Aetna and Billing Problem-HELP

HELP!! Last year my company had Aetna. I got the approval letter saying they would cover it. I checked with the Dr's office-they got their letter saying it was approved. I called-yes we have approved coverage for your surgery. Now-I got my bills in. The Dr was paid at 100%. The anesticia (Spelling??) was paid at 50% and the hospital stay was paid at 50%---leaving me to owe $16K!!  When I appealed Aetna's decision-they said in their plan specifics it does say it is covered, but on another page it says only covered by 50%.  I can appeal a second time but I never kept a record of calling them to reconfirm the coverage, what should I do??? Anybody have the same problem and get any results??? Chris

Hi Chris, This sounds like a PPO or POS type plan.  If so, was the hospital and Anesthesiologist participating in your network?  Even if you have to pay 50% of their bill you should only be liable for 50% of the allowed amount (not the total bill).  You should also have an out of pocket maximum for your policy.  I've never seen a policy with an out of pocket more than $7,000 per person (they are often times much lower).  Once you've met your out of pocket max the insurance should start paying 100% of the remaining allowed amount.   Here's my checklist that I suggest you go down: 1.) Get your deductible and out of pocket maximum in writing.  The deductible should be included in the out of pocket maximum.  It probably wouldn't hurt to have them specify this fact in writing. 2.) Find out how much of your deductible and out of pocket you had met prior to these claims. 3.) Find out if both the hospital AND the anesthesiologist are participating.  It's not uncommon for anesthesiologists to NOT be participating in a facility that IS participating. 4.) Confirm the allowed amounts for each bill if the providers were participating. This is a good starting point.  I hope that some other OH'ers will have advice for you, too. 

Thank you so much for replying. For out-of-pocket, unfortunately Aetna has on their Plan Specifics that Bariatric Surgery is not "subject to the annual out-of-pocket maximum expense and are not paid out at 100% when the maiximum is reached" I'm usually a very cautious person and now I feel like a dope. I wonder if the hospital would make me a deal on the bill or let me stretch payments out for 10 yrs...... I'll check on the allowed amounts also. There could be some savings there

Wow.  I'm so sorry.  Hospitals will usually set up payment plans...hope they don't mind financing you for a few decades.  :-)  I suppose you'll just have to nickel and dime the hospital to death.  When I worked for an insurance company we received a lot of calls from members.  The hospital may have line item charges that are considered ineligible for payment because that payment is included in another line item charge (for example:  extra food that is part of the overnight stay).  You would not be liable for those charges.  On a more serious note....This is a really important message on this post.  I've never heard of bariatric surgery not being subject to customary out of pocket expenses.  You certainly alerted me. 

I am in the same position as you. I was approved by Aetna. I now have a bill from the hospital for 12,000 and a bill from the surgeon for 15,000. Aetna paid 10,000 to the hospital and the surgeon was paid nothing. Actually, the anesthesiologist is the only one who did get paid at the right rate. I apparently have a 10,000 limit for weight loss surgery. No one ever mentioned this to me or the surgeon's office. I was approved for an overnight stay. Obviously that in itself is way more than 10,000 so why wouldn't anyone say mention it??  I have just been calling and emailing Aetna every day and I will keep doing so.