Approval question

I was approved for my surgery and Aetna approved 2 post op days, my question is what happens if I go over? what if there is complications and I have to stay longer? My policy says 3 days max. per admission..

 
I would have to see the exact and complete wording of the policy before it could be answered.  Is your policy posted on line somewhere?  Can you copy and paste all the info pertaining to WLS?

Hi, My husband emailed Aetna and this is what they  sent him back:

Thank you for using your secure member website to contact Aetna.  To
help protect your confidential information, please continue to use our
online form to contact us.  The online form provides greater security
than standard Internet e-mail.

Your benefits
Your plan includes coverage for in-network services only.
* You must select a primary care physician (PCP) to access to your
benefits.
* Your plan has a $30.00 copayment per visit with your PCP.
* You must have a referral from your PCP to see a participating
specialist.
* Your plan has a $30.00 specialist copayment per visit.
* Your plan has a $150.00 copayment for an outpatient surgical procedure
when done at a participating outpatient surgical facility.
* Your plan has a $300.00 copayment for an outpatient surgical procedure
when done at a participating hospital.
* Your plan has a $500.00 copayment per day with a maximum of a
$1,500.00 copayment per admission for inpatient hospitalization.

According to our precertification file I was able to find your wife has
been authorized for two days. If additional days are needed the hospital
should call us get any additional days authorized at that time. If they
are authorized those additional days would be covered. There is no
maximum on the number of days that someone can be in the hospital, these
authorizations are based on medical necessity. The maximum comes in on
the copay amounts for inpatient hospital stays not the number of days a
patient can be in the hospital.  Basically your plan has a copay of
$500.00 per day while in the hospital with a maximum of $1,500.00 per
admission.  This means that whether you are in the hospital for 3 days
or 30 days the most you have to pay out of pocket for that stay is
$1,500.00.

* If you use an out-of-network provider for your care, then you will be
responsible for the full cost of the services. (does this count if they approved me out of network?)

Your plan has a yearly out-of-pocket maximum of $3,000.00 per person, up
to the family out-of-pocket maximum of $6,000.00 each calendar year.

Your plan has an unlimited lifetime maximum per person.

The information provided above is not a guarantee of coverage. Coverage
is based on all the terms and conditions of your plan as well as
eligibility at the time services are received.

If you have questions, you can reach Member Services by logging on to
www.aetna.com or www.aetnanavigator.com and selecting the "Contact Us"
feature.  You may also call the toll-free number on your member ID card,
if applicable.

So I think I am clear on everything but the Red Part. If you know the answer to that could you let me know? Thanks, I just wanna make sure I have no surprises> Staceeann

 
Did they approve you out of network?  Is there some reason such as they have no in network providers that do your surgery type?

I would get in writing that they will pay out of network since your policy clearly states they will not.

Yes, I was approved out of network because the medical group we are assigned to is very small and there is no surgeon who does the DS. Dr. Crookes and the hospital are both contracted with Aetna, just not my medical group.

 
This one I'm sure is probably fine but I'd still check with someone who knows a whole lot more than me.  It worries me that they specifically state they will not cover out of network yet in this case they have no choice.

I'm not sure how to CYA on this one.

Do you have anything in writing showing specifics of what you will have to pay the out of network providers?  Will it be at the same rate?

I think it will be at the same rate, since the surgeon and hospital are both contracted to Aetna. I hope... I will make some more calls and find out..