Aetna health insurance and the 20 week u/s -- BEWARE

[Anonymous]

I have Aetna (Choice POS II plan), and I just got a bill from Foxhall OB/GYN for my 20 week u/s -- $612.

I was shocked -- in what 3rd world plan would the 20 week ultrasound not be covered?? I called Foxhall immediately to inquire and they were not very helpful. I told them that Aetna is not considering the charge "medically necessary", but wouldn't the Dr's office determine whether or not it was medically necessary? It's not as if we were given a choice about whether or not to get this scan -- it's something that Foxhall considers necessary because they automatically schedule every patient for this scan. The person I spoke to was not helpful at all. She said there was no way they would change the code to Aetna, and kept reminding me that I signed a waiver form and I needed to pay the $612. She also said this is a change that was done in the last year by Aetna and Foxhall get calls about this all the time. I know I signed a waiver, but honestly, I signed a million forms that first day and I'm angry that Foxhall obviously knows this is an issue but gave no warning.

I've also spoken to Aetna and my HR department and I think I'm out of luck. After more research, I've discovered that there are two codes for the "routine" ultrasond. 76811 is what Foxhall used, which is a detailed anatomy scan. 76805 is the basic anatomy scan. 78605 reimburses the doctor's office somewhere in the neighborhood of $130, but 76811 scan is reimbursed $238. 76805 would have been covered, but 76811 is only covered if there is some risk associated with the pregnancy. As I'm under the age of 35 and we've had no issues, I don't qualify. I sure wish I knew this beforehand. If I had chosen to have an amnio, it would have been covered.

Foxhall is unwilling to change the code. Right now, I feel so defeated. I'm hoping that I'll be able to convince them to let me pay the $238 they would have gotten from Aetna instead of the full retail u/s price. I can't talk to them right now though, I'm still too angry about the whole process. I wish they could charge the basic code and I would pay the extra $100, but that's not going to happen. I hate Aetna insurance so much right now. I changed my insurance from Kaiser to Aetna this year, and I never, ever, had any issues with Kaiser.

This is a warning to others with Aetna insurance. Here's a link to their clinical policy bulletin regarding ultrasounds. The relevant section says:
"The Society for Maternal-Fetal Medicine (SMFM) has stated that a fetal ultrasound with detailed anatomic examination (CPT 76811) is not necessary as a routine scan for all pregnancies (SMFM, 2004). Rather, this scan is necessary for a known or suspected fetal anatomic or genetic abnormality (i.e., previous anomalous fetus, abnormal scan during pregnancy, etc.). Thus, the SMFM has stated that the performance of this scan is expected to be rare outside of referral practices with special expertise in the identification of, and counseling about, fetal abnormalities (SMFM, 2004)."
http://www.aetna.com/cpb/medical/data/100_199/0199.html

And here's a forum from professionals discussing this issue:
http://forums.obgyn.net/ultrasound/ULTRASOUND.0509/0010.html

$612! I'm going to leave Foxhall if they won't come down on price. At this point, I'd rather deliver my baby in a cave and not deal with any more health professionals.

[Anonymous]

At this point, I'd rather deliver my baby in a cave and not deal with any more health professionals.

No need to do that when your own bed is available. Many amazing homebirth midwives in the area who will work with you and be extremely upfront about every single aspect of your maternity care, soup to nuts.

[Anonymous]

OP here.

Aetna doesn't cover homebirths either.
http://www.aetna.com/cpb/medical/data/300_399/0329.html
"Aetna considers planned deliveries at home and associated services not medically appropriate."

My coworker had a home-birth earlier this year, and prenatal care is covered but they are out thousands for the actual birth.

[Anonymous]

I (gasp) work for an insurance company (no not Aetna). They really are not all that evil. Insurance for health is just like that for car insurance, its a business. Yes I know people aren't cars but otherwise insurance wouldn't exist. No one is willing to foot the bill for unlimited healthcare for all. Not people, employers or the gov't. I work in pricing/financial and we work with docs/nurses all the time on these sorts of things. Everyone always wants the best most cost effective care. Really the biggest battles we have are providers and patients that insist on care that just isn't necessary or means a better outcome. We take on some risk and for sure there are often plans we price wrong and we lose money. We try to get people on more generics, not cover drugs that don't work, limit unneccessary procedures, pricy care that does nothing for the patient. Yes, we do make some profits (as a reward for taking on the risk) and correctly pricing and predicting risk. A girl on my floor works her tail off ensuring transplant patients qualify if they indeed meet the clinical criteria.

