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

[Anonymous]

Anonymous wrote: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.

I think this is good advice. OP, I'm sorry that you (and others) are going through this. I'm not with Foxhall but am awaiting my 20 wk u/s bill and this thread makes me nervous. We've already gotten slammed with a ton of bills that were a complete surprise and WAY different than the experience we had with my first pregnancy where we paid for barely anything out of pocket. I feel like I never know what is around the corner/coming in the mail and it SUCKS. I'm afraid to check the mail and cringe when I see an envelope from my practice or the lab. Along the lines of the poster who made the political statement, I have become so passionate about health reform in this country. I think the people who are afraid of change just haven't had something like this happen to them yet (or God forbid, much worse). I will be so discouraged if something doesn't finally change.

[Anonymous]

I use Foxhall as well and LOVE their doctors but HATE their office staff. I urge you to talk to Dr. Pardo about this...she will help you!!!

[Anonymous]

I would not trust this practice to make medical decisions for me. The practice has caused this issue. About the detailed scans, a scan is neccessary to check for abnormalities and general health of the child but no everyone does not need the very detailed scan that is more to followup on suspected abnormalities found under the other scan or bleeding etc. They are fast tracking to the more detailed one to bill more. If everyone had the more detailed and yes costly scan we'd all be paying a lot more for health care and not really improving things. At 20 weeks things that would need intervention (stomach outside baby), not growing properly etc. things where they'd intervene would be seen in the basic scan they are obvious. I'd bet the amount picked up in the detailed is small and even then much won't be able to be done. Everyone can't have care just to reassure or we all have to pay. Do you want everyone getting a CT scan of the belly for a tummy ache? If so watch your costs soar. I'd rather have skilled professionals and my own research determine what is "medically necessary" to prevent an emergency or intervene where it would actually help.

[Anonymous]

I would write a letter to whoever owns/co-owns the Foxhall practice. This sounds like a policy issue that just needs to be changed, and if enough customers/patients complain, they probably will.

In my cynical opinion, Foxhall only does this detailed scan because they can charge more for it. It's a money-maker. Every noticed that the women who get the most ultrasounds, generally, are the ones seeing OBs with fancy u/s equipment in their office? Cha-ching.

I sympathize, OP and those in the same boat. It really sucks. I'm out $160 right now for blood tests that... it's not even worth trying to explain, it's so complicated. But if I had figured out the byzantine system in advance and gone through like 5 steps of referrals and separate appointments, I could have gotten the $160 covered. Because I acted like a rational person and didn't do/realize I needed to do the above, I'm out the money, and both the blood test people and my insurance have "F you" attitudes. "You signed the waiver" -- I've heard that one too...

[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.

I have had Aetna Open Acces HMO for two pregnancies, and both times I have had the 20 week ultrasounds, and both times it was covered without a problem. Foxhall is definitely the problem, not Aetna.

[Anonymous]

Well, I don't let Aetna off the hook this easily either.

1) Foxhall is to blame for automatically scheduling every patient for the detailed scan, especially knowing this is an issue for Aetna patients.

2) Aetna is the only major insurance carrier that does not pay for at least one detailed scan. United pays for one (or 2 if done by two different providers). BC/BS says they pay for up to 4 ultrasounds (including the detailed) per pregnancy.

[Anonymous]

Anonymous wrote:Well, I don't let Aetna off the hook this easily either.

1) Foxhall is to blame for automatically scheduling every patient for the detailed scan, especially knowing this is an issue for Aetna patients.

2) Aetna is the only major insurance carrier that does not pay for at least one detailed scan. United pays for one (or 2 if done by two different providers). BC/BS says they pay for up to 4 ultrasounds (including the detailed) per pregnancy.

Amen. Aetna is a problem too.

[Anonymous]

I have Aetna and my doc told me that Aetna would not cover in-office ultrasounds (in the doctors office) for whatever reason, so I was referred to a radiology center for the ultrasounds. Maybe Foxhall doesn't know this?

[Anonymous]

Not sure if this is your insurance policy or your DH's but I'd strongly suggest using your HR department at your job or your DH's. As I'm sure you've been told, calling and asking to confirm that something will be covered in advance doesn't do much good because they give you that blah blah blah, this is not an authorization or confirmation or payment. But I've found that if I have a question about coverage, I contact my HR lady and she emails her higher contact at the insurance company and gets a response for me in writing confirming if something will or will not be covered.

Of course I haven't had to call upon the 'written approval' yet but it makes me feel a bit better to get the ok in advance, in writing. Just an idea for next time - sorry you have to deal with all of this!

