Business Profile

Insurance Companies

Aetna Inc.

Headquarters

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Complaints

This profile includes complaints for Aetna Inc.'s headquarters and its corporate-owned locations. To view all corporate locations, see

Customer Complaints Summary

1,344 total complaints in the last 3 years.
491 complaints closed in the last 12 months.

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The complaint text that is displayed might not represent all complaints filed with BBB. Some consumers may elect to not publish the details of their complaints, some complaints may not meet BBB's standards for publication, or BBB may display a portion of complaints when a high volume is received for a particular business.

Initial Complaint
Date:02/20/2024
Type:Customer Service Issues
Status:
AnsweredMore info
Complaint statuses
Resolved:
The complainant verified the issue was resolved to their satisfaction.
Unresolved:
The business responded to the dispute but failed to make a good faith effort to resolve it.
Answered:
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
Unanswered:
The business failed to respond to the dispute.
Unpursuable:
BBB is unable to locate the business.
I applied through healthcare.gov to receive health insurance through the Aetna Silver S plan. I paid a premium in August of 2023 and ended up never receiving coverage and never receiving a refund either. The issue is that they keep mixing my insurance profile with my twin sisters so it results in them either giving her two member ID numbers or switching our names back and forth on one member id number. I let last year pass and never received any health insurance despite calling them numerous times and being told repeatedly they would fix it they never did. Since then, they have switched the name on bills from when my sister went to the hospital to my name or her name and they have issued multiple ID cards with the same number and different names. In 2024, I applied for insurance again and paid a premium AGAIN for coverage to begin on 02/01/2024 and it was the same issue. I called multiple times and spoke with health concierges who have given me reference numbers and even received a call back saying the issue was corrected only to call again and the issue still be an issue. Multiple concierges have hung up the phone or simply lied about the issue and they keep providing me with my sister's member ID number over the phone multiple times. I have been lied to about this issue multiple times and I have contacted the marketplace when my coverage was active with them, which they involuntarily canceled but that will be a separate complaint. I want this issue resolved ASAP with my member ID number and my plan, I do not want to be listed under my sister in any way. If they cannot resolve this issue after working with the marketplace as well as issue a refund for last August in a reasonable time, I will be seeking legal help with intention of suing them.
Business Response
Date: 03/01/2024
**** *** ******* **********

Please see our response to complaint #******** for ****** ********** was received by us on February 20, 2024. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Upon receipt of your request, we immediately reached out to our Customer Service Team, who reviewed Ms. **********’s concerns. Based on their review it been confirmed that Ms. **********’s enrollment has been unlink from your twin sister’s enrollment and updated in all the Aetna systems. Our Customer Service Team has contacted the member and advised of the new ID number and the mailing of the new ID Card, which will arrive in 7-10 business days. The member will have access to the ID card on the Aetna Secure Member Website within 24 hours. Our team has reminded the member that there is a balance on the account of $13.53 that is due by March 31, 2024.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms. **********’s concerns. If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [email protected].

Sincerely,

Marshell H.
Analyst, Executive Resolution
Executive Resolution Team
Initial Complaint
Date:02/20/2024
Type:Order Issues
Status:
AnsweredMore info
Complaint statuses
Resolved:
The complainant verified the issue was resolved to their satisfaction.
Unresolved:
The business responded to the dispute but failed to make a good faith effort to resolve it.
Answered:
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
Unanswered:
The business failed to respond to the dispute.
Unpursuable:
BBB is unable to locate the business.
Aetna has violated the terms of our provider agreement without our consent or approval by changing the terms of our approved services in accordance with medicare as outlined in *******. Multiple attempts to resolve the issue have gone unanswered with no follow up or resolution. CAP has been attempting to resolve the issue since December 2023 and to this date and multiple calls and reference numbers has no resolution nor has any provider relations representative returned my call to discuss.
Business Response
Date: 02/29/2024
**** ******* **********

Please see our response to complaint # ******** for ***** ****** that was received by us on February 20, 2024. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Upon receipt of the provider’s concerns, we immediately reached out internally for review. Our Provider Services team confirmed that additional claim information is required before they can proceed with a thorough review. Ms. ******** concerns were assigned to a designated point of contact who will continue to work with her directly until resolution. Please know, Tiffani L. emailed Ms. ****** on February 23, 2024, which stated: “As a courtesy I have attached a spreadsheet that may be utilized to compile the claim data. Please review and submit the claim data over to me no later than end of day Thursday February 29, 2024, a project will be submitted on your behalf. During this process if you have any questions or concerns regarding the information supplied within the complaint, please reach out to me directly.” To date, Tiffani has not received a response. Ms. ****** must respond to Tiffani’s email and contact her directly (contact information is found in the email) for further assistance with this matter.
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms. ******** concerns. If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at *******************************.