I think most of your anger at Aetna is misdirected. Your employer pays a premium to aetna to cover a predetmined set of services. They seem to have chosen a carrier with lower cost benefits in exchange for lower premiums. I'm sure Aetna offers self insured (they pay the claims but employer retains risk) plans with A+ fully covered maternity. This maternity benefit was well known by your employer when they chose the services. Takings these services off is how employers try to save $$ every year. Aetna should have sent a letter to you clearly defining the benefits once you were flagged as maternity. We do those interventions all the time.

Direct anger at your docs office. They should agree to accept the lower discounted amt. You presumably only went to them since the practice was in Aetna's network anyway. We've seen a good protion of docs in this ecomony especially, forgetting to tell patients things aren't covered (or else they'd lose the $612) or pushing things you might not need. They have a financial bottom line as well. More CT scans when an xray is sufficient etc. Even my 80 year old grandpa had this at his eye doctor. He already had a special set of glasses from his other cateract. She wanted to bill the other pair and submit it to medicare. He refused saying he didn't need it and she replied "what do you care" you're not paying, Medicare is, why do you care? Well he does, his small premium piece goes up when everyone is getting things they don't need. Docs and hospitals play games all the time in billing.
Having 2 kids myself, I absolutely think Aetna should only offer plans with the scan covered and your employer should only purchase coverage with it.
I'm not disagreeing with you, I just think some of your anger at Aetna should really be on your employer and doctor's office for being greedy and not on the ball with what's covered (or letting it go) when they should have said something.
Every woman has the 20 week scan, how many Aetna patients do you think they have here?? I'm sure more than you and they were well aware.

Best of luck to you, I hope they at least agree to pay the lowered amount. If you had a plan that covered it I'd bet your premiums would be more as well which the employer would have passed on some of to you. Divide the scan price by 12 and just assume it was more like additional $$ monthly for a plan that covered it. Insurance is frustrating, no one wants to pay. I've been there. I'm sorry you're so frustrated when you should have to worry about more important things.

[Anonymous]

OP again -- thanks for your detailed and thoughtful reply.

You're right, my anger is more towards Foxhall OB/GYN. My anger was more from earlier before I knew the difference between the detailed and basic fetal scan and I thought Aetna wasn't covering any 20 week u/s. Although, from what I read, Aetna's the only insurance company that doesn't automatically cover the detailed scan.

However, this doesn't excuse Foxhall for hiding behind this waiver. The person I spoke to says she gets 1000s of calls about this policy of Aetna's, so they obviously know it's an issue. But when I pressed them about why they don't warn us and offer any alternatives, she *laughed* and said it's my responsibility to find out what's covered and they can't possibly tell us.

My company is known around the area for having excellent benefits -- they actively market their benefits as being better than any other company. That's why this took me by such surprise, since this is the top health plan (and priciest one) they offered. If I stuck with the cheaper Kaiser plan, it wouldn't have been an issue.

Again, I really think Foxhall should offer to do a basic fetal anatomy scan. But then again, should I get lesser care because I'm under 35?

I have my next appt next week. I'm going to talk to my doctor and see what she has to say about this. Maybe she'll be more understanding than whoever it was I spoke to last time. Hopefully the office will agree to negotiate the price. I really do need to calm down before I talk to them though. I'm still royally pissed off about this whole situation.

Anyway, this is more a warning to anyone with Aetna. For your 20 week u/s, ask beforehand if it's the detailed anatomy scan and if it is and you don't have any risk factors, just be aware that this could happen to you.

[Anonymous]

I understand you are angry. I would be livid if I were in your shoes. I have Kaiser now and they are pretty good. I still question every test they recommend. I used to assume that if the doctor ordered a specific test of medication, it was because I needed it. I got burned on a bill years ago and now question everything. It turns out that half the shit they order is not actually necessary. I say "Is that really necessary?" and they say "well, it is just to be sure" and I say "Let's not do it if there aren't any other indications/symptoms" and they agree. If we miss something, it is my fault and I make my decisions carefully and as informed as possible.

