I’m having issues with my Aetna insurance and my psychiatrist’s office. Aetna denied two psychiatry claims but approved therapy claims from the same doctor, as well as one psychiatry claim. When I called Aetna, they said the doctor appears out-of-network but could not explain why some claims were approved. They insisted the doctor’s office needs to call them directly to confirm and resolve the issue.
However, the office refused, saying they don’t confirm coverage with insurance. I asked if there was an error in how they billed, and they maintained that it’s my responsibility to deal with Aetna.
Is this correct? Is there no obligation for the office to assist with this? It’s frustrating, especially when I’m already dealing with mental health challenges.
If the doctor is out-of-network, they’re not required to work with your insurance. Their responsibility ends at providing you with the documentation to submit a claim. You’ll need to handle the follow-up yourself.
It’s possible the claims processed as in-network were an error or that the provider went out-of-network recently. Ask the office to confirm their network status and ensure they’re billing under the correct NPI. If everything checks out, the issue might be with Aetna misprocessing the claim. Unfortunately, offices are often reluctant to call insurance because it’s time-consuming and doesn’t always resolve the issue.
You can ask Aetna to set up a three-way call with you, the insurance rep, and the provider’s office. That way, they can confirm the network status directly. This approach sometimes gets better results when the office isn’t cooperative.
If the doctor is out-of-network, they’re not obligated to resubmit claims or deal with your insurance. Their role is to provide accurate billing information for you to use. Offices often don’t call insurance because it’s time-consuming and unproductive. If they’re in-network, however, they should be willing to help resolve the discrepancy. You might need to escalate the issue with Aetna or ask for a supervisor.
Confirm with Aetna if the doctor is listed as in-network for your specific plan. If they are, ask for documentation of this and escalate the matter if needed. You can also ask the provider’s office to give you a detailed invoice and submit it to Aetna for reconsideration. It’s frustrating, but unfortunately, insurance issues often require persistence.