[Anonymous]

I posted about this issue a few months ago. I didn't read the thread, but here is what I would do.

1) Call you OB/GYN and ask them to call the ultrasound center. The ultrasound center needs to code the ultrasound properly. Clarify what code needs to be used with the ultrasound center for them to cover it.

2) Call AETNA and ask for a manager. Go up the chain as far as you can there. I had to talk with 3 separate people. If the procedure is medically necessary, which it is at 20 weeks, then it will be covered. Keep calling AETNA until you get someone to agree to note in your file that you are submitting a claim for an ultrasound that is medically necessary. Give AETNA the charge code that the ultrasound center will be using and clarify with them that it will be covered.

I went through the exact same thing, and everything was covered for a 20 week ultrasound and a follow-up ultrasound at 22 weeks because they didn't get a clear picture.

[Anonymous]

Anonymous wrote:I posted about this issue a few months ago. I didn't read the thread, but here is what I would do.

1) Call you OB/GYN and ask them to call the ultrasound center. The ultrasound center needs to code the ultrasound properly. Clarify what code needs to be used with the ultrasound center for them to cover it.

The ultrasound lab is part of Foxhall. The OB is the one that scheduled the detailed scan. They refuse to recode to a basic scan.

2) Call AETNA and ask for a manager. Go up the chain as far as you can there. I had to talk with 3 separate people. If the procedure is medically necessary, which it is at 20 weeks, then it will be covered. Keep calling AETNA until you get someone to agree to note in your file that you are submitting a claim for an ultrasound that is medically necessary. Give AETNA the charge code that the ultrasound center will be using and clarify with them that it will be covered.

Aetna is very clear that they do NOT cover the detailed scan unless there is a specific risk factor. I might try to keep speaking to a higher up, but each person I spoke to referred to their clinical policy bulletin and that was it.

I'm going to follow up with my HR department. And I'll update this thread after I speak to one of the doctors next week.

For all the PPs that had their U/S covered, would you happen to know if it was the basic scan or the detailed scan? I think it's standard practice for most OBs (except Foxhall) to order the basic scan. I wish I knew there was a difference before this whole mess started.

The funny thing is, at Foxhall, they have these signs that warn that if you use these insurance companies (Aetna included), you will be charged $20 for each blood draw. I like how they warn you for $20 and then sneak this $600 procedure in later.

[Anonymous]

The OB practice I saw for my last pregnancy dealt with this issue by scheduling a separate appointment with all patients prior to their 12 week appointment to go distribute the basic pregnancy info (nutrition, etc.), go over your reproductive history and give you an opportunity to ask questions (this was with the NP, not a doctor), and meet with their billing person, who discussed their policies and went over this issue of not covering a second ultrasound in detail. She did not mention Aetna by name, just that insurance companies are increasingly deciding not to cover more than one ultrasound per pregnancy unless there was a medical indication and to check with my insurance company and/or be aware that a second might not be covered. So at least all their patients have a heads-up. I'm not sure that would help with the regular/detailed issue, but they at least raised the possibility of having to pay out of pocket and encouraged people to check into their policies.

[Anonymous]

I had this same problem with United Health Care back in 2007. Needless to say, I was pissed off and couldn't believe they would deny it. The issue was eventually sorted out, but I actually had to get my HR department involved because the insurance company was basically trying to go back and limit coverage. I think it's outrageous that they deny this and I hope you get some resolution, OP!

[Anonymous]

I currently have Aetna, but had BCBS for my pregnancy (and United for a previous pregnancy).

Basically my experience with both BCBS and United was that if the OB requested a procedure and coded it appropriately it would be covered by the insurance. My OB would fill in a "code" so that I could get additional ultrasounds during a pregnancy after I'd had a miscarriage to reassure me that everything was going well - he usually indicated "measuring large" or something like that so there was a medical "reason" for the additional scan.

Sorry your doctors office screwed this up for you - it's like the people who say their kids' annual checkups are not covered because they come a few days early or whatever. Your doctors office should know better!!!!

[Anonymous]

Anonymous wrote:

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.

I have had Aetna Open Acces HMO for two pregnancies, and both times I have had the 20 week ultrasounds, and both times it was covered without a problem. Foxhall is definitely the problem, not Aetna.

I'm the original poster of the message (four U/S). I don't know if it was the basic or the detailed scan. Even if it was just the basic scan, the problem still lies with Foxhall going with the detailed scan when there isn't anything to indicate that it's necessary. My 20 week US came back clear, so I didn't have anymore US until the AFI/NST when I was post-date.