESS YOU RECEIVE CONFIRMATION IN WRITING FROM YOUR INSURANCE COMPANY.

 

[sisymay]

I have been with this ins. co for about 9 years, I have never recieved EOB for any doctor, hosptial, anything. I even checked on their website for my EOB's there, nothing.
The website does have an area for EOB's listed, just none for me.

I have never thought to get written approval from ins. to go to any doctor. They always said it was ok. Even for this doctor in question.

I just called ins. co. and asked if I am suppose to recieve something in writing showing they paid this hosp. bill. They said there is nothing showing they paid, only that it has been denied. She got ugly and said 'why are you even going to a dr. we don't cover anyway?' and I said 'it's a long story but I'll tell you'.

So I told her the whole story and she said I was wrong. 'You didn't get that info from us' or 'that is not right' and on and on.
Then she wanted me to hang on while she talked to someone and then I got cut off. I didn't call back and she didn't call me back. Nothing getting done there.

I called the hospital back to tell them the ins co does not show they paid for the hosp. bills. She wanted the phone # to the ins to call them herself. She said they are probably not going to have any documented records showing they paid this because the 'higher ups' will question it if they knew.

So for right now, I don't know how this stands...

 

[lealea1005]

You may be enrolled in an HMO that is capitated. That means that the Physician you are assigned to gets a small flat fee per month (regardless of whether you are seen once or 20 times that month), as well as your co-payment at the time of service. Since the Doctor receives a monthly membership list, the insurance company doesn't send individual EOB's to the Doctor...BUT....you, the consumer/patient/customer/client are entitled to one just as you are to a receipt from the Doctor's office. That is why they are called "explanation of benefits" . It irritates the heck out of me that the insurance company is giving you such a run around!!

You won't find EOB's on their webite. Since your daughter saw a non-participating Doctor, they surely have an EOB from Aetna. Ask them if they would be kind enough to make you copies. They may be willing to help you out. Their EOB's will indicate whether the services were covered (or denied) and how much was paid to the Doctor.

If the hospital representative is nice enough and willing to call the insurance company, let her. She has much more experience dealing with them and will get some answers. Hope you got her name and remember to give a call to follow up.

hope this helps

 

[sisymay]

It never ends. Wrongdoing is not just in the insurance world, but the world in general. In all aspects of life, all there is is crap.
Anyway, on to my point. The person from the hospital told me that our hospital bill shows $0 balance because the HOSPITAL made a mistake!!
When we first got to hosp. for paperwork, they were suppose to tell us then that our ins did not cover their hospital. We just didn't know this since the ins. had been paying for the doctor that did this hosp. referral.
So, it was the insurance AND the hospital that made the mistakes on both sides!
The ins said the hospital did not have grounds for an appeal, so the hospital was the one who dropped the bill.

 

[lealea1005]

glad it worked out for you