Sincerely,

Shay G.
Analyst, Executive Resolution
Executive Resolution Team
Business Response
Date: 02/29/2024
Dear Stewart Henderson:

Please see our response to complaint # ******** for ***** ****** that was received by us on February 20, 2024. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Upon receipt of the provider’s concerns, we immediately reached out internally for review. Our Provider Services team confirmed that additional claim information is required before they can proceed with a thorough review. Ms. ******** concerns were assigned to a designated point of contact who will continue to work with her directly until resolution. Please know, Tiffani L. emailed Ms. ****** on February 23, 2024, which stated: “As a courtesy I have attached a spreadsheet that may be utilized to compile the claim data. Please review and submit the claim data over to me no later than end of day Thursday February 29, 2024, a project will be submitted on your behalf. During this process if you have any questions or concerns regarding the information supplied within the complaint, please reach out to me directly.” To date, Tiffani has not received a response. Ms. ****** must respond to Tiffani’s email and contact her directly (contact information is found in the email) for further assistance with this matter.
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms. ******** concerns. If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at *******************************.

Sincerely,

Shay G.
Analyst, Executive Resolution
Executive Resolution Team
Business Response
Date: 02/29/2024
Dear Stewart Henderson:

Please see our response to complaint # ******** for ***** ****** that was received by us on February 20, 2024. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Upon receipt of the provider’s concerns, we immediately reached out internally for review. Our Provider Services team confirmed that additional claim information is required before they can proceed with a thorough review. Ms. ******** concerns were assigned to a designated point of contact who will continue to work with her directly until resolution. Please know, Tiffani L. emailed Ms. ****** on February 23, 2024, which stated: “As a courtesy I have attached a spreadsheet that may be utilized to compile the claim data. Please review and submit the claim data over to me no later than end of day Thursday February 29, 2024, a project will be submitted on your behalf. During this process if you have any questions or concerns regarding the information supplied within the complaint, please reach out to me directly.” To date, Tiffani has not received a response. Ms. ****** must respond to Tiffani’s email and contact her directly (contact information is found in the email) for further assistance with this matter.
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms. ******** concerns. If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at *******************************.

Sincerely,

Shay G.
Analyst, Executive Resolution
Executive Resolution Team
Initial Complaint
Date:02/20/2024
Type:Billing Issues
Status:
AnsweredMore info
Complaint statuses
Resolved:
The complainant verified the issue was resolved to their satisfaction.
Unresolved:
The business responded to the dispute but failed to make a good faith effort to resolve it.
Answered:
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
Unanswered:
The business failed to respond to the dispute.
Unpursuable:
BBB is unable to locate the business.
I switched to a different part D in December 2023 because they wanted to charge a copay. January came and I got a bill. I thought it was a mistake. Called Centers for Medicare and they said I hadn't been switched so they switched me. Still getting this $12 charge. I switched and it didn't get switched so how am I responsible for that $12? How many seniors and disabled are you doing this to? I called and it should have been a simple yeah we'll remove that but instead I argued with the guy for an hour and waited on hold for a supervisor. Supervisor never came and the guy hung up on me. He said his name was Jay but they give fake names so who knows. He did say that he was not in the us. That's all I got.
Business Response
Date: 02/23/2024
Dear Mr. ******* *********:

Please see our response to complaint # ******** for Ms. ******* ******, that was received by us on February 20, 2024. Our Executive Resolution Team researched the concerns, and I would like to share the results of the review with you.

Upon receipt of the concern, we immediately reviewed the member’s enrollment history. The member enrolled in the SilverScript Choice Prescription Drug Plan (PDP) on February 1, 2022. The member was disenrolled from the SilverScript Choice PDP on, January 31, 2024. We have reviewed the call history to the plan. There are no calls on file prior to February 17, 2024.

We reviewed the calls from February 17, 20204. We found that the member contacted the plan to express dissatisfaction with the enrollment process. We have found opportunities for service improvement after reviewing the calls. The representatives failed to escalate the member’s concerns properly. We reviewed a call where the Customer Care Representative identified himself as Jay. We have taken the appropriate action with the representatives Ms. ****** spoke with on February 17, 2024.

We sent an Annual Notice of Change to the address on file on September 9, 2023. The Annual Notice of Change (ANOC) gives a summary of changes to the member’s benefits and costs for next year compared to their current benefits. The ANOC advised that the monthly plan premium was $39. 30 for the 2023 plan year. The ANOC advised that the monthly plan premium will be $59.50 for the 2024 plan year. The member receives Low Income Subsidy. In 2024, your subsidized amount is $46.60. This means that the member’s 2024 monthly plan premium is $12.90 with extra help applied.

