Medical Insurance Not Paying My Medical Bills?

Question

So last summer, I broke my ankle pretty bad, displaced fracture and at the time I had limited insurance. They claimed to pay up to 1k in ER visit, 250 for anaestesia, 2k in doctor visits, and up to 20,000 for secondary care. This happened last august and they JUST paid the ER 1000 dollars after I had to file some paperwork. This company is a subsidiary of Aetna, and instead of denying claims they just ignore them. At the time I was out of work for 4 and a half months because my job involved me walking and my car was a manual transmission. Usually they auto deducted my payments out of my paycheck every week but I had to pay them by credit card while I was not working. I have a receipt for my payments all the way to 11/9. They sent me a partial denial of my doctors bill on 11/16/07 because I was not up to date with my insurance and could no longer afford insurance as I just got a job back. My questions are how do I get them to pay and is physical therapy considered secondary care?

Answer 1

I'm familiar with SRC - I had coverage through them for about 8 months last year.  (I was working as a contract/temporary employee for an organization.  Had a limited benefit plan through SRC provided as part of the job, since I wasn't a permanent employee and couldn't get on the full benefit plan.)

With your claims getting "ignored," here's something that could be happening:  Make sure that your medical providers are sending claims to the SRC address (if I recall correctly, its a PO Box in South Carolina).  A couple of my doctors sent claims directly to the Aetna claims mailing address and couldn't figure out why they weren't getting paid.  :)

Regarding the physical therapy...I would look in your actual policy document to see how they define "secondary care."  The legal definition in your policy is going to be the deciding factor.  In general, physical therapy is considered an ancillary service, and I'd assume it would fall under the "secondary service" definition. (But your policy's official definition would override my assumption, of course.)

Answer 2

I am not positive, but it sounds like you have one of those little insurance companies that use the network of doctors that is already in place of one of the larger ins companies. So even though Aetna is not the actual insurance company, their name will be on the card.

Some of these companies are self paid plans. That means as they get the money in from the people who are paying the premiums, they sent it out to the doctors who have sent the claims in, usually on a first come first serve basis. These plans can run out of money fairly easily, so any claims must wait until they get more money next month. Some claims are processed and just sitting, waiting for the funds. This can go on for months. These plans are usually pretty inexpensive, and sounds like what you might have. The doctor is generally not allowed to bill you for the money until a certain amount of time has passed, usually a year.

Self paid isn't the only type of insurance companies that use the larger one's network, there are a number of different versions of these problem payers. These little companies are sometimes called third party payers.

You can call the insurance company and ask them why they haven't paid. This will be the claims number on the card. If there isn't one, call whatever is there, if it is Aetna # for the doctors network information, tell them you have SRC and you need to get the number to ask about a claim payment.  Sometimes the claims gets sent to the larger insurance first for some processing, so you may be be able to find out if they receive it there. If it went there first it, Aetna would then send it on to SRC. SRC can tell you how they process the claims, and where yours is.  Usually though, if it is waiting for funds, they don't want to tell you that. They like to say it's waiting to be authorized.

You will need to know the date of the service you received, and the amount. The doctor's office can tell you what charges  were, ask to know the amount of each charge as they may have combined them in odd ways. (Three $25 charges listed as $50 and $25 for example)

I am glossing over a lot, since it is even more outrageously complicated than it sounds here. Hopefully this is enough to get through to them.

As far as PT, I didn't deal with it, but I believe it is secondary care. Ask when you call. Those claims are probably sitting there too.

I don't mind trying to help if you get stonewalled. You can send me a question.

Answer 3

Were you on your job at the time of your injury? If so, your worker's comp. should pay.

As far as your medical bills are concerned, it's hard to answer your question without seeing the policy.

You might have the agent who sold you the policy explain the benefits. If you can't get the agent to explain the policy, you might want to write your State Insurance Commissioner's Office, explaining the circumstances, along with a copy of the policy.

Limited pay health policies are just that; limited pay. You get what you pay for when it comes to health insurance. When trying to save money in the purchase of health insurance, usually the less you pay, the less it will pay.

Best wishes, and God bless.

Answer 4

Be honest,It is gonna take some time to find the answer for your question.Try to have a look the resource here for reference.http://car-insurance.online-helpers.info...

Answer 5

Aetna?  I don't think they have a separate company that sells to indiviudals.  What's the actual name of the company because my guess someone told you it was related to them and isn't?

Also sounds like a discount plan, because some of the discount plans use the Aetna discount dental plan as well.  Sounds like an IAB plan to me.  I"m guessing the company is out of Texas either way.

Either way for about the same money you might have been able to get something good.  As someone mentioned the less you pay, the less they pay.  BUT, I find that people just jump on a plan without doing any homework because they can usually get a better plan without much more (if any) out of pocket.  Let me know because I'm curious as to what you have.

Good luck,

Jeff

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Never heard of it, but yes it looks more like a worksite product like an Aflac.  The site quotes "specializing in limited accident and sickness insurance plans."  And yes, for $80 a month you could have gotten a higher deductible comprehensive plan.

Answer 6

File an appeal with the insurance company and contact the state insurance commissioner and file a report.