What might I do with this insurance denial of coverage issue?

September 17, 2015 6:15 AM

I have a six-year patient-doctor relationship with a psychiatrist who is the best. I'd very much like to continue it. But he is in his late eighties, a sole practitioner, and does not understand the internet. My insurer, Aetna, has messed things up in a mind-blowing way, and to fix it, they want my doctor to communicate via the intertubes--they refuse to address it via mail or phone. This has my doctor at a loss. How can I, the insured, make some righteous noise about this? More inside.

So I realize that I may be fighting a losing battle here but I am quite angry at the prospect of having to terminate my relationship with my provider because the insurer is being an asshole.

My provider's contract with Aetna expired some time in 2014. He received no notice of it (possibly they sent him something electronically, but he is operating in old school mode and doesn't feel like he has the tools to figure out their new system while he continues to meet with patients and prescribe them medication--if this seems unreasonable, well, he's not of the internet age and I'm not going to judge him for trying to learn a new skill set in his ninth decade on this earth).

The first time we knew there was trouble was in 2015, when they began to deny his claims on the basis of lack of medical necessity. This basis of the denial, Aetna admits, was erroneous--the problem was that he didn't have a contract.

So now the next step would be for my provider to negotiate a new contract with them, which Aetna is willing to do, but only via their internet provider interface. My doctor has an address and fax number; he is certainly capable of interacting with Aetna this way. But Aetna is refusing to cooperate.

When I call as the insured, I'm told to find another provider. Yesterday I reached peak rage when the Aetna representative suggested that my doctor needed to retire.

So my questions are:
1) Is this a futile battle on my part?
2) If it's not a futile battle, how can I best make some noise? I can easily speak to my diagnoses, which I won't go into but are most definitely things that need to be managed, and the need for a lack of interruption of care.

THANK YOU

posted by angrycat to Health & Fitness (6 answers total)

Best answer: He could hire someone (not you! not a patient!) to do his contracting and billing. If Aetna's being this insistent that the contracting needs to be electronic, my guess is that they're going to require that the claims be submitted electronically as well.

If it were me, I'd call Aetna and ask what my coverage for out-of-network providers was (depending on your insurance, there may not be any) and how to submit my own claims myself for reimbursement (which would require you to pay the psychiatrist's full fee out of pocket, probably ditto for any medications) and then be reimbursed by the insurance company.
posted by jaguar at 6:24 AM on September 17, 2015 [4 favorites]

Best answer: First, I'm sorry about all of this. My therapist is in his late 70s and does all his own paperwork (but he's at least minimally internet-savvy), and I absolutely dread the day he retires. Before I found him, I had a horrible therapist that did have a contract but refused to file the claims--that ended badly for a variety of reasons, but oh, I feel your pain!

Is there any chance you could convince your therapist to hire a part-time assistant for internet-related matters? Many people would be happy for a bit of extra income and flexible hours.

In the meantime, I don't think anything much can be done about the time that he didn't have a contract, but for you personally, some reimbursement may be available by filing your own out-of-network claims.

On preview: what jaguar said.
posted by whoiam at 6:31 AM on September 17, 2015 [1 favorite]

Best answer: And if medication costs are an issue and you're mostly seeing this psychiatrist for therapy, you might be able to have your primary care provider prescribe the medications so that they're (presumably) covered, especially if your psychiatrist is willing to consult with your PCP about it.
posted by jaguar at 6:53 AM on September 17, 2015 [1 favorite]

Best answer: Yes, in my experience it IS a futile battle to convince an ins company to do something they don't want to do. Don't bother calling them - those people manning the phones have no information and have no idea what they're talking about.

It is also futile to convince someone to run their business differently. Personally I find it strange that a doctor would both contract with insurance companies AND do everything himself. I think it's more typical that you either deal with insurers and hire a biller or not deal with them at all and let your patients submit claims themselves. So I have little sympathy for your doctor, he brought this mess on you both.

I would just submit the claims yourself as out of network. I don't think you have any choice.
posted by bleep at 10:59 AM on September 17, 2015 [1 favorite]

Best answer: Electronic healthcare is the future and the future is now. There's a lot of top down governance- CMS guidelines, Medicare & Medicaid "incentives" (i.e. fee reductions if you don't use certain tech certain ways"), other stuff that was passed on the ACA that is being implemented now. Aetna probably has about as much choice on their minimum participation level with going electronic as your provider does (I feel sorry for all providers in his situation, who want to continue to practice as they have their whole lives, but aren't realistically going to be able to implement the new technology and workflows). So unfortunately, I do think it would be futile to try and fight them on this. Seeing if you can submit the claims yourself out of network seems like a good work around.
posted by ThePinkSuperhero at 10:27 AM on September 18, 2015

Response by poster: Thanks everybody. My shrink apparently spent some significant time on the phone this week and while there's still some weirdness he has managed to get them to email him a contract. So I think that it's going to be okay one way or another. If it wasn't for you all I was gonna get super righteous and probably achieve nothing but feeling like an impotent idiot; it's good to know what battles are not worth fighting.

Thanks again!
posted by angrycat at 12:44 PM on September 18, 2015