We understand the member advised that she switched her Prescription Drug Plan in December 2023. Unfortunately, we cannot confirm that a plan change was made in December. SilverScript Choice PDP was effective January 1, 2024, through January 31, 2024. The premium amount of $12.90 has been applied correctly. The Centers for Medicare & Medicaid Services (CMS) requires plans to equitably administer benefits to all enrollees. The monthly premium cannot be adjusted without confirming that there was a plan error. If the member has proof that she changed her plan in December of 2023, we will be happy to review it accordingly.

Please note, our plan does not report billing to the credit bureaus. However, if the member decides to enroll in any of our plans in the future, the balance will be applied.

The member may contact her current plan to file an enrollment complaint. The member can also contact Medicare to file a complaint.

The member will receive a written resolution with 7-10 business days.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms. ******* ******’s concerns.

Sincerely,
Jasmine W.
Analyst
Medicare Enterprise Resolution
Business Response
Date: 02/23/2024
Dear Mr. ******* *********:

Please see our response to complaint # ******** for Ms. ******* ******, that was received by us on February 20, 2024. Our Executive Resolution Team researched the concerns, and I would like to share the results of the review with you.

Upon receipt of the concern, we immediately reviewed the member’s enrollment history. The member enrolled in the SilverScript Choice Prescription Drug Plan (PDP) on February 1, 2022. The member was disenrolled from the SilverScript Choice PDP on, January 31, 2024. We have reviewed the call history to the plan. There are no calls on file prior to February 17, 2024.

We reviewed the calls from February 17, 20204. We found that the member contacted the plan to express dissatisfaction with the enrollment process. We have found opportunities for service improvement after reviewing the calls. The representatives failed to escalate the member’s concerns properly. We reviewed a call where the Customer Care Representative identified himself as Jay. We have taken the appropriate action with the representatives Ms. ****** spoke with on February 17, 2024.

We sent an Annual Notice of Change to the address on file on September 9, 2023. The Annual Notice of Change (ANOC) gives a summary of changes to the member’s benefits and costs for next year compared to their current benefits. The ANOC advised that the monthly plan premium was $39. 30 for the 2023 plan year. The ANOC advised that the monthly plan premium will be $59.50 for the 2024 plan year. The member receives Low Income Subsidy. In 2024, your subsidized amount is $46.60. This means that the member’s 2024 monthly plan premium is $12.90 with extra help applied.

We understand the member advised that she switched her Prescription Drug Plan in December 2023. Unfortunately, we cannot confirm that a plan change was made in December. SilverScript Choice PDP was effective January 1, 2024, through January 31, 2024. The premium amount of $12.90 has been applied correctly. The Centers for Medicare & Medicaid Services (CMS) requires plans to equitably administer benefits to all enrollees. The monthly premium cannot be adjusted without confirming that there was a plan error. If the member has proof that she changed her plan in December of 2023, we will be happy to review it accordingly.

Please note, our plan does not report billing to the credit bureaus. However, if the member decides to enroll in any of our plans in the future, the balance will be applied.

The member may contact her current plan to file an enrollment complaint. The member can also contact Medicare to file a complaint.

The member will receive a written resolution with 7-10 business days.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms. ******* ******’s concerns.

Sincerely,
Jasmine W.
Analyst
Medicare Enterprise Resolution
Initial Complaint
Date:02/15/2024
Type:Customer Service Issues
Status:
AnsweredMore info
Complaint statuses
Resolved:
The complainant verified the issue was resolved to their satisfaction.
Unresolved:
The business responded to the dispute but failed to make a good faith effort to resolve it.
Answered:
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
Unanswered:
The business failed to respond to the dispute.
Unpursuable:
BBB is unable to locate the business.
I was lied to by an Aetna insurance agent by the name of Allan whose number is ********** #**** he said I was in network with two doctors that i see and now i can't see my doctors because of a co pay I can't afford and I can't get Aetna to help me find a new doctor. I just want to be contacted by someone competent and good that will help me find a new doctor. The right doctor. I want to keep my food card and gas card from Aetna.
Business Response
Date: 02/23/2024
Dear Mr. ******* *********:

Please see our response to complaint # ******** for Mr. ****** *******, that was received by us on February 15, 2024. Our Executive Resolution Team researched the concerns, and I would like to share the results of the review with you.

Upon receipt of the concern, we immediately contacted the vendor that handled the member’s enrollment. We investigated the concerns through our Marketing Misrepresentation process. Unfortunately, the recorded enrollment call does not include the conversation about the network status of the member’s providers. We were unable to verify that incorrect information was provided. We have reviewed calls made to our internal customer service team. We confirmed that the provider the member was told is in network is with ****** * ****** ******. We have confirmed that ****** * ****** ****** is not in the Aetna Medicare Dual Choice (PPO D-SNP) network. We are very sorry for the inconveniences. We have also found opportunities for service improvements after listening to the calls to the plan.

