Aetna HMO IOQ Denial

[southernlady]

Hello everyone!

Quick update...today in the mail I received an authorization letter from my secondary insurance stating that they are approving me for surgery which we all knew that they would. Still waiting on my primary...this is exhausting.

What happened with me, my primary denied me, my secondary approved. It was filed with both. Primary denied payment. Secondary paid 100%.

 

[Judith]

Hi everyone.

Update....So Aetna denied my network deficiency exception. They're stating that I must go to one of their IOQs which are more than 50 miles away from my home even though those IOQs will be out of network for me.

I spoke to a nurse at Aetna who felt horrible about all of this. She stated that even though the IOQs are out of network that possibly a network deficiency exception would then work because I'd be requesting it for the exact reason that the exception was created even though I'd have to drive over 50 miles to one. I honestly don't believe an exception would be approved though because these were created for out of network facilites close to home when in-network facilities are 50+ miles away.

I'm so angry, heartbroken & discouraged. How do I have 2 insurances that cover bariatric services at 100% but I can't have the surgery unless I drive over 50 miles away to have it done according to Aetna? Please make it make sense.

At this point I think my best option is to terminate the Aetna insurance during our open enrollment period this October and make my secondary my primary insurance effective January. Then start the process all over again with my hospital knowing that the secondary (now the primary) will pay for the surgery.

 

[southernlady]

At this point I think my best option is to terminate the Aetna insurance during our open enrollment period this October and make my secondary my primary insurance effective January. Then start the process all over again with my hospital knowing that the secondary (now the primary) will pay for the surgery.

That’s up to you. Who is your current secondary?

 

[Judith]

That’s up to you. Who is your current secondary?

I have Amerihealth Caritas through the PA MAWD (Medical Assistance for Workers with Disabilities) program that I pay a monthly premium for.

But the Aetna nurse discovered that my other local hospital is in fact an IOQ but they're out of network for me. She believes that if they are willing to take me on as a patient and then request a network deficiency exception for me that Aetna will approve it because the request is being made for the exact same reason that these network deficiency exceptions were created...close to home out of network facilites because other in & out of network facilites are more than 50+ miles away from me. If this hospital agrees and Aetna approves the exception then Aetna pays them at in network rates (which they are in network with Aetna just not my with my Aetna HMO plan) and they are also one of Aetna's approved IOQ facilities. She said that she can't see Aetna denying the exception request.

I called my weight management program and they said that they will send all of my records to the other hospital if they're willing to accept me into their program. I'm gonna try this route before I take drastic measures by ending my Aetna insurance.

 

[southernlady]

I called my weight management program and they said that they will send all of my records to the other hospital if they're willing to accept me into their program. I'm gonna try this route before I take drastic measures by ending my Aetna insurance.

That makes perfect sense.

 

[Susan in Tennessee]

I have Amerihealth Caritas through the PA MAWD (Medical Assistance for Workers with Disabilities) program that I pay a monthly premium for.

But the Aetna nurse discovered that my other local hospital is in fact an IOQ but they're out of network for me. She believes that if they are willing to take me on as a patient and then request a network deficiency exception for me that Aetna will approve it because the request is being made for the exact same reason that these network deficiency exceptions were created...close to home out of network facilites because other in & out of network facilites are more than 50+ miles away from me. If this hospital agrees and Aetna approves the exception then Aetna pays them at in network rates (which they are in network with Aetna just not my with my Aetna HMO plan) and they are also one of Aetna's approved IOQ facilities. She said that she can't see Aetna denying the exception request.

I called my weight management program and they said that they will send all of my records to the other hospital if they're willing to accept me into their program. I'm gonna try this route before I take drastic measures by ending my Aetna insurance.

I hope this plan of action works!

 

[Judith]

Hi everyone!

Update: Aetna denied my pre-auth again but this time they denied it as a plan exclusion and didn't mention anything about the IOQ. The surgeon's billing coordinator said she read the denial like 3 times and quickly submitted it my secondary before Aetna could submit another update rejection. She said that we must've made some good friends or an impact at Aetna for them to deny it as such when we all knew that it should've been denied for the IOQ requirement. Well my secondary insurance approved it and...

I just received the call to report for surgery this upcoming Monday! I'm beyond excited, nervous, & scared but I'm so ready for this change!

Thank you all for your wise words & advice!

 

[Susan in Tennessee]

Wow, that is great news! I’m really thrilled for you. I know it’s been quite a roller-coaster ride with the insurance companies. Hold on your roller-coaster ride isn’t over but it’s a good one.
I’m sure you’re feeling nervous, very normal. Ask anything you are worried about or wondering about.

 

[k9ophile]

Hooray! Congrats on your victory over evil and conniving insurance policies and procedures. It has always amazed me that they tend to want people to get sicker before treating them. That's why I qualified for my surgery after my initial denial; I gained more co-morbid conditions. Sheesh, that idiocy of it all.

 

[southernlady]

Congrats on your upcoming surgery date.

 

[galaxygrrl]

That is awesome!!!!

 

[JackieOnLine]

I just received the call to report for surgery this upcoming Monday! I'm beyond excited, nervous, & scared but I'm so ready for this change!

so glad to hear it!

 

[navygrrl]

Yay!

 

[hilary1617]

Hi Judith! How did it go? Please remember to hydrate. It's really important to a smooth recovery.

 

[galaxygrrl]

Congrats to a new life. You will be amazed at how much your life opens up.