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

[Anonymous]

I am one of the PPs with this same problem. To answer your question OP, I did speak with Dr. Lightfoote and Dr. Pardo about it but neither were able to help me sort it out. If you have any better luck, please let me know. I plan to appeal via Aetna but I am not very optimistic and am very frustrated that Foxhall didn't explain this better and give me a choice between the routine scan, which Aetna would have paid for, and this detailed one.

[Anonymous]

OP, I have Aetna POS II, same as you. But did not pay for any of my u/s when I was pregnant. I think it depends on the plan that your employer negotiated. After 20 weeks, I developed complications and I had u/s every two weeks for monitoring. I did not have to pay any of it. Thank goodness, or else we'd be broke. I am thankful to my company for that.

[Anonymous]

Anonymous wrote:

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.

You can't make blanket statements about Aetna being the problem. There are different plans under Aetna and some cover it and some don't. I have Aetna and have never had a problem with any ultrasound being covered (as some of the previous posters have also stated). The OP's plan doesn't cover it and that is because her employer chose a plan with maternity benefits that don't cover it.

[Anonymous]

What Foxhall is doing is called "upcoding" and it is illegal. Not only does it leave people like OP to cover the $$, but the practice makes a ton of money off of the insurance policies that DO cover this upgraded u/s that they are apparently routinely doing on all patients, regardless of need.

[Anonymous]

Amen, 17:32. Shame on Foxhall. The detailed scan isn't medically necessary for every patient, and they know it.

[Anonymous]

So what can we do about it? It seems like Foxhall needs to be confronted by a group of patients. One person doesn't really get anywhere on their own.

[Anonymous]

seriously, if it is illegal who does one report it to?

[Anonymous]

Have any of you Foxhall patients posting here written a letter to the owners of the practice complaining about the problem? I think this is different from talking to the docs in person. If a bunch of patients write angry letters, they're more likely to sit up and take notice. Tons of patients everywhere are grumpy about insurance for various reasons -- a verbal conversation isn't likely to make a dent.

Write letters, ask for responses, and let us know what you hear back.

[Anonymous]

OP do you have a lawyer?

One approach might be to call some larger places as a potential patient that do ultrasounds and ask what they code the 20 week scan Washington Radiology, Fairfax, GU, GW etc. This could give you some comparisons to show Foxhall that they are upcoding and send a written letter. Do not pay the bill, I read once that once you pay a bill you are accepting responsibility and it is hard to get the money back.

We had a 'scam' situation with our first ob/gyan as well (not Foxhall). After our AFP she told us we were positive for down's syndrome but a positive just meant that we had to go get an amnio and it would probably be a false alarm. I asked her what the actual tests results were and what she meant by positive and she said it didn't matter. She also made a big deal about going out to this one particular guy in Fairfax because you really want the best for an amnio. She never told us that the AFP is notorious for false negatives, that it only show statistical risk, or that our risk profile based on my age had not really changed it was just equal to the risk of miscarriage from an amnio and the AFP results did not lower the risk. She also convinved us that it is difficult to do an amnio and we really needed to go to this person she was referring us to.

When we got there, the office staff told us that a FSH test (few hundred) would give us quickest results but insurance doesn't cover this part and insurance would not cover the rest of the amnio (over 1K) if we did it. They also told us we had to pay there so we gave them a credit card. Later on we called our insurance company to submit the bill anyway and were thinking of appealing. The insurance company told us that not only was it covered but this office had already submitted a claim and been reimbursed! So we called the office and they didn't want to refund us, they tried to tell us they would pull the original claim and just keep the full amount we paid which we could try to get back from insurance. We threatened to report them for insurance fraud and call the VA AG office and then they refunded the amount we paid on credit card immediately.

[Anonymous]

This is awful - sorry to hear about your dilemma. I just want to make sure you are picking the right battle - the Dr. should not have ordered the detailed US without cause. That is where you need to focus. Ignore the billing dept, ignore the code used for the US, go right to the Dr. who ordered the detailed test. You were not informed that there was a difference between the US and it has nothing to do with your ignorance of Aetna's policy (you knew they only covered the 20-wk US).

I would send a letter in writing (receipt confirmation) to the Dr. and state that if they do not provide medical justification to you and the insurance company explaining their rationale for ordering the detailed test, or cover the cost of the detailed test that was obviously ordered in error by them, then you will see them in small claims court. For the amount of money it doesn't make sense to get a lawyer involved, but state that if you the issue is not resolved by a zero-balance statement from Foxhall by (I'd give it 30-60 days), then you will file in DC small claims court and a complaint with the Better Business Bureau.

In DC, they make you go through arbitration before you see a judge, and the cost of sending a lawyer to arbitration would negate the amount you owe. If they don't show, you win, if it even gets that far. Plus the medical office is a business, so they have an interest in not making waves with BBB.

I'm not a lawyer but that's how I'd handle it.

[Anonymous]

Let them know you will be informing the appropriate Ethics and Medical Boards.

[Anonymous]

Hi Ladies,
If enough of us write to Foxhall, they will have to pay attention.

Here is the recommendation from Society of Maternal Fetal Medicine that specifies that only a routine ultrasound, with the routine code, should be used unless there is a medically indicated reason. As you all know, Foxhall orders the more complex ultrasound for all patients, even those that have no medically indicated reason, and that is the problem. Including this white paper in your letter might help make your case stronger -- Foxhall is clearly violating the recommendation of this society. (Aetna follows the recommendation of the society.)

https://www.smfm.org/index.cfm?zone=news&nav=viewnews&newsID=238&smfmon=yes

Here is an excerpt that clearly says the code Foxhall is using should not be used:
"CPT 76811 is not intended to be the routine scan performed for all pregnancies. Rather, it is intended for a known or suspected fetal anatomic or genetic abnormality (i.e., previous anomalous fetus, abnormal scan this pregnancy, etc.). Thus, the performance of CPT 76811 is expected to be rare outside of referral practices with special expertise in the identification of, and counseling about, fetal anomalies."

[Anonymous]

To the OP on this, did you ever work this out with Dr. Pardo?

[Anonymous]

OP here. I've been putting off updating because things aren't completely finalized yet, but I think the dr's office will agree to charge us the discounted Aetna price for the u/s instead of the full $612.

The PPs were right, talking to the doctors wasn't helpful at all. Their stance is that the detailed ultrasound is necessary and the docs don't deal with billing. For the PPs that are in the same situation, I'd recommend going in person and speaking to the office manager, Kathy Johnson and negotiate a discount. I think that's the best that's going to happen. When I pointed out that it would be good practice to warn the Aetna patients that this would be an issue, Kathy said that if they couldn't risk doing that, or Aetna would drop them from their network.

Still annoyed, but now I just want to put this behind me. $238 still bugs, but it's a lot better that $612.

If you have Aetna, and you have a low risk pregnancy, please read the bulletin I linked to in the original post. Find out what kind of ultrasound your doctor's office will be using and be prepared.

[Anonymous]

I think it has something to do with what plan your employer chose. I had a CVS, for a good reason, I was 42, and then had an u/s with a specialist at 20 weeks, even after we knew our baby was healthy. I paid one co-pay, the first pre-natal visit, and then nothing. I did have to pay the specialists a co-pay though. I love Aetna and have had it for years, but I'm sorry that you're having issues.