As a member of the Aetna Medicare Dual Choice (PPO D-SNP) plan, Mr. ******* can choose to receive care from out***************;network providers. Our plan will cover services from either in******;network or out***************;network providers if the services are covered benefits and are medically necessary. However, if the member uses an out***************;network provider, the share of the costs for covered services may be higher. The member can review the provider directory on our website at ******************************* The member can contact customer service at the phone number on the back of his member ID Card for assistance with finding providers in the plan network. The member can also request to have a copy of the provider directory sent to him by mail.

The member is enrolled in our Case Management program. A representative with Case Management contacted the member on February 6, 2024. The Case Manger followed up with the member on, February 12, 2024. The Case Manager was unable to reach Mr. ******* on February 12, 2024. We have reached out to the Case Management team. The member's Case Manager has advised that she will follow up with him to address his needs. The Case Manager contacted the member on February 22, 2024 at 4:49 pm. The Case Manager was unable to reach the member by phone. We will continue to follow up. Our Case Management team has mailed the member a list of in network ********** ****** providers in his area.

Most people with Medicare can end their membership only during certain times of the year. Because Mr. ******* has Medicaid, he may be able to end his membership in our plan or switch to a different plan one time during each of the following Special Enrollment Periods:
-January to March
-April to June
-July to September

The member will receive a written resolution with 7-10 business days.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr. ****** *******’s concerns.

Sincerely,
Jasmine W.
Analyst
Medicare Enterprise Resolution
Customer Answer
Date: 02/23/2024
When the company said there was no record on the recording with the agent about my doctor being in network I ignored everything after that because they started out of the gate by lying.
Business Response
Date: 02/27/2024
Dear Mr. ******* *********:

Please see our response to the rejection our response to complaint # ******** for Mr. ****** *******, that was received by us on February 23, 2024. Our Executive Resolution Team researched the concerns, and I would like to share the results of the review with you.

Upon receipt of the rejection, we immediately reviewed the members statement he made of the rejection of our previous response.

In our previous review of the members concern, it was found that there was no mentioning of the member's provider and the status of the provider's network on the enrollment call. At this time we our still unable to determine which provider the member is referring to upon enrollment because we are unable to locate the provider being mentioned on a call. We do show the member was able to get his medication prescribed by a *** ******.

As a member of the Aetna Medicare Dual Choice (PPO D-SNP) plan, Mr. ******* can choose to receive care from out-of-network providers. Our plan will cover services from either in-network or out-of-network providers if the services are covered benefits and are medically necessary. However, if the member uses an out-of-network provider, the share of the costs for covered services may be higher. The member can review the provider directory on our website at ******************************* The member can contact customer service at the phone number on the back of his member ID Card for assistance with finding providers in the plan network. The member can also request to have a copy of the provider directory sent to him by mail.

Please know, most people with Medicare can end their membership only during certain times of the year. Because Mr. ******* has Medicaid, he may be able to end his membership in our plan or switch to a different plan one time during each of the following Special Enrollment Periods:

-January to March
-April to June
-July to September

Therefore, if the member is dissatisfied that his provider is not in-network with his current plan he can change plans and has until March 31, 2024, to do so. He can contact his local State Health Insurance Assistance Program (SHIP). SHIP is a state program that gets money from the Federal government to give free local health insurance counseling to people with Medicare. The program is not connected with us or with any insurance company or health plan. The counselors at this program can help you understand which process you should use to handle a problem you are having. They can also answer your questions, give you more information, and offer guidance on what to do. The services of SHIP counselors are free. The member can contact them at their toll-free number ###-###-####, or visit their website: ****************

The member can also contact Medicare to get help. To contact Medicare:
• Call ************** (###-###-####), 24 hours a day, 7 days a week. TTY users should call ###-###-####.
• Visit the Medicare website ******************.

The member will receive a written resolution with 7-10 business days.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr. ****** *******’s concerns.

