Question:
I have Aetna insurance and so far I am so upset with what they are paying.

They said they would pay for the surgery and yet with each bill that is sent to them they are paying only a portion leaving me with thousands. Anyone know what I can do ???HELP    — Kathy S. (posted on October 21, 2003)

October 20, 2003
Is your Aetna plan an HMO? It doesn't sound like it. I have Aetna HMO and they paid for everything 100% except for the psych and nutritional consults (total of $400). If you have a non-HMO plan that involves co-pays of 10%, 20% or more, then you are obligated to pay those co-pays until you reach an out-of-pocket maximum amount. I suggest you call your Member Services # for Aetna (it should be on your ID card) - the card also will tell you what plan you have (on the front of the card). Talk to someone from Aetna to make sure what you are getting billed for is simply your part of the bill or whether there's been some sort of error...JR
   — John Rushton

October 20, 2003
I had Aetna insurance. My out of pocket was $850.00 for the total surgery/etc. I had a PPO. Check with member services to see what your co-pay and out of pocket are. I would have known these things before hand, so there would not have been any surprises. Good Luck!
   — Hazel S.

October 20, 2003
Hi...I have Aetna HMO, and they covered 100% of my surgery, with the exception of the psych consult and I paid $90 for that..I agree with the previous poster, you should call member services to find out if you have copays...good luck..Denise 316/158
   — lily1968

October 20, 2003
As you have found out just because the surgery is covered does not mean it's paid in full. If you have an HMO or PPO and used an in-network provider then you are not responsible for any of these bills. If you have a point-of-service plan or used an out-of-network provider then you are subject to usual, customary and reasonable charges (UCR). This means that the provider can charge as much as they want and your insurance can say it's too much and only pay what they feel is appropriate. You need to be talking to the insurance company to find out if these providers should be writing off these balances. Do you have a high deductible and co-pay when you go out-of-network? That could very well be what this is. I will have a $2000 deductible and co-pay next year if I got out of the PPO network. Good Luck!
   — zoedogcbr

October 20, 2003
When you get your statement from insurance does it state how much patient owes? Mine does - and if I've chosen an in network doctor there is usually a great difference between the original bill and the amount they negotiate to pay, but I don't have to pay the huge difference. It's a discount. Could this be the case? My insurance negotiated over 15,000 off the cost of my surgery....please check if this is the case and gee, I HOPE it IS!
   — [Deactivated Member]

October 20, 2003
I also have Aetna. So far I'm owing about $7,000 because I chose to use and out of network provider. I knew in advance I'd have a large out of pocket bill. Since I used out of network providers, I'm responsible for the entire difference between what was billed and what Aetna paid. When you use out of network providers, there is no true out of pocket maximum. (My plan paid 70% of Reasonable and customary up to $4,000, then the paid 100% of R&C, however, I am still responsible for the difference between billed and R&C). This is why it's so important to know your policy frontwards, backwards, upside down and sideways. They approved your surgery and they are paying a portion, but what they are obligated to pay is dependent on what your policy states. Good Luck.
   — Carolyn M.

October 23, 2003
DEFINITELY check on your explanations of benefits or call your insurance company and ask whether you are responsible for the difference between the billed and allowed amounts... IF you were using an IN-NETWORK surgeon AND an IN-NETWORK hospital, I don't believe that LEGALLY you are responsible for that difference. DOUBLE-CHECK them definitely before paying ANYTHING you're not 100 PER CENT SURE you owe!! God bless & best wishes!!
   — Amy G.

November 4, 2003
I also have Aetna. The QPOS type. Everyone has told you to call your insurance provider but also check with the folks who are billing you. I have actually gotten better answers from them. In my case, I was responsible for the difference between what the insurance paid and the CONTRACTED amount. The contracted amount is the amount the 2 parties, the insurance company and the service provider (i.e. doctor, hospital), have agreed to pay and accept. Make sure you know what the contracted amount is. Your explanation of benefits forms from the insurance company should tell that. I also saw that amount on the bills I get. Don't panic. Call and get answers. It is also important to know whether the service providers were in or out of network. Good luck.
   — Katherine B.