[Anonymous]

I can't resist but make a political statement here...

and people say we don't need health reform...

this is insanity.

[Anonymous]

Aetna's policy is awful. I know with my insurance (not Aetna) they generally cover 1 ultrasound per pregnancy unless more are "medically necessary." I had to have an early ultrasound to date the pregnancy, so I was concerned about coverage for the 20 week. When my doc told me to schedule the 20 week, I told her my concern and she went on and on about how it was ABSOLUTELY medically necessary and wrote those words right on the prescription form for the ultrasound. They covered it without any problems.

I'm sorry you are stuck with this horrid insurance company. It is awful when people try to make a profit off of denying people health care!

I suppose it is cheaper for Aetna to deny the 20 week ultrasound than to allow all women to get it. They probably determined that it is cheaper for them to pay for babies to be rushed off for emergency surgeries--with the hope that the women happens to be at a hospital that can deal with whatever problem the baby has--because of a fetal defect than to routinely cover ultrasounds for all women.

[Anonymous]

I have AETNA open access HMO (so different from OP's) and I received two ultrasounds on top of the 20 week anatomy scan and a NT scan (four ultrasounds total and I am under 30). I went to GU and they made sure it was covered. I also had an AFI/NST at the end of my pregnancy which was covered without question.

Your anger should definitely be directed towards Foxhall.

[Anonymous]

I have Aetna ppo and they have covered everything including the ultrasounds. I am delivering at Georgetown.

[Anonymous]

I haven't had this happen with medical insurance, but have for dental - and even though a procedure wasn't covered by insurance, the dentist was required to charge me their lower (negotiated) amount rather than the full price. I would look into that, maybe call Aetna and see if their contract with the OB requires that or not. I went to GU for OB care but had to go elsewhere for all my ultrasounds/NT scan because the hospital's ultrasound center was out-of-network (even though the hospital itself is in network).

[Anonymous]

The exact same thing happened to me, I was shocked to be charged $612 - I am trying to appeal it as well. I don't understand why Foxhall can't offer us the alternative, routine ultrasound that is covered at 20 weeks. It seems irresponsible for them to pretend there is only one option, and it's the one that costs us $612. I am really frustrated with how Foxhall is handling this -- they know Aetna doesn't cover this level of ultrasound, yet they continue to give it to all patients.

[Anonymous]

This happened to me too. What do you think is the best way to appeal it? I tried talking to Foxhall and they were completely unhelpful.

[Anonymous]

OP here. Wow, it's good to find a few others who are going through the same thing. At the same time, I'm sorry that you guys have this experience too -- it's so unbelievably frustrating.

I've only called the billing department at Foxhall. The girl who answered was completely unsympathetic. She admitted that 1000s of people have complained about this exact same scenario, but then said in the same breath, "We can't possibly keep track of everyone's insurance." Well, if 1000s of your patients who have Aetna has complained -- maybe you would have the decency not to spring this huge bill on them.

I'm going to try to talk to them in person, maybe that will help. For the two PPs, who have you been talking to? I'm going to have a talk with Dr. Pardo at my next appt to see if she'll be more helpful. Have you offered to pay the $238 that is Aetna's negotiated rate? That's what I plan to do. It can't possibly hurt them because this is what they expected to be reimbursed. If Foxhall refuses and are still unhelpful, I'm going to find another practice. Even though I've already paid my portion of the global fee ($245 as I recall), I'd rather take my business elsewhere.

[Anonymous]

Oh, and I find this line infuriating:
"The Society for Maternal-Fetal Medicine (SMFM) has stated that a fetal ultrasound with detailed anatomic examination (CPT 76811) is not necessary as a routine scan for all pregnancies (SMFM, 2004). Rather, this scan is necessary for a known or suspected fetal anatomic or genetic abnormality (i.e., previous anomalous fetus, abnormal scan during pregnancy, etc.). "

The whole point of THIS scan is to find abnormalities. How would there have been an abnormal scan during pregnancy if they won't pay for this ONE scan?