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| Hello, new to posting but I thought you might want to hear about this.
I've had an Aetna PPO for the past 12 months through my employer.
Before obtaining this coverage I hadn't gone to a doctor's office in
over half my lifetime. Since starting it, I've been able to process
over a half dozen medical and dental claims with Aetna without
incident.
Two weeks ago I went to my doctor to get an immunization. 5 minutes
before the appointment I called Aetna and they promised me all
immunizations were covered (after all, a stich in time saves 9000
dollars in potential hospital bills down the road).
I proceed into the (in-network) doctors office, but they only have one
of the two immunizations I need. OK no problem, doc writes a
prescription and says bring this to the pharmacy, get the vaccine,
bring it back (at another date) and his nurse will administer it.
I go to the friendly (in-network) pharmacy. They don't have it in
stock, either, so they take my card's info, order the vaccine, and I
leave. I figure it's a generic vaccine, whats the most it will cost
me, a $15 co-pay, maybe $30 tops if its a brand-name vaccine.
Three days later I get a call from the pharmacy..."your prescription
coverage was denied by Aetna, you will have to pay the full $355 for
the vaccine". I responded with some choice words and made a beeline
to the Aetna phone number.
<bureaucratic part of the story starting>
Five voice-msg minutes later I was talking with a live person. He
said the claim was denied because immunizations are under Aetna's
"medical" department, whereas prescriptions are under a completely
separate "prescription" department. The "prescription" department is
the one that denied the claim. If I wanted a vaccine, it would have
to be through a "medical department" doctor's office only; Aetna will
not cover 'injectibles' through their "prescription" department.
At first he attempted to argue that I tried buying it through an
out-of-network pharmacy, but then he looked it up in his records and
he went "oh. its in-network".
I asked if he could transfer the claim from one department to another;
he said he could not. I then said, "What do I have to do, go to five
different doctors until I find one with the proper vaccine in stock?"
He said no. He said that I could buy the vaccine, pay the full $355
and then fax the bill to Aetna, and they would decide whether or not
to accept or deny the claim.
I said, "I'm not a pharmacy or a doctor's office! What makes you
think they will accept my claim?!" I asked him if he would guarantee
Aetna would pay the full amount of the vaccine. He said he could not
guarantee that. This is when I started getting REALLY upset. I said
my school demands I get these vaccinations, if I don't then they won't
allow me on-campus. Basically Aetna denied me a potentially
life-saving vaccine because of their incompetent bureaucracy and lack
of flexibility.
I ended the coversation by saying that, before this discussion I was
upset that my (10,000-worker) employer was switching PPO plans at the
end of this year to Sigma, but now I was a lot less upset about that.
Aetna's bureaucracy is a nightmare, if they can't easily process a
common procedure of administering vaccinations, what else are they
incompetent about?
D.
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