Question:
Aetna USHC members how much did the Insurance Comp pay for the Surgeons fee?

I had my initial consult with the surgeon yesterday, and was surprised that he wants his fee paid upfront. This wasn't mentioned during his seminar. The Dr's office said that any money received from the insurance company would be refunded to me. I would like to know how much the Aetna USHC has been paying for the surgeons fee. Thanks for any info you can provide from your EOB. (I'll be rolling my pennies trying to come up with the $$'s)    — John B. (posted on April 9, 2003)

April 9, 2003
Aetna USHC paid 80% of my bill up to an out of pocket of $600 per individual. Ask your surgeon's office if you can set up a payment program.
   — Jane S.

April 9, 2003
It depends on what Aetna you have. If you have an HMO plan then there should be a negotiated amount with the surgeon. This is an amount that he has agreed to accept for a procedure. Now, he doesn't have to agree to perform the surgery, but as far as I'm aware if he does agree to perform it he must accept what they pay and is not able to charge you extra. If you have a PPO plan that may be different. You should still only be responsible for the percentage that your insurance won't pay. And, once you've received your approval letter, why would he be worried he wouldn't get paid. I would call Aetna if I were you and discuss this with them. I'm not saying the Doctor is trying to pull a fast one or be dishonest, however, I would certainly check up on this. Just MHO (my humble opinion). Hope this helps some.
   — Robin V.

April 9, 2003
According to Aetna, if he is a contracted provider, it is against his contract to collect money up front. He can find out exactly what Aetna will pay with a phone call from his office and then you will know what your balance is (and pay it upfront if he wishes). The hospital did this with me. My doctor billed Aetna $5200.00 and the contracted rate was $4940.00 with Aetna. They paid at 80% which was $3952.00 cause I hadnt met my out of pocket deductable which is $1500.00. All my charges after that were covered at 100%. Hope that helps, you can always email me if you have any questions. Best of Luck! :-)
   — Pizofret

April 9, 2003
John - I agree with the previous poster. For an HMO, it is illegal for the physician to collect more than the co-pay from the patient. And if he is contracted with Aetna, then he must accept their payment as payment in full. I would call the surgeon's office and remind them of their contract with Aetna. If they still won't budge, then call Aetna and report it...JR (open RNY 07/17 -167 # - and Aetna paid everything from the surgery (other than the psych & nutritional consults) except for a $10 copay).
   — John Rushton

April 9, 2003
I have Aetna PPO - I don't know whether yours is a HMO or PPO. However, my Dr. is considered "out of network", therefore Aetna will only pay 70% of "reasonable and customary" and I'm responsible for 30% of R&C PLUS the difference between what is billed and what is considered R&C. If your surgeon is considered "out of network", he may be trying to make sure he gets paid first - before the hospital, anesthesiologist, etc. However, as other posters have mentioned, if he's contracted with Aetna (in network), I would ask Aetna about the legalities of his request for payment up front.
   — Carolyn M.

April 9, 2003
I have Aetna PPO, and they paid all of my bills, but the $250 hospital deductable. They paid all of the contract price to the Surgeon. Aetna has contracts with network doctors and hospitals. If your surgeon is in network--then he has a contract with Aetna. Remind him of this, and then report him! Could be that the insurance administrator for his office screwed up. By the way, Aetna paid my bill within 30 days.
   — TERI S.

April 9, 2003
I have Aetna USHC MCN and mine paid 100% of the Network negotiated fee. I only paid my $15 co-pay for my initial visit. It depends on what your contract/plan states.
   — Linda M.