Question:
surgery 5 months ago, covered by AETNA PPO, just got a bill for $5,000!!!

I had surgery over 5 months ago LAP RNY, and have lost 75 pounds. I am 22 years old and am on my dad's AT&T insurance though AETNA PPO. They approved me the first time and said it would be covered fully. Since then, have been getting miscellaneous bills, which he have paid, the rest of what AETNA would not cover for the anesthesia, for the surgeon fee, and for other things. But just last week, we go a bill for the actual surgery fo $5,000!!! Granted the surgery itself was over $20,000. But they were supposed to pay all of it, not 75-80% of it. I am so upset. My dad is going to call and talk to them, but I hope we don't have to pay...Has this happened to anyone else?    — Lezlie Y. (posted on November 11, 2002)

November 11, 2002
First of all, was it an actual bill or was it an EOB. If it is a bill, then contact the insurance company and find out what their criteria for paying was. Sometimes it is a very simple explanation that can clear up any problems that kept them from paying at a higher rate. Was the doctor in network? Was the hospital in network? Was the assistant surgeon in network? Call and ask the surgeon what he will accept. Sometimes they will write a portion of the bill off. All you need to do is ask. Do not get upset until you have exhausted all phone calls to everyone that you possibly can. The medical field is not as mercenary as people think and they are willing to work with you.
   — Sue A.

November 11, 2002
Typically, PPO's - as opposed to HMO's - have annual deductibles and coinsurance amounts for hospitalization. For example, if you had Open Choice 80/70, you would have to pay 20% of the hospital bill in-network or 30% of the contracted rate plus the balance of the ball out-of-network. There is usually an annual out-of-pocket maximum beyond which you will no longer have any coinsurance payments. <p> The best thing your dad can do is to call his insurance company about these bills to see what is going on. He should also look at his health insurance benefits book. <p> People joke about HMO's but I have Aetna HMO and the only costs that I incurred for this surgery were the $10 co-pay for my initial consultation for my surgeon, $200 for the nutritional consultant (which was not covered by insurance), $200 for the psych consult (ditto) and the cost of my telephone and TV while I was in the hospital. No worries about 20% co-insurance payments or worrying about charges about contracted amounts. Good luck to your dad in fighting this...JR
   — John Rushton

November 11, 2002
PLEASE CALL YOUR INSURANCE COMPANY...I have the Aetna MC POS/PPO offered through AT&T. This procedure is covered at 100% provided you used an in network doctor. According to my case manager, you should never receive a bill from the dr. You will receive a statement of benefits from Aetna showing what the charges were, what they paid and what you owe if any. And she is right,that is how I've always received my statements. Review the statements that you have and verify if it's actually a bill. Some hospitals send out statements showing cost to the insurance company and just sends you a copy that says 'pay nothing' or 'this is not a bill'.....BUT AGAIN...CHECK WITH AETNA!!!
   — Alicia M.

November 11, 2002
Definitely run this through Aetna. I had some tests that were out of Network for Aetna. When I submitted them, they paid the amount that they would pay in network and I was only responsible for the difference. Because the lab that did my tests were not on Aetna, they never submitted directly to Aetna. If I didn't do it, I would have been responsible for the whole bill.
   — Julie S.