Sincerely,
Marilyn G.
Analyst
Medicare Enterprise Resolution
Initial Complaint
Date:02/15/2024
Type:Customer Service Issues
Status:
AnsweredMore info
Complaint statuses
Resolved:
The complainant verified the issue was resolved to their satisfaction.
Unresolved:
The business responded to the dispute but failed to make a good faith effort to resolve it.
Answered:
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
Unanswered:
The business failed to respond to the dispute.
Unpursuable:
BBB is unable to locate the business.
Member ID# ************ Aetna Claim ID: ********* **** ******** Aetna approved the claim ( Medical claim ID: *********) shortly after it was submitted On 01/31/2024. Later Aetna sent me a notice stating my claim is now denied with some details for the denial in my online account. Find the notice below from aetna from my account. I called aetna several times and was told by each agent to send the receipts To them again because the ones I submitted were not clear. I immediately mailed the original documents and faxed them to Aetna. I called about a week later to verify Aetna received the documents. I called and talked with Jamie she verified the documents were Received the mailed originals and the faxed originals. I talked with Jamie again today 2/15/2024 and was told the claim now is starting all over again. Jamie says now it could take another 45 days. Aetna should process this claim immediately, instead of starting over with an additional 45 days. Please note that for days the fax number provided to submit reimbursement claims was not working. It made it difficult to submit the documents requested. After several calls and finally speaking with an escalation supervisor, he verified that the fax number had not been working for days, which delayed and complicated the process.
Business Response
Date: 02/16/2024

**** *** ******* **********

Please see our response to complaint # #******** for Mr. **** ******** that was received by us on February 15, 2024. Our Executive Resolution Team researched the concerns, and I would like to share the results of the review with you.

Upon receipt of the complaint, we reached out internally to view the member’s concerns. Claim #********* was denied due to not having an itemized receipt. We submitted the itemized to the Claims’ Department. Claim #********* has been reprocessed on February 16, 2024, with a reimbursement for $600. Please allow 7 to 10 business days.

The customer service representative correctly advised you that it can take up to 45 days to receive the reimbursement. The member will receive a detailed Medicare Resolution Letter within 7-10 business days.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr. ******** s concerns.

Sincerely,

Cindi D
Analyst
Medicare Executive Resolutions
Initial Complaint
Date:02/14/2024
Type:Customer Service Issues
Status:
AnsweredMore info
Complaint statuses
Resolved:
The complainant verified the issue was resolved to their satisfaction.
Unresolved:
The business responded to the dispute but failed to make a good faith effort to resolve it.
Answered:
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
Unanswered:
The business failed to respond to the dispute.
Unpursuable:
BBB is unable to locate the business.
Approximately 3 or 4 months ago, I changed my internet provider. I was under the impression that my password was the same as my *** account. I attempted to login to change my email address. I called customer service and was sent a text,with a link to help me change my email address. I called twice. I was told that the new email address was on file. I was unable to access my account. The problem that was not recognized was that, when the link was sent it asked me to enter the new email,but the verification is designed to be verified by sending it to the old email address. I sent an email to ******** and I never received a response.
Business Response
Date: 02/19/2024
T*** ** *** *********** *** ******* **********

Please see our response to complaint # ******* for Mr. ******* ******, that was received by us on February 14, 2024. Our Executive Resolution Team researched the concerns, and I would like to share the results of the review with you.

Upon receipt of the concern, we immediately reviewed the member’s call history to the plan. We found a call from January 26, 2024. During the call, the member advised that he needs to update his email address for the online member account. The member advised that he must use his new email address to gain access to his account. The representative advised that she has updated the email. The representative advised that the member could use the link that was texted to his phone to re-register using the new email address. Unfortunately, the representative provided the wrong infrmation. We have taken the appropriate action with the representative for service improvements.

We have sent the member’s concerns to our Digital Web team for review. The team has contacted Mr. ****** by phone on, February 16, 2024. The representative left a voicemail message for Mr. ****** to return her call. The Digital Web team will be able to assist the member with updating his email address for access to the online member account.

The member will receive a written resolution with 7-10 business days.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr. ******* ******’s concerns.

Sincerely,
Jasmine W.
Analyst
Medicare Enterprise Resolution
Initial Complaint
Date:02/14/2024
Type:Billing Issues
Status:
AnsweredMore info
Complaint statuses
Resolved:
The complainant verified the issue was resolved to their satisfaction.
Unresolved:
The business responded to the dispute but failed to make a good faith effort to resolve it.
Answered:
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
Unanswered:
The business failed to respond to the dispute.
Unpursuable:
BBB is unable to locate the business.
For the years 2022/2023, Aetna has refused to explain how they can accept a payment from ******* for deductible assistance and still collect the full deductible and out of pocket payments from me.
Business Response
Date: 02/19/2024
**** ******* **********

Please see our response to complaint # ******** for ***** ********* that was received by us on February 14, 2024. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Upon receipt of the member’s concerns, we immediately reached out internally for review. We confirmed with our Pharmacy team that the member’s plan benefits state: SPEC TRUE ACCUM – APPLIES. The plan has medical, prescription drug coinsurance limit and deductible combined. This plan type means that any copayments covered by copay assistance manufacturers will not apply to the member’s accumulators whether it is deductible and/or coinsurance limits.
Please know, *** Specialty used the manufacturer coupon (*******) to reduce the member’s out of pocket cost. However, that amount does not get applied to her accumulators. Per the plan, only the amounts the member actually paid out of pocket will apply to her accumulators.
Unfortunately, this is how the group’s plan is designed and Aetna does not have any control over this benefit. The member must contact the employer directly should she have any additional questions concerning why her plan is designed this way.
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms. *********’s concerns.

