Darn It Jim Part II- Finally Found The Cause

This is in reference to a post I wrote previously which can be found here. I’m mostly writing this post to vent but maybe I can offer some help or advice along the way. You can read the other post, but to summarize, when my youngest son Caleb was 11 days old, we went to visit the pediatrician for baby’s first office visit. For most of the last two years, I have been battling both the pediatrician and Aetna to get that visit paid. After the call that prompted the last blog entry, I thought the charge was resolved. I saw on the Aetna member site that it was paid, at least, I thought I saw that. This afternoon, my wife called to say that we got yet another bill (this makes 6) that states if we don’t pay within 15 days they will report it to the credit bureaus. The fastest way to chill an American’s blood is to threaten his credit rating. (This is only partly a statement of our greed and materialism; far too many things in American society are tied to credit ratings including car insurance, security clearances, etc.) I decided this time to try a change of pace: rather than call Laurel Pediatrics and yell at them, I would call Aetna first. Before I continue, I will say that the Aetna operator was very diligent and patient and we at least now know what the problem is but cannot guarantee that it will be resolved.

The problem appears to be that an entry dropped from the database along the way. To recap, as of this visit, Caleb was 11 days old. It is impossible to register an 11 day old baby for health insurance because you can’t get a Social Security card back in 11 days and you need an SSN to register for health insurance. I know darn good and well that as soon as Caleb got his SSN I registered him with one of the doctors at Laurel Pediatrics as his PCP. In October we changed doctors. Laurel had moved to an office farther from us and became a large practice. My wife didn’t care for the coldness of some of the nurse practitioners. We also found that where there are three doctors there are five opinions, and she thought she was being told something different every time she took the kids to the doctor. We found a single-pediatrician practice closer to us so at least we would only hear one story.

What happened is that somehow the database record was backdated showing Caleb’s primary care physician (PCP) as the doctor we switched to in October effective from his birthday. I told the operator that can’t be right and asked her to check Joshua. Sure enough, Joshua’s PCP reflected our current doctor going back to March of 05 when my insurance became effective. That wasn’t possible. I asked her to check what bills had been paid for Joshua and we were able to establish that his PCP was Laurel Pediatrics through October. After spending a good half hour on the phone working this issue, I asked her to check any record submitted and paid for Caleb prior to October. What came up were the bills for his hospital stay, including a bill paid to a doctor that I clearly remember from Laurel Pediatrics. Because that bill was paid, she checked the tax ID of the claim paid to him against the tax ID of the claim denied to Laurel Pediatrics, and found a match. The claim was resubmitted to the claims department with the explanation but there is no guarantee that it will be paid, although the chances do improve.

After working this for almost two years, I now know the problem was on Aetna’s end the whole time. I would like to publicly apologize to Laurel pediatrics for my accusations of incompetence. We still don’t intend to bring our kids back to your office, but it wasn’t your fault.

I’ve spent so much time working this issue that I’m tempted to add a two your stint as a "medical billing consultant" to my resume.

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