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Help with doctor / insurance

I saw an out-of-network (OON) doctor in Nov 09. Before making the appt I checked with Aetna about my OON benefits and they said I'd pay 30% coins. on the agreed-upon rate between the doctor and Aetna. I also checked with the doctor, who said he took Aetna insurance, and agreed I'd only be billed the 30% coins..

I received a letter from the doctor Dec. 29th stating, "as you are well aware I've been in a long-standing dispute with Aetna...". I was not aware of this. He says that Aetna has withheld payments since April, he's tried to let it impact his patients as little as possible but he can no longer afford to do so and I need to pay my balance of $8000. This was the only sort of "bill" I got. On 1/2/10 I rec'd a letter from his attorney, saying my acct. was in default and I had to pay.

I don't have $8000. I wouldn't have gone had I known of this dispute! Why did he take me as a patient?! What do I do?

Answer Question

Asked by Anonymous at 5:01 PM on Jan. 13, 2010 in Money & Work

Answers (3)
  • If the service needed a prior approval and one was not obtained they can deny the claim. OON is tricky, the insurance can deny the claim just for being OON, even tho your coins is higher for the services and they usually try to discourage you from using OON Dr's because they do not have a set up rate for each service. You can contact the insurance company and find out why they denied the claim. I have dealt with this many times, they tell the policy holder one thing but deny the claim anyways simply because it is an OON provider and the rates are higher.

    Answer by Anonymous at 5:11 PM on Jan. 13, 2010

  • It did not need prior approval.

    If they can deny it just b/c it's out of network, why would they have told me it would be covered?

    Answer by Anonymous at 5:57 PM on Jan. 13, 2010

  • Call them.

    Answer by Anonymous at 1:43 AM on Jan. 18, 2010

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