Local Doctor’s Complaint Spurs Insurance Investigation At Aetna

By John Voket

Late last year, Newtown naturopathic physician Shawn Carney started hearing complaints from several of his patients who were covered by Aetna health care plans. The approximately 18 patients all had the same story — they were initially told that certain visits to Dr Carney’s office were covered, only to receive claim denial notices weeks after their visits.

At the same time, Dr Carney said about 20 new patients who were seeking first-time consultations or initial office visits, who were initially told they were covered by Aetna, were canceling appointments and taking their health care needs elsewhere.

After spending many long hours on the phone trying to resolve the issues with Aetna representatives, Dr Carney made his concerns known to the Connecticut Insurance Department in early March. And on September 28, a state Insurance Department spokesperson confirmed to The Bee that a subsequent investigation determined Aetna had been incorrectly coding naturopathic claims for every patient visit between September 8 and November 2, 2011. 

As a result, Aetna corrected the coding error and made good on 3,892 outstanding, underpaid claims with interest totaling $75,153  including the claims identified by Dr Carney related to his practice. The local physician recently learned of the action and results, and was thrilled to know that not only were his concerns validated, but that his and other naturopathic patients throughout the Aetna health care system were receiving the compensation they were promised by the Hartford-based insurer.

“Last fall I started having three basic problems,” Dr Carney explained during an interview at his Northeast Naturopathic office on Main Street. “I was seeing changed billing codes, I was seeing claims being reprocessed, and I was having patients coming back to me saying claims I told them were covered being denied.”

Dr Carney first began an in-house investigation, enlisting the help of an Aetna provider advocate.

“We started reviewing these claims attempting to sort things out, but after hours on the phone it was going nowhere, even though at first it seemed Aetna’s representative was attempting to help,” he said. “But once I started losing new patients, well that’s unacceptable. So I went to the state Insurance Department for help.”

He said it was tricky trying to pull all the information together because not all health plans cover naturopathic visits, although a recently enacted state insurance law compelled many providers to cover certain naturopathic procedures and consultations. But once the state got involved, it became obvious to Dr Carney that Aetna was improperly processing qualified claims.

The physician eventually learned that a “computer glitch” caused an automated downgrading of claims for many naturopathic physicians, as well as other doctors.

“But I don’t believe Aetna took steps to deal with the problem until the state approached them about the matter,” he said. In the meantime, Dr Carney’s and his patients’ frustrations were growing.

“We were second-guessing every contact we made with Aetna, and facing a constant stream of unpleasant surprises, from initial promises of coverage that were denied to cases where Aetna was paying everything — including the patients’ deductibles,” he recalled. “At one point my patients were involved with a dozen internal claims reviews or appeals that were going on simultaneously.”

In the end, Dr Carney was happy that the issues were resolved on behalf of his and Aetna’s naturopathic claimants.

“Of course I don’t think they care about all the extra time I had to spend, or for the patients I lost,” Dr Carney said, flashing a grin. “But I sent them a bill anyway for the time I spent handling all this extra administrative work. Of course I got no response.”

A voicemail message left at Aetna for comment was not immediately returned.