[watsonsh]

Hey guys,

I am having treatement on left frozen shouler that has been developing other problems including some TOS pain.

My employer switched from a PPO plan to a POS open access plan with Aetna and there have been some issues because Aetna's computer program screwed up the group number. Because of this programming issue they are not paying my doctors and telling them I have no insurance coverage when I do. If the docs actually call they see that I do have insurance but when claims are submitted they are denied.

This has been going on for 2 plus months now and its getting ridiculous and Aetna does not know how to fix the problem and I am getting the runaround. These docs want to get paid and they are looking to me for payment. One is even going to collections becasue he does not care what insurance says.

Is there someone that I can report them to? Should I consult a lawyer? Will a threat like that even carry any weight?

Any help is appreciated.

[Jomar]

demand to speak with higher ups at Aetna??
contact the head honcho?

contact your state rep or congressman,, or Arnold

Is employer or HR dept doing anything to help you??

Seems they should be of some help as they are paying some of the premiums.


there really should be some way of getting a letter to confirm & explain what happened to the drs offices, so they can submit bills and have it handled personally by hand until the computer glitch is fixed.

[watsonsh]

Thanks JO!

Well after two long months, its finally resolved. I have been fighting since the end of january and no one would listen.

But today HR sent a note out telling those of us in the plan that there was a problem (after I told them two months ago).

I guess it helps that the owner of our company had some claims denied in the last week.

And so they called in some big guns and now its resolved and all claims will be reprocessed.

YAY!!!!

[tshadow]

Originally Posted by Shelley

Hey guys,

I am having treatement on left frozen shouler that has been developing other problems including some TOS pain.

My employer switched from a PPO plan to a POS open access plan with Aetna and there have been some issues because Aetna's computer program screwed up the group number. Because of this programming issue they are not paying my doctors and telling them I have no insurance coverage when I do. If the docs actually call they see that I do have insurance but when claims are submitted they are denied.

This has been going on for 2 plus months now and its getting ridiculous and Aetna does not know how to fix the problem and I am getting the runaround. These docs want to get paid and they are looking to me for payment. One is even going to collections becasue he does not care what insurance says.

Is there someone that I can report them to? Should I consult a lawyer? Will a threat like that even carry any weight?

Any help is appreciated.

Ok, let me get THIS STRAIGHT. CUz this stinks to high hell, to me, and not you, Shelley, the insurance company.

First, you have some injuries to your left shoulder and possibly TOS (vascular or neuro?) Neuro TOS is one of the hardest and costliest work comp claims.

So firstly, if these injuries were caused by your work, they are supposed to be paid by a work comp insurance company - not a "PPO".

That's what I need to know, otherwise, I am not getting this story straight in my mind yet. And Shelley, while my pain is not sky-high, I'd like to help some.

God bless.

[watsonsh]

HI Tam,

Sorry your pain is sky high. Right there with you today, although probably not nearly where you are at.

No, not caused by work and not covered by work comp. I actually still work full time.

Was a frozen shoulder that unthawed and complicating rotator cuff tears/issues and nerve compression in shoulder.

BUt it looks liek the insurance issue worked itself out. They were refusing to pay claims saying I was not insured. Was a computer glitch that seemed to affect me, but last week others in the company came forward and it was affecting a dozen people. I went ot HR about it 6 weeks ago and they said no you are covered and the insurance rep says so too but no one could figure out the computer glitch.

But now that the head of the company had his claims rejected for non coverage HR gto involved and its now worked out and i am covered.

But I was at the point where I wanted to report them or something else.

So hopefuly nothing to worry about now. THe insurance company called and said it was fixed and they were reprocessing and paying everything.

Phew

[Rrae]

I'm sorry to hear you've been caught up in this 'pickle' of a situation. I've seen it time and time again.
I don't know anything about your company/employer, but my first thought was that since your employer 'switched' your Ins carriers, then it's their (your employer's Administrative office personnel) responsibility to get that 'Group Number' straightened out with the Insurance company.

This is part of what I do for a living and my boss would've had my butt in a wringer for this!

Yes, it's the Ins Company's flub-up, but it's your employer's responsibility to make sure they have their contracting provider information correct - since that is what is holding up the claims being approved.

You shouldn't be caught in the middle of this. Your employer's staff (HR?) needs to step up to the plate and cover for you.......you are working FOR this company and the insurance coverage is supposedly a 'benefit' that you are working for!

Well, I'm glad they got this straightened out finally. I hope your credit rating didn't suffer a blow due to this.

[watsonsh]

Thanks Rrae. Yeah I tried to get HR involved in the beginning and they checked with their rep who said everythign was fine just resubmit them. Well it was not fine and HR and the rep kept saying the same thing over and over again. So I battled it on my own since I kept getting EOBs saying I had no insurance.

Well today they figured out that when they switched form one plan to another he computer had information that said the old plan was cancelled even though everything was being processed against the new plan and a new group number. Apparently adjusters saw this information and just started denying everything. But when the insurance rep would check things it would show as i had coverage.

I am so glad its all worked out becaue I literally was about to report them to the state and threaten to hire a lawyer.

Only by the because HR got complaints from several other people last week did they all of a sudden take this serisously.

Very frustrating.

Originally Posted by Rrae

I'm sorry to hear you've been caught up in this 'pickle' of a situation. I've seen it time and time again.
I don't know anything about your company/employer, but my first thought was that since your employer 'switched' your Ins carriers, then it's their (your employer's Administrative office personnel) responsibility to get that 'Group Number' straightened out with the Insurance company.

This is part of what I do for a living and my boss would've had my butt in a wringer for this!

Yes, it's the Ins Company's flub-up, but it's your employer's responsibility to make sure they have their contracting provider information correct - since that is what is holding up the claims being approved.

You shouldn't be caught in the middle of this. Your employer's staff (HR?) needs to step up to the plate and cover for you.......you are working FOR this company and the insurance coverage is supposedly a 'benefit' that you are working for!

Well, I'm glad they got this straightened out finally. I hope your credit rating didn't suffer a blow due to this.

[Rrae]

Frustrating indeed... not what you need especially battling a health issue!
If it would have continued to drag on, then you probably would have had to take those Explanation of Benefits you were receiving to the Company's attorney if the HR were dragging their feet....
.... oh well, at least it didn't go that far