Slammed by Aetna Health Insurance: who says we don't need health care reform? by gimleteye

I had a curious experience last week, contesting a health care bill for a CAT scan. My policy with Aetna covers my family. I'm an individual buyer; in other words I don't benefit from buying within a pool like a business or government. I pay close to $1000 per month, with a $5000 deductible. I've never needed-- until recently-- to spend on health care more than the small fortune it costs to insure my family from catastrophe.

Recently I discovered the need for a small procedure, a hernia repair. After a round of calls to find a provider qualified by Aetna, I matched up with a doctor at Jackson and began an uncomfortable round of visits. My doctor ordered a CAT scan. I didn't ask how much it would cost. I had other things to worry about, like my health and believed the cost would be covered or I would owe a reasonable expense. What I discovered was a shock. (click, 'read more')

The bill from Jackson for the CAT scan was $7000. My jaw dropped. Below the line, there was a debit of $3500. It was called a "contract adjustment". Whatever that means, it left me holding a bill for about $3500. I made several phone calls to Jackson to attempt to discuss the bill. It took me more than an hour to find a living person, who claimed to have no direct knowledge how to contest a bill, but finally directed me to a mail address for my outraged "to whom it may concern" letter. A month passed, and still no response.

In the meantime I also called Aetna. That also took more than an hour to obtain a living person with a passing knowledge of how to register a complaint. A few weeks after my phone call to Aetna, a letter arrived by mail notifying me of a time and date for my "Level Two Appeal" conference call. Three phone calls later, I was able to verify the call-in number.

At the appointed time, last week, I had my phone call with Aetna. In addition to the call moderator, there were three other Aetna employees on the call. The call moderator quickly introduced the Aetna participants. She said, after the call within seven to ten business days I would receive a letter informing me of the committee's decision regarding my appeal. I asked for a phone number and name I could call, to follow up. The moderator refused to give me any phone numbers or even to repeat the names of the people on the call. She told me, if you have a question later you can call the 800 number for individual service. I explained that I really wanted someone I could speak with. So much, for that.

I laid out my case to Aetna: that I needed the CAT scan, it was ordered by an Aetna qualified physician at Jackson, that I had never asked before hand what the cost would be, but that I never expected it would be $7000 and $3500 out of pocket or I would have checked other CAT scan imaging services. In fact, after receiving the bill, I did check around and discovered I could have had the CAT scan performed for $250. There was a silence at the end of the line.

The moderator asked me, "Why didn't you try to find a lower cost provider before getting the CAT scan?" I was shocked. "Um," I answered, "I was actually focused on not feeling well. I was relieved I was seeing a doctor who was an Aetna provider and I assumed that Aetna, my health insurance company, was using the same skill set to qualify imaging costs for a CAT scan as it did to qualify its contractual terms with doctors." Silence. When the moderator responded, it was along the lines that I was at fault. In other words, I should not only pay $1000 a month, and be certain that any health care provider is inside the Aetna network, but I should not also assume that I will have a reasonable charge for imaging or testing even if the services are provided within the same facility or hospital as the doctor.

Later, I wondered how I could be at fault when I have paid nearly $12,000 annually for health insurance, over many years for which I have drawn no benefits. And I wonder how it is even possible to have to cough up another $3500 or $7000 for a CAT scan. There are nearly 80 million CAT scans in the United States per year. I know that this exorbitant bill is how the health care system manages to cope with the enormous number of Americans who cannot afford any of the medical services they need. But if everyone who received a CAT scan DID pay their $3500 bill (I assume I haven't been singled out, just because I'm a good credit risk), then the fully assessed value of CAT scans alone in the United States adds up to more than $30 trillion. I lost track of reality, or am I bad at arithmetic or is the health care system that the Tea Party rails against, insane, or is it the Tea Party'ers who have lost their minds.

I am waiting for the response to my "Level Two Appeal" and, naturally, instructions should I care to push the appeal further up the Aetna food chain. I would invite any member of Congress-- who have the privilege of a health care plan that is gold plated in comparison --to try out Aetna; and I don't mean by taking campaign contributions from the insurance industry.