Sincerely,

Shay G.
Analyst, Executive Resolution
Executive Resolution Team
Initial Complaint
Date:02/13/2024
Type:Billing Issues
Status:
AnsweredMore info
Complaint statuses
Resolved:
The complainant verified the issue was resolved to their satisfaction.
Unresolved:
The business responded to the dispute but failed to make a good faith effort to resolve it.
Answered:
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
Unanswered:
The business failed to respond to the dispute.
Unpursuable:
BBB is unable to locate the business.
Prior to receiving an echocardiogram, I contacted Aetna Member Services via phone on a recorded line and requested the out-of-pocket cost for this procedure. I was told it would be $220-$450 (base amount plus all modifiers). Then, I received a bill for $2,642.02; the echocardiogram was performed on 1/29/24. When I called to have this reprocessed on 2/5/24 (I’ve had to do this multiple times with Aetna because they process claims incorrectly very often), I was told that the claim WAS processed incorrectly and that the amount was closer to $400 out-of-pocket. I called back on 2/9/24 and was told the claim was processed again but the $2,642.02 would remain. I have emailed Aetna Member Services multiple times appealing my bill to no resolve; they have not opened an appeal and are putting me through the ringer. I also confirmed the billing code on their website; it should be around $250. I believe it is unethical to quote someone $450 for a procedure (both before AND after), and then charge them $2,650 (roughly). Please help me get this resolved.
Business Response
Date: 02/22/2024

Dear Mr. *********:
Please see our response to complaint ******** for ******* Stine that was received by us on February 13, 2024. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.
Upon receipt of the member’s concerns, we immediately reached out to have the claim reviewed. Per the plan benefits, the claim processing is correct. I also pulled the pre-service phone calls where the estimates were given. Per the phone call on January 21, 2024, the member was advised procedure code ***** and had an estimated base fee of $270.93 and depending on any modifiers billed on the claim could have an upcharge of up to $144.84. While the estimates provided were advised to be “estimates only and approximate costs”, the true costs far exceeded what the member was anticipating. Unfortunately, we cannot give exact amounts because there are a lot of variables that can change costs once the claim is received however, we do strive to provide estimates that are close to the true costs a member can expect. Unfortunately, we did not meet that expectation in this situation. While that was not truly an Aetna error, as we’re going based on the information we have which doesn't include any provider pricing rates, or other variables that factor into claim processing, we do believe the member is the one stuck in the middle of unfortunate circumstances. Therefore, we’ve granted a one-time exception to reprocess the claim to reflect the “high-end rates” she was given on the phone call estimate. The claim has been reprocessed and the member’s financial responsibility is now only $415.77. The difference between the $2,642.02 and the $415.77 equals $2,226.25 and that amount was issued to the provider. The provider should receive that payment within 7-10 business days. Once they receive the payment and update their accounts, the member should receive a new bill from them. Additionally, the member will receive an updated Explanation of Benefits (EOB) which can be viewed on the Aetna member portal.
The new claim number is EKJNBXCQV01 and the breakdown of that claim processing is below:
Billed amount: $5,140.11
Allowed amount: $2,642.02 (provider’s contractual rate)
Member’s deductible: $415.77 (this is the amount Ms. ***** is responsible for)
Paid to provider: $2,226.25
We’d like to reiterate that this is a one-time exception. Obtaining estimates from Aetna is available to all members however, we do encourage the member to obtain quotes from their provider as well.
Additionally, I do see where an appeal was filed on February 14, 2024, under case number *************. I will make outreach to the Appeals department to let them know this issue was received via the Better Business Bureau (BBB) and that it’s been resolved to avoid any duplication of efforts.
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms. ******* concerns.
Sincerely,
Destiny S.
Analyst, Executive Resolution Team
Initial Complaint
Date:02/13/2024
Type:Product Issues
Status:
AnsweredMore info
Complaint statuses
Resolved:
The complainant verified the issue was resolved to their satisfaction.
Unresolved:
The business responded to the dispute but failed to make a good faith effort to resolve it.
Answered:
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
Unanswered:
The business failed to respond to the dispute.
Unpursuable:
BBB is unable to locate the business.
I had a procedure done on 7/26/23. This was supposed to be covered at 100% as it is preventative and I have a high history of cancer in my family. My father died of colon cancer in 2016. I am also in a high risk field as a fireman and a smoke diver. My doctor suggested the procedure. After my procedure I received a bill of $2,324.50 from the hospital. After I consulted Aetna I was told this was a "facilities charge" that was charged by the hospital. I contacted the hospital and was told this was not the case and received an itemized bill. After mailing all of this certified to Aetna, I am now told by Kedra (agent) that it will take 1-2 months to be reviewed. I would like my reimbursement as soon as possible. This should have been covered at 100 percent.
Business Response
Date: 02/21/2024
**** *** ******* **********

Please see our response to complaint #******** for ******* ***** that was received by us on February 13, 2024. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Upon receipt of your request, we immediately reached out to our Claims Management Team, who reviewed Mr. *****’s concerns. Based on their review it was confirmed that the claim from ********* ******** ******* with a billed amount of $7,719.50 was processed correctly for the colorectal cancer screening on July 26, 2023. The member’s responsibility of $2,324.50 was appropriately applied to the plan’s deductible and coinsurance.

Mr. *****’s appeal ************* was reviewed for the out-of-pocket amount of $2,324.50 for the services rendered on July 26, 2023. The appeal decision was upheld as we consider the colonoscopy and colorectal cancer screening to be a preventive service for members ages forty-five and older, when it is recommended by the member’s provider. Since Mr. ***** was under the age of forty-five when the services were performed, the plan covers the procedure under the medical benefits. These services are subject to the plan’s deductible and coinsurance. I have included a copy of the appeal resolution letter that was mailed to the member on February 19, 2024.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr. *****’s concerns. If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at s****************.

Sincerely,

Marshell H.
Analyst, Executive Resolution
Executive Resolution Team
Initial Complaint
Date:02/13/2024
Type:Billing Issues
Status:
AnsweredMore info
Complaint statuses
Resolved:
The complainant verified the issue was resolved to their satisfaction.
Unresolved:
The business responded to the dispute but failed to make a good faith effort to resolve it.
Answered:
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
Unanswered:
The business failed to respond to the dispute.
Unpursuable:
BBB is unable to locate the business.
Aetna's explanation of benefits are intentionally misleading to consumers. The EOB statement that I received states that I received a "plan discount" for services received on 1/29/2024 - however there is no such discount or any amount off the bill, other than the amount paid. The advocate I spoke to on the phone defined the discount as the amount billed minus the amount paid my aetna. Here is the explanation of calculations provided: "We total up the amounts for all 2 services on this claim to give you the big picture. Amounts for individual services are calculated the same way. We started with the amount billed by Dr. [redacted]: $160.00. Based on your plan's coverage rules, we negotiated a plan discount of $82.00 off the amount billed. Then we subtracted your plan's share of $78.00. This amount can vary based on your plan's coverage rules and whether or not you have a deductible. Your share is the remaining $82.00. You should always confirm the amount you owe with your provider. The amount we calculate does not factor in payments you've made." The math is simply incorrect, as there is no discounted amount. The pie chart is unintelligible and intentionally misleading. The "advocate" I spoke to on the phone was adamant that I was interpreting the explanation incorrectly, suggesting that it's complicated to understand and that it could take some time to understand. Her insinuations are insulting - the language is simple and clear, and quite obviously incorrect. Aetna is intentionally misleading customers about the amounts of their bill that they are responsible for, and suggesting that they have negotiated discounts when they have not.
Business Response
Date: 02/19/2024
Dear ******* *********:

Please see our response to complaint # ******** for ****** ****** that was received by us on February 13, 2024. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Upon receipt of the member’s concerns, we immediately reached out internally for review. We confirmed that the claim was processed correctly at the out-of-network benefit level, and the member is responsible for the $82 that was not covered by the plan. We also confirmed that the wording and calculations in the member’s printout are correct. Furthermore, we reviewed the member’s call history and online conversation and found that the explanations given were accurate and well explained. The plan discount is the discount negotiated by the plan for in-network providers in the area. Based on the member’s plan type (preferred provider organization (PPO) max) the negotiated rate is used to calculate the plan’s payment. However, if the member utilizes an out-of-network provider (in this case she did), they are responsible for the difference between the billed amount and allowed amount of the claim, which in this case was $82. Please know, a plan advocate attempted to contact the member multiple times to explain the plan discount and the printout she was viewing online. However, the attempts were unsuccessful. The advocate left voice messages with her name and direct phone number should the member have any additional questions regarding this matter.
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms. ******** concerns.

Sincerely,

Shay G.
Analyst, Executive Resolution
Executive Resolution Team
Customer Answer
Date: 02/20/2024

Complaint: ********

I am rejecting this response because: I should not receive documentation explaining in-network coverage as an explanation of my benefits when I seek care at an out-of-network provider. The explanation in text above is different than the explanation I received from the customer service representative that I spoke to on the phone. My concern has never been about the amount of money that I have to pay, My concern is that the explanation of benefits online is inaccurate, or is perhaps designed to display information only for consumers who access in-network providers. The documentation and explanation provided remains confusing for the consumer and I suspect this is intentionally misleading. I received a single phone call from an Aetna provider while I was at work which was filtered automatically by my cell phone provider as a suspected spam call.

Sincerely,

****** ******
Business Response
Date: 02/20/2024

Dear *** *********:
Please see our response to complaint ******** for ****** ****** that was received by us on February 20, 2024. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.
Upon receipt of the member’s concerns, I immediately reviewed the previous case, the screenshots previous submitted with the Better Business Bureau (BBB) complaint and the claim processing. The claim we received for *** ***** ***l was processed per the member’s out-of-network (OON) benefits. OON claims may still apply plan discounts however, OON providers are not obligated to accept the rates we pay for the billed services. Therefore, the provider can bill the member for the difference in what the plan allowed and what was billed.
All claims, once processed, have a billed amount, allowed amount and paid amount long with the member’s cost shares as they apply per the plan’s benefits (copay, deductible and coinsurance). The billed amount is the amount the provider billed to Aetna for the services they rendered. The allowed amount is the amount Aetna “allows” either per the provider’s contract (for in-network providers) or the amount the plan allows for that service if OON. The paid amount is any amount the plan pays for that service. Copay, deductible and coinsurance amounts are all the member’s out-of-pocket (OOP) financial responsibility for that claim.
The “plan discount” is the difference between the billed amount and allowed amount. Example: if the provider bills Aetna $100.00 for a service they rendered and the plan’s “allowed amount” is $25.00 and the plan pays $25.00, the plan discount will be listed as $75.00. Therefore, the same applies to the member’s claim in question. Claim number E6FC85F4J00 for date of service (DOS) January 29, 2024, was billed for $160.00, the allowed amount, per the member’s plan benefits for OON services, was $78.00 and Aetna paid $78.00. The $82.00 difference between the $160.00 billed and the allowed amount of $78.00 is considered the “plan discount” and could be the member’s financial responsibility if the provider opts to bill her for that difference. The plan discount doesn’t change anything for the member. We do encourage members to use in-network providers to get the most of their benefits and save money. However, if the plan has OON benefits and the member chooses to use an OON provider, that’s the member’s choice to do so.
The screen shot provided on the original complaint filed with the BBB doesn’t mention the services being rendered by an in-network provider, it only mentions the “plan discount” which is referring to the $82.00 difference between the billed amount and allowed amount.
We assure you that it’s not our intent to mislead or misrepresent any benefit that may or may not be available under a member’s plan. Explanation of Benefits (EOB) statements along with the information listed in the member’s screenshots on the previous case are all system-generated documents with system-generated verbiage and is not member-specific. Additionally, a member of our Dental team attempted to contact Ms. ****** on February 14, 2024, to explain the screenshots Ms. ****** submitted with her initial BBB complaint. Per the case notes, outreach attempts were unsuccessful and a voicemail with contact information was left. If Ms. ****** has any additional questions or concerns, we encourage her to return the call from last week at the contact information left on her voicemail. They can assist with answering any dental-related questions Ms. ****** may have.
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms. ******’s concerns.
Sincerely,
Destiny S.
Analyst, Executive Resolution Team

Customer Answer
Date: 02/20/2024

Complaint: ********

I am rejecting this response because: The definition of "plan discount" from Aetna is only being provided now, after calling and speaking with multiple representatives from Aetna and asking this specific question verbatim "What is the definition of a "plan discount". When presented with the "plan discount", myself or any person would interpret this differently than the way that they are using these words. The term "plan discount" on the website remains confusing for both in-network, or out of network bills, and I stand by my allegation that the information is misleading to the consumer.
Oxford English Dictionary states that a the definition of "Discount" is: deduction from the usual cost of something, typically given for prompt or advance payment or to a special category of buyers.
Aetna is using the term "discount" to mean something completely different in this case, and this is misleading to consumers.

Sincerely,

****** ******
Business Response
Date: 02/27/2024
Dear ******* *********:

Please see our response to complaint #******** for ****** ****** that was received by us on February 21, 2024. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Upon receipt of the member’s concerns we immediately reached out to our Dental department to assist with our investigation. After further review, we found that the member’s dentist is contracted with Aetna under special contract terms. We alerted our Dental claims department, who reprocessed the claim. An additional payment, along with a new statement, will be sent to the provider within seven to ten business days. The claim paid at 100 percent, with zero patient responsibility.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms. ******** concerns. If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at *****************.

Sincerely,

William B.
Analyst, Executive Resolution
Executive Resolution Team

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